Dr. Nyein Moe ThawM.B.,B.S, M.Med.Sc (OG), Dr. Med.Sc (OG)

P redicting age at menopause and ovarian reserve is of great interest in women whoPPwish to delay childbearing and who wish to know their ovarian reserve. Age at menopause may also be of relevance because many health conditions are linked to age at menopause. Lower age at menopause is linked to an increased risk for cardiovascular disease and osteoporosis. Older age at menopause is linked to an increased risk for breast cancer, endometrial cancer, and possibly ovarian cancer. So, women may be able to target certain interventions for reducing risk earlier in life if they have this information about when they are likely to gothrough menopause. A valid prediction of the time to menopause is still a challenge for a practising physician. Ovarian aging is dictated by decreasing quantity and quality of the resting follicles and depletion in the oocyte stock, after which menopause occurs. Because it is not feasibleto directly assess the oocyte or follicle pool, endocrinologic and sonographic markers are used as an indirect measure. A woman’s fertility ends ten years prior to the fi nal menstrual period (FMP) and can even occur around the age of thirty. With regard to family planning and a career, it is extremely valuable for women to know the expected length of their fertility. This knowledge will enable women who are predicted to become infertile at an early age tochoose the option of having their eggs frozen. This means that they will still be able to have children if it turns out that they can no longer get pregnant spontaneously. Prediction of age at menopause can be enhanced by using markers of ovarian reserve; estradiol, follicular stimulating hormone (FSH), inhibin , and antimüllerian hormone (AMH). While one cannot use a single test to determine time to FMP, the menstrual cycle pattern and hormonal characteristics can be used to generate rough estimates for counseling patients. The reproductive stage is generally characterized by regular menstrual cycles, earlyfollicular phase FSH levels less than 10 mIU/mL, and AMH levels greater than 0.3 ng/mL. The early menopausal transition begins approximately 7 to 8 years prior to the FMP. FSHvalues are generally greater than 10 mIU/mL, and AMH levels are less than 0.4 ng/mL inthis group of women.1,2 The late menopausal transition begins approximately 3 to 4 yearsprior to the FMP. Occurrence of the late menopausal transition stage is confi rmed when early follicular phase estradiol levels are greater than 100 pg/mL or FSH values are greater

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NEWS L E T T ER

Holistic, Compassionate and Quality Healthcare

Issue 5 December, 2011

Editorial Board

Dr. Myint Lwin

Dr. Shwe Baw

Dr. Zay Ya Aye

Dr. Tin Moe Phyu

Dr. Khin Than Htay

Dr. Thidar Oo

Dr. Nyein Moe Thaw

Dr. Hnin Thuzar Aung

Advisory Group

Contact UsNo-60, G-1,

New Parami Road, Mayangone Tsp,

Yangon, Myanmar.Tel : 651674, 660083, 657228 to 657232

info@paramihospital.

Free DistributionThe contents of the

newsletter are not to be reproduced in any form

without prior written approval of the editorial board.

Prof. U Thein Aung

Prof. U Khin Maung Aye

Dr. Tin Nyunt

Prof. U Saw Win

Prof. Daw Mya Thidar

Prof. U Ne Win

Predicting Age at MenopausePredicting Age at Menopause

Issue - 5, December 2011 Parami Hospital - Yangon, NewsletterPage - 2

than 30 to 40 mIU/mL.1,3 AMH values are generally lessthan 0.1 ng/mL (or below assay sensitivity).4 While the term Menopause appears easy to defi ne as “12 months of amenorrhoea,” differentiating women in the late menopausaltransition from those in early postmenopause can be diffi cult within the fi rst 12 months following the FMP. Among these various markers, serum AMH has several unique characteristics that emphasize its robustness as a biologic marker of ovarian aging. AMH is secreted exclusively in ovarian follicles and is independent of themenstrual cycle; its level remains almost constant from onecycle to another.5 AMH seems to regulate the early follicular development,6 and its serum concentration decreases with advancing age before changes in other markers such as follicular-stimulating hormone and inhibin B become apparent.7,8

Referencesf1. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the

menopausal transition: a crosssectional study of a population-based sample.

J Clin Endocrinol Metab. 1995;80 (12):3537-3545.

2. Gracia CR, Sammel MD, Freeman EW, et al. Defi ning menopause status:

creation of a new defi nition to identify the early changes of the menopausal

transition. Menopause. 2005;12(2):128-135.

3. Santoro N, Brockwell S, Johnston J, et al. Helping midlife women predict

the onset of the fi nal menses: SWAN, the Study of Women’s Health Across

the Nation. Menopause. 2007;14(3 pt 1):415-424.

4. Sowers MR, Eyvazzadeh AD, McConnell D, et al. Anti-mullerian hormone

and inhibin B in the defi nition of ovarian aging and the menopause transition.

J Clin Endocrinol Metab. 2008;93(9):3478- 3483.

5. Hehenkamp WJ, Looman CW, Themmen AP, de Jong FH, Te Velde ER,

Broekmans FJ. Antimüllerian hormone levels in the spontaneous menstrual

cycle do not show substantial fluctuation. J Clin Endocrinol Metab

2006;91:4057–4063.

6. Durlinger AL, Visser JA, Themmen AP. Regulation of ovarian function: the

role of antimüllerian hormone. Reproduction 2002; 124:601–609.

7. Van Rooij IA, Broekmans FJ, Scheffer GJ, et al. Serum antimüllerian hormone

levels best refl ect the reproductive decline with age in normal women with

proven fertility: a longitudinal study. Fertil Steril 2005;83:979–987.l

8. de Vet A, Laven JS, de Jong FH, Themmen AP, Fauser BC. Antimüllerian

hormone serum levels: a putative marker for ovarian aging. Fertil Steril

2002;77:357–362.

Continued from Predicting Age At Menopause (Page - 1)

Dr. Tin Moe Phyu M.B.,B.S, MMedSc ( Paediatrics ), MRCPCH (UK),

Assistant Lecturer, Department of Paediatrics,

Yangon Children Hospital, University of Medicine ( 1 ) Yangon

A n eight years old boy, body weight 21 kg, came to Parami Hospital-Yangon OPD with the complaint of gradual increase in weakness of lower limbs since 3 years ago. He also had history of frequently falls during playing. He was previously well and there was no historyof hospitalization. Birth history (Including both antenatal and natal history) was uneventful. There was no similar problem among family members . His developmental milestones are normal. Hestarted to walk at about 1 year and 3 months. He is currentlyattending 4th standard and he is doing well in school lessonsand examinations. Immunization history was said to be complete. On examination, currently he is well, alert and happy. He does not have any dysmorphic feature. However, his legs are big compared to his upper limbs. The followingpictures showed his funny big legs and his activities in trying to stand up from lying position.

(To Page - 3 _____>)

Pic ture QuizP ic ture Quiz

Page - 3

Respiratory system, cardiovas-

cular system and locomotor system

examina t ions a re normal . His

neurological examination is normal

apart from slight decrease in tone of

both lower limbs and diffi culty to stand

up from sitting and lying position.

All laboratory investigations

( CP, U&E, Calcium ) are within normal

range. However, serum creatine kinase

( CK ) is 15632 IU/L ( normal <160

IU/L ). Chest X-ray and ECG are

normal.

QuestionQ

1. What is the abnormality of his

legs?

2. What is the important physical

sign shown in the photograph ?

Answers To Page ( 4 )

A wise and understanding heart does not repay a hurt with a hurt.In doing so, the heart is diminished. Fissures form. Love leaks out. Every pain given in return for one received, changes the contents of the heart. It is no longer defi ned by love, wisdomand understanding. It is redefi ned by the bearers of hurt and hate, pain and prejudice, meanness and madness,sorrow and sadness. You give away control of your very own heart. The despair of being hurt is healed by overcoming it, not clinging to the hurt and infl icting more of it on the world. When darkness is added todarkness, no one can see, no one can love. Everyone loses. Love is not always warm and fuzzy. Sometimes it’s the integrity we hold on to when we’re tempted to strike back. Sometimes it’s the honour that keeps us from exchanging the valuablecontents of our heart for the harsh satisfaction of lashing back. No, the way of love is not always easy, but when night falls, dawn is assured. The integrity and honour of a wise and understanding heart, rises with the sun of a new day.

( Ref : Morning Reading Classics )

Issue - 5, December 2011 Parami Hospital - Yangon, Newsletter

Continued from Picture Quiz (Page -2) Control of Your Control of Your

HeartHeart

Leisure Reading

Page - 4

Answer

1. Calves pseudohypertrophy2. Gower sign3. Duchenne muscular dystrophy ( D/Dx Becker muscular dystrophy).

Duchenne muscular dystrophy is the most common hereditary neuromuscular disease . Its characteristic clinical features are progressive weakness, intellectual impairment,hypertrophy of the calves, and proliferation of connective tissue in muscle. The incidence is 1 : 3,600 liveborn infant boys. This disease is inherited as an X-linked recessive trait. The abnormal gene is at the Xp21 locus. Becker muscular dystrophy is the same fundamental disease as Duchenne dystrophy, with a genetic defect at the same locus, but clinically it follows a milder and more protracted course. The serum CK level is consistently greatly elevated, even in presymptomatic stages, including at birth. Cardiomyopathy and respiratory muscle weakness are complications of disease progress. Echocardiography, electrocardiography (ECG), and radiography of the chest are essential and should be repeated periodically. Electromyography (EMG) shows characteristic myopathicfeatures. Blood polymerase chain reaction (PCR) for the dystrophic gene mutation and muscle biopsy are diagnostic tests. There is no specific treatment. Multidisplinary team approach including physiology is an essential part of management. Oral prednisolone therapy may have improvement in short term and long term prognosis. Because of progressive muscle weakness, some patients become wheelchair users around 7 years of age. Death occurs usually at about 18–20 years of age. The causes of death are respiratory failure in sleep, intractable heart failure, pneumonia, or occasionally aspiration and airway obstruction.

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Issue - 5, December 2011 Parami Hospital - Yangon, Newsletter

.... to our Beloved Customers …..... to our Beloved Customers …. Picture Quiz Answers