A role of Croatian family doctors in the provision of women's health care: a study based on routinely collected data

The aim of this study was to investigate how often Croatian FDs are involved in the provision of women's health, having in mind that women's health is primarily organized by the gynecological service. Only the data related to women's health were collected from the Croatian health statistical yearbooks from 1995 to 2012, in which ICD X was used. Results showed that total number of diagnoses are increasing. The greatest increase is observed in the category named as other diseases of female organs, then diagnoses related to the pregnancy, delivery and postpartum and malignant diseases, especially, breast cancer. Contrary, number of menopausal disorders continuing decreased. Diagnoses related to family planning (Z30) are relative small in amount and stabile. Results indicated that policy makers should take in account readiness of FDs to be involved in the provision of women's health.

[Gynecological care to children and adolescents. Twelve-year experience at National Pediatrics Institute, Mexico]

BACKGROUND

In major regions of the world, the importance of gynecological care to children and adolescents has been recognized. There are multiple publications, journals and associations dedicated to this purpose. In Mexico, it has not been the case.

OBJECTIVE

The aim of this publication is to raise awareness to the medical community about the importance of sub specialized gynecological care to children and adolescents.

MATERIAL AND METHODS

Retrospective study. The number of office evalu- ations issued by the Department of Gynecology of the National Institute of Pediatrics (INP) from January 1, 2002 to December 31, 2013 were counted. Results were grouped by age groups. Group 1: 1 year or less. Group 2: 2 to 9 years. Group 3: 10 to 18 years. The major causes of morbidity were analyzed by groups and in general.

RESULTS

In the 12 year period reported, 21,190 girls granted gynecological consultation: 15.2% were first consultations (n = 3,221), 74.76% subsequent consultations (n = 15,842) and 10.04% evaluations and interconsultations (n = 2,127). The yearly average was 1,766 consultations. From 2002 to 2005, two certififyed obstetrician-gynecologists (OB-GYN) worked in the Departament, with the subsecuent increase in the number of attentions; 2005 was the year with the highest productivity (2,265). From 2006, only one OB-GYN continued laboring, and the number of visits decreased gradually. 2013 was the year with fewer productivity (1,351). The main causes of morbidity were: abnormal uterine bleeding (26.48%), inflammatory conditions of vagina and vulva (13.58%), dysmenorrhea (12.31%); which occupied 52.37% of the total (10,404 / 19,867). 81% of the patients corresponded to group 3 (17,079/21,190). To a younger patient, corresponded a smaller number of visits.

CONCLUSION

It is required to institute the subspecialty of Child and Adolescent Gynecology in Mexico and to establish Services formed by subspecialists in this matter in the top pediatric hospitals of the country.

Human genital myiasisin extremes of age

Genital myiasis is a very rare entity associated with poor personal hygiene, restricted mobility, and immunosuppressed status and ulcerating lesions. With the reported incidence of only 0.7%, only a few cases have been published so far in literature but none from Nepal. Despite such rare occurrence, we present here two such cases which we encountered in an interval of three days; one in an unmarried teenager and another in a postmenopausal lady with fungating ulcerative growth of vulval carcinoma. Both were successfully managed.

Balneotherapy and coenzyme Q10 in clinical and experimental medicine

Balneotherapy or Spa therapy is used in neurological, cardiovascular, musculoskeletal, dermatological and gynecological diseases, in infertility as well as in metabolic disturbances. Beneficial effects of balneotherapy at the metabolic level is not fully understood. Authors have documented enhancement of antioxidants concentrations (coenzyme Q10- CoQ(10-OX) and alpha-tocopherol) of women with gynecological diseases by treatment with natural mineral water (Spa Lucky balneotherapy, Slovakia). In an experiment with rats, drinking of Spa Lucky mineral water decreased oxidative stress and enhanced concentrations of antioxidants CoQ(9-OX), CoQ(10-OX) in the myocardium, and alpha-tocopherol in uterus, ovaries and myocardium. Drinking of Spa Lucky water by rats stimulated myocardial mitochondrial respiration and energy production, and diminished skeletal muscle mitochondrial function. Simultaneous ingestion of coenzyme Q10 with drinking spa water returned mitochondrial parameters to the values of the control group. This pilot study helps explain the role of antioxidants, oxidative stress and mitochondrial energy production in beneficial effects of Spa Lucky balneotherapy.

Update on the treatment of genital warts

This review summarizes new treatments from the last seven years employed for the treatment of genital warts caused by human papillomavirus (HPV). Imquimod 3.75% is a new agent with fewer side effects and perhaps a better dosing schedule than imquimod 5%, but is not more effective. Sinecatechins/Polyphenon E 15%, a novel extract from green tea can be effective against genital warts but requires three times a day dosing and is not more effective than existing treatments; the treatment course is 12-16 weeks. Photodynamic therapy combined with other destructive modalities might increase the cure rate for genital warts. The quadrivalent vaccine against HPV 6, 11, 16, 18 is decreasing the incidence of warts in the western world but the evidence does not support vaccination as a treatment for those already infected by HPV. Hyperthermia and immunomodulators might be positive additions to the armamentarium of clinicians. In sum, there are new tools that physicians can use but none is really a great advance over what was available a decade ago.

Laparoscopic treatment of endometriosis

Endometriosis can be considered as a chronic disease which is characterized by the presence of ectopic endometrium outside the endometrial cavity and which is associated with symptoms as pelvic pain and infertility. Medical treatment is often not sufficient in patients with moderate to severe endometriosis and deep infiltrative endometriosis (DIE), therefore requiring surgical intervention. Over the past 15 years, we have built a multidisciplinary surgical team to perform a radical but fertility preserving resection of extensive endometriosis with involvement of surrounding organ systems, realizing a good clinical outcome with low complication and recurrence rate, a very good improvement of QOL and a high pregnancy rate. However, for future research evaluating surgical treatment of extensive endometriosis, it is important to reach agreement on study design and on reporting clinical outcome data. A multicenter study with clear patient identification and well defined outcome parameters needs to be set up. Moreover, prevention of DIE with colorectal extension is important, ideally by early identification and management of girls and women at risk. Years of pain and disability as well as a lot of money could be saved when patients, at risk of developing extensive forms of endometriosis could be diagnosed during adolescence.

Update on adolescent gynecology

Adolescent gynecology is an important part of clinical care of adolescent females. This discussion provides a basic review of current issues in adolescent gynecology, including consideration of current pubertal concepts with attention also given to delayed and precocious puberty. Causes of breast masses are reviewed, including discussion of the ANDI classification. It is recommended that physicians provide sexuality education to their adolescent patients, in addition to the community, to reduce the high rates of unintended adolescent pregnancy and STIs in teens that continue in the United States. Finally, attention is provided to ovarian masses and their management. Adolescent medicine physicians may have to work with a variety of specialists in their care of adolescents and the many gynecologic conditions that may arise.

Predictive factors and treatment of recurrence of endometriosis

Endometriosis remains an enigmatic disease process. The key is early recognition of symptoms and treatment. Treatment may begin with hormonal suppression. If medical suppression fails or if fertility is desired, surgical intervention should be used. During primary surgical intervention, the goal is for optimal treatment to decrease disease burden. However, despite adequate treatment, reoperation is needed in a good proportion of woman. Factors contributing to recurrence are multifactorial and some can be predicted and some pain recurrence occurs despite obvious evidence. Recurrent surgery should also aim to decrease disease burden and conservative versus definitive treatment is based on patient's childbearing status. In addition, use of medical treatment can temper recurrence rates. There is still tremendous work that must still be completed in the field of pain recurrence and disease recurrence with endometriosis.

[Obstetric-gynecologic care for female soldiers: status and prospects]

The article presents the analysis of primary gynecologic pathology in female soldiers for the last years. The basic disease groups are marked out. The information about the very medical help standard in different hospitals is given. This paper presents the perspective directions of development of the delivery of obstetrical and gynecological care for women due to level of military medical establishments of the Russian Federation Ministry of Defense.

Primary dysmenorreah-leading problem of adolescent gynecology (review)

Adolescent gynecology is a rapidly developing area. Dysmenorrhea is one of the most common complaints among women of young reproductive age. About 25-95% of young women suffers with dysmenorrhoea and is associated with significant psychological, physical, behavioral and social distress. This review summarizes epidemiology, strategies of establishing the diagnosis, discussion of pathophysiology of the disease and risk factors. We performed a comprehensive search through MEDLINE, EMBASE, Scopus, MD consult and Web of Science. Inclusion criteria specified review and research articles reporting primary dysmenorreah in adolescents. The search resulted in 214 articles. We point out a variety of noninvasive nutritional and psychological therapeutic interventions that have been suggested to relieve dysmenorrheal. This review of Primary Dysmenorreah identifies gaps in the literature, some contradictions and highlights the need for further study.

Inflammatory linear verrucous epidermal nevus with genital involvement

An 18-year-old woman was admitted to our clinic complaining of pruritic lesions on her inguinal and genital areas that had been present since birth. She had previously used topical steroids and a combination of topical steroids and calcipotriol for approximately 6 months; however, the treatment was unsuccessful. Her medical history was unremarkable. On dermatologic examination, mild erythematous, lichenified, and verrucous papules occurring in a linear pattern on the right inguinal area and on the region extending from the right labium majus to the perianal area were noted (Figure). Additionally, an erythematous area with central erosion surrounded by maceration was noted on the intergluteal area. Two separate punch biopsy samples were obtained from the erythematous, lichenified, verrucous, papular lesion on the inguinal area and from the erythematous, eroded, macerated lesion on the intergluteal area. Histopathological examination of both biopsy specimens revealed a thin orthokeratotic layer and scattered parakeratotic layers, as well as papillomatosis and acanthosis of the epidermis with a slight hyperpigmentation of the basal layer. A mild, perivascular, chronic inflammatory cell infiltration was noted in the dermis. Based on the clinical and histopathological findings, the patient was considered to have inflammatory linear verrucous epidermal nevus, and cryotherapy was initiated. At the 2-week follow-up after the first application, it was observed that the itching complaint decreased substantially and the eroded lesions in the intergluteal area were re-epithelialized. On clinical follow-up, no improvement was observed in the papular component of the lesion after 4 sessions of cryotherapy. The patient voluntarily discontinued the follow-up after 4 sessions of cryotherapy.

[Modern ways of treating female genital infections]

In article various ways of increase of efficiency of treatment of is mixed the bacterial-virus infection of the bottom department of sexual ways at women by means of application in complex therapy of homologous bacteriophages, pectovit, antiviral -immunomodulation therapies and sated with oxygen (oxygenic) water solutions of antiseptic tanks are considered. The scientifically-practical urgency of this problem is represented and actual for the decision of an important social and economic problem of improvement of quality of life, decrease in number of infectious complications and perfection of the medical help to sick women with frequent recidives an infection of the bottom department of sexual ways.

[Health assessment of newborns with congenital urinary malformation]

Improvement in diagnosis of prenatal congenital urinary malformations (CUM) resulted in increased detection of CUM cases among newborns. To facilitate medical care for CUM newborns, we have developed an objective method of CUM newborns' health assessment. We studied 40 case histories of newborns with prenatally detected CUM admitted to urological clinics (20 with diagnosis of poor health and 20 with moderate condition severity) and 40 CUM newborns examined outpatiently (moderate health hazard). The computer analysis of the available data has established 13 most informative diagnostic criteria: 4 sonographic criteria, 3 lab criteria and 6 physical exam criteria estimated by 4 points - from 0 to 4. The criteria were pooled to a table which was used as a scale to assess general health condition. After delivery, CUM newborn gets inpatient health assessment by a neonatologist using 13 criteria. According to the total score, the condition is assessed as satisfactory (0-5), moderately severe (6-11), severe ( > 12). Efficacy of such health assessment was proved in a population study of 312 prenatal CUM newborns. Grouping of such newborns helps design of programs of further examination and management.

Probiotics--an alternative treatment for various diseases

Modulating the microbiota of the gastrointestinal tract through probiotics is an alternative to the conventional treatment of various diseases, based on synthetic drugs. The lifestyle, nutrition and stress of the present modern society could be among the factors responsible for modifications in the intestinal microbiota, correlated with specific diseases. The present study describes the positive effects of probiotics use, with special reference to the yeasts use in several frequently encountered diseases, such as hypercholesterolemia, the irritable bowel syndrome, gastritis and several uro-genital disorders.

Challenges in the gynecologic care of premenopausal women with breast cancer

Premenopausal women with a new diagnosis of breast cancer are faced with many challenges. Providing health care for issues such as gynecologic comorbidities, reproductive health concerns, and vasomotor symptom control can be complicated because of the risks of hormone treatments and the adverse effects of adjuvant therapies. It is paramount that health care professionals understand and be knowledgeable about hormonal and nonhormonal treatments and their pharmacological parameters so they can offer appropriate care to women who have breast cancer, with the goal of improving quality of life. Articles for this review were identified by searching the PubMed database with no date limitations. The following search terms were used: abnormal uterine bleeding, physiologic sex steroids, endometrial ablation, hysteroscopic sterilization, fertility preservation in endometrial cancer, tranexamic acid and breast cancer, menorrhagia treatment and breast cancer, abnormal uterine bleeding and premenopausal breast cancer, levonorgestrel IUD and breast cancer, tamoxifen and gynecologic abnormalities, tamoxifen metabolism, hormones and breast cancer risk, contraception and breast cancer, pregnancy and breast cancer, and breast cancer and infertility treatment.

[New possibilities for elimination of human papillomavirus from the organism]

The variety of mechanisms of human papillomavirus (HPV) infection suggests that the success of treatment depends on the choice of a universal method, which combines the actions of etiotropic, pathogenetic and symptomatic approaches, without causing unwanted side effect. All these requirements are met by a drug based on the products of plant origin - Indinol. The observed patients with resistant forms of genital warts were divided into 3 groups: first group received the treatment according to the standard, conventional scheme; patients of the second group in addition to the standard scheme 2 times a day (for 90 days) received 2 capsules of Indinol (200 mg) and the patients of third group simultaneously with Indinol undergo infrared irradiation. The results of the observation have shown that the addition of Indinol to the standard treatment had a significant positive effect on the healing process of patients with resistant forms of genital warts. The effects of the Indinol in combination with infrared therapy revealed a statistically significant reduction (3 times) the frequency of relapses in cases of clinically sever forms of disease. Thus, during combined treatment of patients with recurrent, clinically severe forms of genital HPV, it is advisable to use the Indinol, which evidently has the well pronounced virus-eliminative and anti-recurrent actions.

Pediatric urologic conditions, including urinary infections

Genitourinary complaints are common in children, and the busy primary care provider must determine initial treatment and assess need for specialty referral. Many complaints are self-limited, but some represent disorders that can threaten organ function. In this article, an initial approach in the primary care office and a guide to specialty referral for pediatric urologic conditions of the urinary tract, male genitalia, and female genitalia are suggested.

[Comparative assessment of the methods of treatment of Condylomata acuminata]

The treatment of Condylomata acuminata often causes disappointment to both the physician and the patient since most of the current medical approaches require multiple examines while on the other hand success rates are low and recurrence rates remain high. The treatment approaches include surgical as well as non-surgical methods. The non-surgical treatment includes the application of local agents such as imiquimod, podophyllotoxin, and 5-fluorouracil. Other local agents, used in outpatient treatment settings, include trichloroacetic acid (TCA), podophyllin, or the intralesional application of agents such as interferon and bleomycin. The surgical methods include cryotherapy, electrosurgery, excision and laser therapy. Their major goal is the removal of the visible lesions. The development of the laser systems and the new HPV vaccines are a significant progress in the treatment and prevention of the HPV infections.

Genital psoriasis: A systematic literature review on this hidden skin disease

It is well known that the genital skin may be affected by psoriasis. However, little is known about the prevalence and clinical appearance of genital psoriasis, and genital skin is often neglected in the treatment of psoriatic patients. We performed an extensive systematic literature search for evidence-based data on genital psoriasis with respect to epidemiology, aetiology, clinical and histopathological presentation, diagnosis and treatment. Three bibliographical databases (PubMed, EMBASE and the Cochrane Library) were used as data sources. Fifty-nine articles on genital psoriasis were included. The results show that psoriasis frequently affects the genital skin, but that evidence-based data with respect to the efficacy and safety of treatments for genital psoriasis are extremely limited. An advised treatment paradigm for genital psoriasis, based on the levels of evidence, is: first-line: (weak) topical corticosteroids; second-line: vitamin D preparations or tar-based treatments.

Medical treatments for endometriosis

Despite the extensive research, endometriosis remains an enigmatic disease as up to now there is no consensus regarding the exact underlying mechanisms which could explain its development and progress. A local environment enriched in estrogens, progesterone resistance, local inflammatory response and multiple other molecular alterations appear to be pivotal events in the establishment and development of ectopic tissue. In the light of the evidence produced by molecular pathology research, in vivo and in vitro studies, modifications in current treatment options are anticipated. Current management of endometriosis is based on pharmacologic treatment and surgical intervention. In particular, combined oral contraceptives, danazol, gonadotropin-releasing hormone (GnRH) analogues and progestins have been extensively used in clinical practice. Novel agents that will hopefully improve the therapeutic potential include aromatase inhibitors, immunomodulators, anti-inflammatory agents, steroids receptor modulators and GnRH antagonists. It is still early for enthusiasm as there is limited knowledge about their short- and long-term side effects, their optimal administration route, their selectivity towards their target genes and the duration of treatment. Although there is a continual report of novel findings, the application of them in clinical practice is a long-lasting procedure requiring longitudinal clinical trials so as to achieve a balance between efficacy and safety.

Management of common psittacine reproductive disorders in clinical practice

The reproductive organs play a key role in the maintenance of normal homeostasis in psittacine birds. For this reason, sex determination should be part of the baseline data collected on every avian patient. Disorders of the psittacine reproductive tract can have a negative effect on the function of other organ systems in the body. Reproductive organs may be plagued by a multitude of problems ranging from infection and neoplasia to inflammation and idiopathic issues that affect fertility. Detection of reproductive problems may require the use of a variety of modalities. The ability to treat these problems often depends on the presenting complaint as well as the clinical condition of the avian patient. Different reproductive disorders of male and female psittacine birds, with their detection and treatment are discussed in this article.

Current therapy for condyloma acuminata of the patients attending female STD Unit, Siriraj Hospital

OBJECTIVE

To describe the treatment pattern of condyloma acuminata in female.

MATERIAL AND METHOD

The 5-year medical records of 449 women treated for genital condyloma acuminata at the Gynecologic Infectious Diseases and Female Sexually Transmitted Disease (GID-FSTD) unit were reviewed. Data included the distribution of age, client by category, anatomical site and size, serologically coexisting sexually transmitted infection (STI), and treatment modalities.

RESULTS

About half, 50.1%, of treatment was the application of topical trichloroacetic acid; followed by podophylline in the proportion of 35.5%. While the electric cauterization and imiquimod applications were uncommon therapy. Two-fifth ofthe subjects, 40.7%, was completely cured, and the remaining cases required additional management.

CONCLUSION

The present setting, the wide range of treatment available is reflection of the fact that there is no ideal management.

[Endometriosis]

Endometriosis is an estrogen-dependant disease that affects 10 to 15% of women of reproductive age. Its aetiology and molecular mechanisms involved have not yet been fully explored. Endometriosis is defined by the presence of endometrium-like tissue outside the uterus, primarily on the pelvic peritoneum and ovaries. The main clinical features are chronic pelvic pain, pain during intercourse, and infertility. Due to the limitations of clinical examination, additional explorations such as transvaginal sonography and magnetic resonance imaging are required to precise mapping of endometriotic lesions. Medical therapies based on progesterone and gonadotropin-releasing hormone agonists have a suspensive effect. In some cases, surgery is necessary and will be best achieved in specialized centers.

Symptomatology of gynecological malignancies: experiences in the gynecology out-patient clinic of a tertiary care hospital in kolkata, India

BACKGROUND

This cross-sectional observational study was undertaken in a gynecology out-patient clinic to identify the symptoms suggestive of gynecological malignancies followed by histopathological confirmation of their diagnoses and to determine the proportion of the histopathologically confirmed cases specific to sites.

METHODS

In a gynecology out-patient clinic in Kolkata, India, patients with symptoms suggestive of gynecological malignancies were screened to identify possible cancer cases. Diagnoses were confirmed by histopathology. One hundred thirteen patients with histopathologically confirmed gynecological malignancies were interviewed further.

RESULTS

This study shows that 5.3% of the overall outpatients or nearly one-fourth (23.7%) of the patients with the symptoms suggestive of gynecological malignancies was histopathologically confirmed as having gynecological malignancies. Most of the patients (87.0%) with the symptoms suggestive of gynecological malignancies reported excessive, offensive with or without blood stained vaginal discharge, followed by irregular, heavy or prolonged vaginal bleeding (61.4%). The commonest histopathologically confirmed gynecological malignancy was cervical cancer (61.9%), followed by ovarian cancer (23.9%).

CONCLUSIONS

This study highlights the need to increase the awareness about the symptoms of gynecological malignancies among women and the community. Health care personnel have a major role to identify the warning symptoms early for further investigation of the possible cases of gynecological malignancies.

[Diagnostic-therapeutic guidelines for men whose partners have HPV genital infection]

Human papilloma virus infection is the most frequent sexually transmitted disease. HPV infections are connected with different diseases such as benign warts, condylomata acuminata, malignant cervical, vulvar, vaginal, penile and anal carcinoma. Peniscopy with HPV detection is a specific diagnostic method for diagnosis of subclinical HPV genital infection in asymptomatic men. Taking the samples for HPV detection from asymptomatic men with curette is more qualitative way of getting enough samples then taking swab with wooden stick or (tongue) depressor. Early diagnosis and treatment of HPV infections in men is of potential benefit because their eradication can reduce the viral reservoir and as the result of that the incidence of CIN, carcinoma in situ and invasive cervical carcinoma can be reduced. For the correct diagnosis and for choosing the adequate therapeutical technique, we suggest diagnostic-therapeutic guidelines for HPV genital infection in men.

[Characteristics of hemodynamic and skin temperature during application of individually prescribed and corrected magnetotherapeutic regimes (experimental study)]

The objective of this study was to determine functional characteristics of the cardiovascular system and skin temperature believed to adequately reflect its response to the action of an alternating magnetic field (AMF). The estimated parameters included index of cardiovascular regulation and average temperature of the body surface. The time and the skin temperature were determined for each value of regulation index at which AMF action should be terminated. Algorithm for the choice of the AMF treatment regime and its correction depending on body surface temperature and its correlation with the index of cardiovascular regulation.

High intensity focused ultrasound in the treatment of abdominal and gynaecological diseases

In recent years high intensity focused ultrasound (HIFU) has received increasing interest as a non-invasive modality for the treatment of tumours of solid organs. Surgeons continue their quest to find the optimal technique whereby a diseased organ can be treated with a minimum of damage to the patient, while providing a comprehensive treatment to produce either cure or resolution of symptoms. Two of the areas in which HIFU is beginning to establish itself as a real therapeutic alternative, are in the treatment of abdominal and gynaecological disease. In this paper, we will review the literature available regarding the use of HIFU in the treatment of various organs: liver, kidney, pancreas, bladder, uterus and vulva.

Treating gynaecological disorders with traditional Chinese medicine: a review

Traditional Chinese Medicine (TCM) has significant advantages in treating gynaecological disorders. The paper has provided a brief introduction on the current progress of treating some gynaecological disorders including endometriosis, infertility, dysmenorrhea, abnormal uterine bleeding, premenstrual syndrome, menopausal syndrome, uterine fibroids, chronic pelvic inflammation, polycystic ovarian syndrome (PCOS), cervicitis and vaginitis with Chinese Herbal Medicine (CHM) and acupuncture. The use of TCM in the field of assisted reproductive techniques (ART) has also been included in the review. In addition, thirty-two commonly used Chinese medicinal formulas in treating gynaecological disorders have been introduced.

Emergency service in an ambulatory outpatient women's health centre

In order to optimise the service for patients who require an emergency service, and to meet patient needs, we conducted a study in Shillo ambulatory outpatient women's health centre, affiliated to Rabin Medical Center and Tel Aviv University. The study population consisted of 512 women, aged 25 - 55 years, attending the centre for emergency consultation and urgent obstetrics and gynaecological day care. Before the doctor's visit and at the end of the session, the women were asked to complete a 20-item questionnaire survey. The most common complaints were related to pregnancy complications (29%). Significant improvement in their problems was reported by almost 70% of these women; 20% thought that the information they received was inadequate or unsatisfactory. Less than 10% were referred to the hospital for further care such as surgery. Most of the women (96%) reported that they would continue to use these emergency services in the future if needed. There was a statistically significant difference between the doctors' opinion and the nurse regarding the urgency and severity of the patients' problems. The nurses graded them lower than did the doctors. There was also a statistically significant difference between patients' opinion and the nurses and the doctors regarding the urgency and severity of the patients' problems. The patients graded the problems as more urgent and more severe than the nurses or doctors. We concluded that an ambulatory emergency service is an essential part of an ideal ambulatory womens' health centre but it requires substantial progress to meet the patients' needs.