Dr. Sagnika Dash

Trying to bring a change in Women's Healthcare through evidence based , empathetic and unbiased clinical practice.

19/08/2023

Lower Urinary Tract Symptoms

Women in their 30s and 40s would have experience the following at least once in their lifetime

Leaking of urine during
Heavy weight lifting
jumping
Squatting
Exercising
Coughing
While getting up from toilet

Such symptoms combine the lower urinary tract symptoms which needs to be understood and addressed to relieve them better.

These symptoms gets better in most of the women , however it may worsen with time in some others.

The greatest barrier in addressing the problem is embarrassment and lack of understanding that such a condition can be managed and needs to be managed before it worsens

Cause:
Infection
Pelvic floor muscle weakness
Defect in the nerves supplying the urinary bladder
Injury to the bladder

Risk factors:
Non-modifiable: With increasing age, there is a tendency of the pelvic floor muscles to undergo certain changes like loss of collagen which would result in a weak pelvic floor.
Repeated childbirth and instrumental delivery associated trauma to the pelvic floor
Chronic diseases with weakening of muscles
Menopause

Modifiable risk factors: Obesity
Drinking habits (avoidance of fizzy drinks along with coffee, cola and citric juice consumption)
smoking
avoiding drugs which causes lower urinary tract symptoms

Types
Storage problems:
Inability to store urine which leads to leakage of urine with cough, heavy weight lifting and during exercises like jumping.
Inability to hold urine when there is a urge
Increased number of visit to the toilet to p*e during day time and waking up more than once at night to p*e.

Voiding problem:
straining
dribbling of urine
hesitancy
intermittent stream
terminal dribble(drops of urine trickling at the end of urination)

Post micturition symptoms
feeling of incomplete emptying
loss of urine while getting up from the toilet

The above symptoms may be present as one at a time or in combination.

dismissing the symptoms as a normal part of ageing or an association with childbirth may lead to late identification of serious issues.

What can you do if you have a lower urinary tract symptoms?

Initiate Pelvic floor muscle exercises
Maintain a Bladder Diary ( follow this link for more informationhttps://www.futurelearn.com/info/courses/understanding-continence-promotion/0/steps/46133 )
Visit a doctor after 3 days of maintaining a bladder diary.
Visit a doctor if there are chances of urine infection without delay if you have other medical conditions like diabetes, kidney failure or taking immunosuppressive medicines.

Send a message to learn more

Photos from Dr. Sagnika Dash's post 30/07/2023

Pregnancy Sickness

Nausea and vomiting affects upto 80% of women during pregnancy and is the leading cause of hospital admission which lasts for around 3-4 days.
The terms used for this nausea and vomiting can be the following
NVP: Nausea and vomiting of pregnancy without any other cause for the vomiting
Hyperemesis Gravidarum: Severe form of NVP which leads to Weight loss of 5% as compared to pre-pregnancy body weight, abnormal electrolytes and dehydration.

What causes the nausea and vomiting?

A rising trend in the pregnancy hormone beta HCG is associated with the nausea and vomiting of pregnancy.
This is sometimes considered as a sign of healthy pregnancy. However it is not mandatory for everyone to have a NVP during pregnancy nor is it considered healthy when it starts affecting the daily activities of women.
The proposed theory to explain the cause are
Feto-protective
Immunological
Biochemical
Biosocial
To ensure that the pregnancy progresses smoothly without causing undue discomfort, It is important to address this issue as it has been observed that almost 1 in 10 women having Hyperemesis gravidarum will opt to terminate the pregnancy because of the distress it causes.

How to know that the vomiting in pregnancy is severe?

A scoring system has been developed to make the soring quantitative. It is known as the PUQE (Pregnancy unique quantification of Emesis) score. As per the score , the vomiting is termed as mild , moderate or severe.

What can be the other causes of vomiting?

Gastritis
Cholecystitis
Infection : Kidney, gut , lower Urinary tract,
pancreatitis
Hepatitis
metabolic: Diabetes and complications
Abnormal pregnancy like molar or twins
Neurological causes
Drug or food induced

What to expect when visiting a doctor?

If the vomiting prevents you from having a discussion, then you will be offered fluid and treatment initially and then assessed for associated abnormalities which can trigger/cause vomiting.
Blood tests will be offered to check for the functions of Kidney, liver and urine test is done to search for "KETONES" which is a measure of the severity of dehydration.
Certain pre-existing diseases like diabetes can present as vomiting so it is wiser to do a thorough assessment.
If you are suggested an admission, blood thinners will be given through an injection to reduce the chances of development of clots in your legs and lungs. These will be discontinued upon discharge.

To assess the growing fetus, a scan will be offered.

Is there any way to avoid Nausea in pregnancy?

Simple dietary measure during early pregnancy which includes
Addition of carbohydrates during snacking , switching over to bland food and frequently eating small meals in a ratio of 3 meals and 3 snacks might avoid the onset of NVP

Ginger: In the form of juice or ginger tea can be helpful in suppressing nausea.
Avoidance of triggers and smell that provokes vomiting
Massaging Neiguan point: acupressure point which relieves nausea.

What is the impact of NVP on the fetus?

NVP is a common condition and doesnt have a sustainable impact on the fetus.
In cases of hypermesis gravidarum, almost 10% women wish not to continue the pregnancy as they are unable to carry on with the disability.

What medicines are given for this condition?

Simple anti-vomiting medicines are the first line to be used.
cyclizine, prochlorperazine, promethazine and chlorpromazine are safe to consume but caution needs to be taken regarding a rare but bothersome condition known as Extrapyramidal side effects.

If the first line does not act, second line anti-vomiting medicines are
Metoclopramide, domperidone and Ondansetron.

Third line medications consist of Steroids which needs to be given in a hospital set up through the veins.

Severe nausea and vomiting of pregnancy is a disabling condition which needs to be dealt with compassion and acknowledgement of the symptoms of the pregnant woman.
This condition might recur in the same pregnancy and there is a high likelihood of reappearing during subsequent pregnancies. This is one of the reasons why the management of this condition should take into account addressing the issue with empathy.

If managed properly, the pregnancy outcome is good with a healthy mother and a baby. It is important to try the non-medical methods of tackling this condition moving over to first line followed by second line medications.

For your healthcare needs, please visit me at Wellkins medical Centre.

Dysmenorrhea (Painful periods) 27/07/2023

Dysmenorrhea (Painful periods) Painful Periods (Dysmenorrhea) "I was a kid when I was dealing with pain so severe that it led to blackouts and I never asked for help" Pain during menstruation affects one in 6 women. Despite being so common, this condition is not given enough attention as it has been accepted to be a normal part o

Photos from Dr. Sagnika Dash's post 27/07/2023

Pregnancy Test

Those two lines on the strip test meant the world to me!

What did you feel like when you first found out that you are pregnant?

I am really pregnant?
Do I need to visit a doctor?
Should I repeat this test?
Why is the line so faint?
Is my baby healthy?
How do I confirm if whatever I am seeing is actually true!!!
And a lot more questions and concerns...

Detecting the pregnancy is the first step towards a relationship with your unborn baby and a bitter-sweet relationship with your gynecologist. This is an attempt to make the information clear, comprehensive and practical so that you can take an informed decision and are well prepared for the journey.

When to perform a pregnancy test?

The hormone measured in a card-test is beta HCG . This is produced by some cells which can be active as early as 10 days after ovulation. Technically, you can detect a pregnancy before your missed periods. However, It is advisable to wait at least until a missed period to detect the pregnancy.
In case of irregular cycles, one can wait until 35 days from the first day of the last periods before taking the test.

How to perform a pregnancy test

An early morning sample is recommended to check for pregnancy to prevent excessive dilution of urine.
Check for the expiry date of the card and if you are unable to see even a single line(the control line), do the test again.

Can the results be misleading

Yes,
sometimes, even if you are pregnant, the card shows a negative result. It can happen due to the following causes
1. If the urine is extremely diluted or the sample taken very early in pregnancy
2.Hook effect: when the amount of the pregnancy hormone is extremely high, the card is unable to read it : this would need a blood test

At times when you are not pregnant, but the card shows a positive test can happen in the following circumstances
1. Blood or protein in urine
2. Intake of certain medicines like Aspirin, Carbamazepine, methadone or contamination with Seminal fluid.
3. Certain Tumors which produce the pregnancy hormones

What are the other symptoms of pregnancy that I need to be aware of?
The following signs and symptoms can be seen during pregnancy but caution has to be exercised as none of these features might be present , yet there is a pregnancy.
Missed period is the commonest symptom of pregnancy : Sometimes, women may bleed even if they are pregnant well into their third month of pregnancy. This condition will need an assessment with an ultrasound to date the pregnancy.
Breast tenderness: Other causes of breast tenderness include pre-menstrual syndrome.
Nausea and vomiting(Usual around 6 weeks into pregnancy) : One must rule out gastric, renal(kidney related), Hepatic (liver related) causes of nausea and vomiting.
Mood changes : A frequent association with pregnancy but can have numerous causes.

How is pregnancy confirmed?
Having a blood report of pregnancy hormone is not sufficient to diagnose pregnancy.
An ultrasound will be needed to
detect the earliest sign of pregnancy: the gestational sac
follow up the developments in subsequent scans: visualizing yolk sac
Confirm if the baby is healthy: Detecting heart beat
An early scan has the advantage of detecting the expected date of delivery with the highest accuracy and can be an important tool in managing twin pregnancy.

Therefore it is important to get an early scan done along with a blood test for pregnancy hormone.

If the line is faint, does that mean I have a weak pregnancy?

A faint line can appear in early pregnancy and does not determine if it is a healthy pregnancy or not.
The pregnancy needs to be followed up with blood tests on a weekly basis or every 2 days if there is any spotting/bleeding.
The rise in the hormone levels will be a guide to determine if the baby is healthy.
If the hormones keep rising, your doctor would suggest you when to go for a scan.

Will an internal scan ( Transvaginal/TVS) harm my baby?

A transvaginal scan will not harm the baby and does not cause miscarriage.
It is equally important to understand that miscarriage is age dependent and can happen to anyone. Almost 1 in 5 pregnancy has a change of not developing into a full term pregnancy. At 30 years on age the miscarriage risk is 20% which increases to 50% at 40 years of age.
A transvaginal scan will be additionally helpful if there is a suspicion of an Ectopic pregnancy ( An unhealthy pregnancy where the baby is present outside the womb and can turn into a life-threatening condition if not diagnosed and managed appropriately)

Being pregnant comes with its set of dreams and apprehensions, if you feel you would need help to cope up, please visit your doctor. Follow the advices and stay calm.

For further queries and consultations , visit me at Wellkins Medical Centre

Photos from Dr. Sagnika Dash's post 25/07/2023

PCOS

PCOS or Polycystic Ovarian Syndrome is considered as one of the commonest complaints seen in women of reproductive age. Its incidence varies from 2% o 26%. This variation can be attributed to many factors and can give an insight into the cause, effect and outcome of these women. Managing PCOS is mostly treating the symptoms along with lifestyle modifications which would help in reversing the risk factors, get a better control over symptoms and enable a healthy living.

What causes PCOS?
There are various hypothesis but none of them is based on larger studies. The reason could be
Genetic: If the condition runs in family, there is a higher possibility of it affecting you.
Environmental: Poor dietary choices having high calorie junk diet along with a lack of exercise
Stress related: The effect of modern living and higher stress leads to poor lifestyle choices ultimately bringing about metabolic changes and hormonal disorders.

How to diagnose PCOS?

Rotterdam criteria: 2 out of 3 factors being present in a woman while other causes of the presenting symptoms are ruled out
1. polycystic ovaries (either 12 or more follicles or increased ovarian volume [> 10 cm3]
2. oligo-ovulation or anovulation
3. clinical and/or biochemical signs of hyperandrogenism

various blood tests and scanning are needed if there is a specific symptom.

What are the different symptoms seen with PCOS?

Irregular cycles
Male pattern of hair growth (Hyperandrogenemia)
Infertility
Skin changes : Acne , Acanthosis Nigricans(thick and dark skin at skin folds)
Obesity
Sleep apnea (Day time sleepiness)
Low mood and fatigue
Insulin resistance and Diabetes
More likelihood of Heart diseases
High blood pressure
Cancer (Endometrial)

What can I expect during a visit to the doctor when I have been diagnosed as a PCOS?
The doctor would take history . Do the general examination to check for changes associated and then try to address the major concern for visit. Additionally, blood tests and imaging which is relevant to the complaints will be performed. A routine assessment of mental wellbeing by asking questions to rule out depression.

Tests needed to diagnose PCOS
Women presenting with irregular cycles will need
An ultrasound scan to have a look at the ovaries
Blood levels of Androgen: male hormones if there isn't sufficient evidence of clinical changes.

Additional tests
Glucose tests: 75 gram 2 hours Glucose challenge test to identify Glucose intolerance
Insulin : If there is evidence of insulin resistance
FSH and LH : As an adjunct to workup for infertility
TSH : To rule out thyroid disorders as a cause for changes seen with PCOS
Lipid profile : Risk of cardiac effects
Liver function and Renal function tests
Transvaginal sonography: to identify polycystic ovaries and assess endometrial thickness in those presenting with heavy menstrual bleeding

What are the treatment options?
The treatment for PCOS is done by addressing the symptoms along with optimizing lifestyle factors.
Depending on the symptom , the following treatment can be offered
Irregular cycles: Pills which contains cyproterone acetate is a good option as it is anti-androgenic and can ensure regular cycles. Giving a few cycles of pills along with lifestyle changes will set the cycles regular in most of the women. For those who are additionally planning for a pregnancy will not be offered the contraceptive pill. Before prescribing the pills , one needs to understand the risk factors and choose an appropriate pill taking into account various risk factors in the history, examination or blood parameter.

Male pattern of hair growth (Hyperandrogenemia) : If associated with high male hormones in the blood, an Anti-androgen will help in reducing the hair growth. Coarse dark hair may not respond well to the medicines and will need mechanical methods like waxing or shaving to improve the appearance. Laser and Electrolysis are other methods of hair removal that can be used to ensure permanent hair removal.

Infertility: A thorough investigation for infertility is needed to begin any treatment for PCOS. Regularizing the cycles and ensuring the development of follicles( eggs) is an important factor to be considered along with addressing the safety of ovulation induction drugs. Letrozole is a novel drug for induing ovulation induction and is associated with single egg development. prior to starting a treatment, it is always advisable to achieve a moderate degree of weight loss. A high LH is often associated with PCOS and sometimes might need some surgical intervention which is rare but an option to consider.

Skin changes : Acne , Acanthosis Nigricans(thick and dark skin at skin folds) Development of acne is mostly due to high levels of circulating male hormones while Acanthosis nigricans is due to insulin resistance. Identifying the cause of the skin changes and addressing them is essential in treatment of such conditions. An anti androgen , local creams , antibiotics may help with severe Acne. For insulin resistance, Insulin sensitisers such as Metformin are used as a first line agent.

Obesity: Depending on the grade of obesity, there are various recommendations. While those above 40 kg/M2 will benefit from bariatric surgeries , those with lower BMI can opt for oral tablets to reduce weight. Those with Grade 1 Obesity can initiate lifestyle modifications and expect dramatic results including reversal of the ultrasound features.

Sleep apnea (Day time sleepiness): Addressing the cause of sleep apnea will help in resolution of the same. This condition is associated with obesity and happens when there is airway obstruction during sleeping which commonly presents with snoring. Reduction of body weight and changing sleeping posture may have benefits.

Low mood and fatigue: A negative body image along with various health issues lead to development of depression and low mood among women suffering from PCOS. Taking help from professionals and having a CBT (Cognitive behavioral Therapy) would be sufficient for majority of women while a few may need additional help with a short course of Anti-depressants which should be prescribes after a consultation with a mental health expert.

Insulin resistance and Diabetes: Insulin sensitizer and glucose lowering drugs can help in reducing the blood sugar levels and prevent the onset of TYPE 2 Diabetes.

More likelihood of Heart diseases: Unlike the general population , Women with PCOS will not follow the usual risk stratification for a metabolic syndrome. As this condition is associated with diabetes, abnormal lipid and high blood pressure, it is important to educate the patient about the risk of developing cardiac condition. The risk can be reduced by improvising the risk factors.

High blood pressure: Medicines for reducing blood pressure are prescribed keeping in mind the various side effects and safety profile in case of an unplanned pregnancy as most of the women with PCOS are in the reproductive age group.

Cancer (Endometrial): This is a rare long term complication of PCOS. Surveillance with ultrasound and a biopsy of the endometrium if there is any heavy bleeding will help in identification of pre-cancerous conditions. The risk factors for development of cancer of the womb are high blood pressure, diabetes and obesity. If these factors are optimised, the chances of development of a cancer is unlikely

Is there a role of surgery in PCOS
In case of high LH, an ovarian drilling may help in reducing the high LH levels in the o***y and help in egg release/ovulation.
To diagnose changes in the endometrium, a biopsy (usually hysteroscopic) using a camera is recommended to take samples and study them.
The definitive treatment of Endometrial cancer is Hysterectomy/removal of the uterus.
Gastric banding/ balloon/gastric bypass are the surgical options for weight loss in selected patients

Is there a permanent solution to PCOS?

PCOS is a lifestyle disorder and follows the lifestyle choices and habits. Most of the symptoms of PCOS can be managed with lifestyle changes and relevant treatment. However , the symptoms may reappear at a later date. This is the reason for a longer follow up and frequent check up when any symptoms appear.

What is Lifestyle modification?
Lifestyle modification refers to the daily habits of diet and activity undertaken.

Diet:
A poor diet which is rich in calories but poor in nutrition (junk food) will ultimately lead to deterioration of health. the food choices made on a day to day basis affects the health and one needs to aware of what they eat when they have been advised to improvise their lifestyle. Staying away from FAD diets and rapid weight loss is essential as these methods are temporary and PCOS will reappear once you are not on a strict diet.

Activity:
Having an active lifestyle with exercise incorporated in day-to-day activities is essential in ensuring weight loss. cardio and strength training both needs to be done as a part of weight loss phase.

Choice:
Ultimately, lifestyle is a personal choice and a person should be motivated to take responsibility of their choices. While a short term healthy choices will help in overcoming an immediate issue, to ensure that a long term change is sustainable, a high degree of dedication towards ones' health is needed.

For further queries and opinions you can visit me at Wellkins medical Centre.

22/07/2023

Menopause

Longevity brings about a set of issues which needs to be handled with adequate information. Menopause is an inevitable (and necessary) part of life. In an era of information boom and unrestricted access to knowledge, the insight into menopause if disheartening.

Lets address a few common questions/myths regarding menopause as it is extremely difficult to address the entire topic.

Menopause hits at a certain age and means stoppage of periodic bleeding.
Truth: menopause is a gradual phenomena which begins from perimenopausal age when the menstrual cycles start getting irregular. while there is an average age of menopause but it depends on many factors including Genetic, regional , Medical and personal reasons for having an early or a late menopause.

Every woman bleeds heavily around menopause and its normal.

Truth: Its a fact that women may bleed heavily but it may cause anemia and is not considered normal when it affects YOUR day-to-day activities. One should seek help when the bleeding bothers them rather than to wait for menopause

The treatment of Menopause is HRT
Truth: The treatment of menopause depends on what is the most bothersome symptom. While 80% women find Hot flashes to be the major symptom, some might ask for help with regard to their mental health to something as trivial as Itching!!! It totally depends on YOUR symptoms and the treatment would be tailored to your need.

menopause brings about physical changes which are irreversible
Truth: Ageing is inevitable. What's possible is ageing in a healthy way. While many would not seek help with trivial matters , those who seek support will have time and energy to focus on associated symptoms and will enjoy a better health in the post menopausal period. There might be change in body habitus but it is not irreversible. With a proper consult and motivation, Its possible to be as healthy as in your pre-menopausal era.

Hormone treatment in menopause will give me cancer
Truth: Whenever hormones are started for menopausal symptoms, a thorough history, examination and follow-up plan is agreed. The possibility of breast cancer is higher but with a good follow up, the chances of detecting an early cancer and treating it completely is possible. While everyone needs to get a screening mammography at 49 years in Qatar, undergoing HRT will need a few more visits to the doctor while you enjoy a better life with the hormone replacement

I have a teenager at home and I am approaching my menopause with my mood swings...what should I do?

Educate yourself more about teenage and try to help your child get through the phase and for yourself : Seek help . Address the most bothersome symptom. Do regular exercise, Eat clean and even if you cheat, Make health your priority number ONE!

For all your healthcare needs you can reach out to me at Wellkins Medical Centre

Photos from Dr. Sagnika Dash's post 15/07/2023

An itch you can't ignore

Every woman, at least at some point of time has experienced itching in the groin. Sometimes it would go away just by using some local creams and at other time , it would linger on as the doctors "Wouldn't advise the magic cream" which works on them.

Lets try and understand a bit more about v***al conditions which brig about the complaints of Itching, burning, soreness, pain or change in skin color or texture.

Is it normal to have some itching?

Generalised discomfort can be explained in terms of the variations in menstrual cycle. E.g during ovulation , some people might find themselves feeling uncomfortable with the discharge. However, any itching which makes you constantly think or act towards relieving the itching will need an assessment.

How to find out the cause?

The following questions need to be answered
1. Age: In vey young age(pre-pubertal) due to lack of estrogen and lack of personal hygiene, an itching can mean an infection. During the reroductive phase, the commonest cause is candidiasis:a fugal infection or other conditions of v***a (to be discussed later). In post menopausal women, one needs to rule out pre-cancerous conditions of v***a as a causes of itching.
2. symptoms: associated with discharge or any skin changes on the body, triggered by some allergy,
3. Any other medical disorder: e.g Psoriasis, diabetes
4. Previous treatment history: with immunosuppressant or steroids for skin conditions of the v***a
5.History of allergy
6. Personal history of smoking.

What can I expect when I go the doctor?

The doctor assesses you by asking questions about the symptoms.
Duration
Aggravating/relieving factors
checking the moth , elbow or other areas of your body to check for rashes
an examination to see and if need be, to take a sample of the discharge or a bit of skin sample is taken for biopsy purpose.

Prescribing
creams (emollient/ antifungal/steroids)
suppository (anti fungal or anti bacterial)
anti-histaminics (anti itch tablets)
giving information about maintaining local hygiene

What can be the cause of itching?

Candidiasis (Thrush): An infection which is caused by a fungus which normally lives in the body. Certain conditions like diabetes, drugs used as immunosuppressants can increase the itching. A sudden weight gain or change in activity leading to increased moisture being trapped in groin can be a cause as well.

Lichen Sclerosus: A typical finding in post menopausal women but can affect any age. There is thinning of skin of v***a and this condition needs a JUDICIOUS use of steroids.

The reason why steroids are avoided in all itching is because it can make candidiasis worse by just masking symptoms and not treating the cause and in cases where it's required, the dosage and type of steroid may be abused which finally leads to skin thinning and more chances of scar tissue formation with long term side effects

Lichen Planus: This condition presents as pain and lesions can be seen on mouth and other parts of body

Vulval Intraepithelial Neoplasia: A pre-cancerous condition which doesn't respond to treatment can be encountered. The treatment involves removing the tissue locally and sometimes might need the inputs from a plastic surgeon if the lesion is large.

Vulval Dermatitis: A term describing an allergic reaction similar to eczema. treatment usually involves removing the irritant. It could be soaps, clothes, external allergens or food.

Vulval atrophy: Lack of estrogen hormone can affect extremes of age. Pre-puubertal girls and post menopausal women can have severe itching and may need to apply estrogen cream locally to treat the condition.

Psoriasis: A generalised or localised psoriasis can cause dryness and thickening of skin. Scalp and nails are involved and treatment would need inputs from a dermatologist.

What can I do before visiting a doctor ?

It is recommended to implement the general measures to prevent/ treat itching before visiting your doctor unless there is a need to do so.
Vulval skin is very sensitive so its important to avoid the irritants. The following is a guide but not an absolute measure to prevent itching of v***a.

Natural Fabric underwear: using cotton or natural fabric as compared to synthetic ones may help in reducing the irritation.

Emollients: skin soothening agents like coconut oil and non-perfumed products will help maintaining the skin integrity.

Washing: Too much or too little can result in imbalance of the skin bacteria. While douching isn't recommended, washing with warm water might help in removing irritants.

Special washing liquids are used for specific causes.

What kind of follow up do I need?

It depends on the cause of itching. Most of the women have a one off event while others may need more than one visit to pinpoint the cause and may need a regular follow up( VIN, Lichen sclerosus)

Finally , Should I itch or not?

The question is, can you stop itching? If it itches, you must and visit a doctor before you get any worse!!
When it does itch, why be shy?

For your healthcare needs, Contact me at Wellkins Medical center.

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