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This results in a build up of saliva in your Treatment options: Atropine or Botulinum toxin mouth impotence solutions buy cheap malegra dxt on-line. Change in Taste & Smell Loss of smell sensation is part of the process of Parkin sons the degeneration afects areas that are responsible for detecting odours smoking erectile dysfunction statistics generic malegra dxt 130mg with amex. It can result in some loss of appetite it is important to buy erectile dysfunction pills online uk purchase malegra dxt with mastercard continue eating a full balanced diet erectile dysfunction what age does it start purchase malegra dxt 130mg fast delivery. Because you may not be able to smell some dangerous odors, ensure that smoke detectors are installed and are in good working order. Some cannot smell changes in taste and smell strong odours that others around them can. If you choke while eating and talking, you may need to ensure your mouth is clear before talking. If you are having consistent choking, it is very im portant to talk to your doctor. Your doctor may recommend increasing your current dose or may ofer a new Parkinson treat ment. Swallowing therapists (speech therapists or occupational therapists) can also help. Proper posture while eating will Occasionally, patients notice more difculty in swallow also be taught. Therefore, it is not hard to imagine Treatment options: Increasing regular why swallowing troubles happen. Nausea & Vomiting If nausea and vomiting appear with a new drug, these symptoms often go away by themselves, even if you stay on the medication. Taking your medications with meals (or with a small snack) may help with these symptoms. However, this can slightly reduce the absorption of certain medications, such as levodopa. If nausea is very bothersome, it can cause you to stop eat ing if so, you must speak with your doctor. You should also be aware that certain medications often used for nausea in people without Parkinsons (ex. If Parkinsons treatment causes nausea, your doctor may prescribe domperidone (Motilium). Nausea is a sense of unease in the stomach, with a feel ing of possible vomiting. All Parkinsons medications can cause nausea this symptom may not persist and vomiting, but some tend to cause this more than others. A when related to a new drug feeling of stomach bloating can also be present in Parkinsons, usually related to slow stomach movements. Foods rich in fbre include: bran fbre whole wheat products lentils and beans prunes or prune juice dried apricots Moderate exercise can help. You can also purchase bulking agents (Metamucil) or stool softeners over the counter. Although constipation is usually not harmful, very severe consti pation can cause obstruction of the bowels, with medical complications if you have gone a week without a bowel movement, take the laxa tives above and talk to your doctor. Constipation is defned as having less than three bowel What are other possible treatments Generally, constipation is If the above treatments dont help, your doctor may recom an easy symptom to recognize. Constipation is related to degeneration of the nerves in the bowel that control bowel movements. That is, it is part of the disease Treatment options: Drink water, itself, not caused by Parkinson treatment. Constipation can be the frst eat fbre, exercise and use bulking symptom of Parkinsons. You may have noticed it years before you had agents, stool softeners, or laxatives motor problems. Uncontrolled Loss of Stool If the incontinence is caused by inability to move fast to the bathroom on time, try to develop a plan to get you there on time. It may be useful to schedule a bathroom trip before times that you often have accidents. It refers more to an inability to control bowel movements, with incontinence, or accidents. Bladder Dysfunction If you are having trouble with hyperactive bladder, try to What is this The most common problem is an overly active (hyperac What are other possible treatments A hyperactive bladder can cause you to: rush to the bathroom (or you would be unable to hold it in) There are several options that decrease the urgency and urinate frequently (less than every two hours) frequency to urinate. Sometimes the medications for the motor get up multiple times at night to go to the bathroom symptoms of Parkinsons can help the bladder problem. Symptoms include: scribed you an anti-cholinergic medication, there is a chance that these medications can make these symptoms worse. If so, difculty starting urination stop these immediately and speak with your doctor. A Urinating more frequently can also appear with prostate rare but dangerous side efect of this drug is low salt levels in the problems. If you start taking this drug, you will need routine blood prostate problems also notice that the urine stream is slow or tests. Often it is related to muscle rigidity, which is a primary motor sign of Parkinsons. Sometimes people will fnd that stretching the muscles, massage, or warm baths will help. If the problem is still there after speaking with your doctor, try over-the-counter pain medications, such as acetaminophen (Tylenol). Many people have pain during of periods (times when the medication is not working well). If this is your case, discuss Of course, people with Parkinsons can have other con with your doctor ways to decrease of times. If pain continues to ditions that cause pain, such as arthritis, lower back pain, etc. If nausea/vomiting are stopping you from eating, there may be treatments (see nausea section). Also, try taking meals during on times (times when the medication is working well). You will fnd it easier to use utensils and you may also have less difculties swallowing. If you are losing weight consistently, consider using milkshakes or calorie supplements. Also, eat during on eating and weight gain after starting medications such as pramipexole times. There is some preliminary evidence that keeping yourself cognitively active might help prevent dementia. Exercise, good diet, good blood pressure control and prompt treatment of diabe tes or elevated cholesterol may also help prevent dementia. Common side efects include: nausea, Mild cognitive impairment means a problem with memory vomiting, diarrhea and upset stomach. Dementia means a severe loss of memory/concentration Medications used to treat other features of Parkinsons enough to interfere with usual daily activities. Forgetting some in or problems with sleep and anxiety occasionally worsen cogni formation sometimes is normal as we age. When prob Therefore, make sure your doctor knows all the medications you lems in memory and decision making impair your daily routine, are taking. Often, Dementia or cognitive impairment may occur with people are unable to follow a complicated conversation.

Tetanus erectile dysfunction pills buy buy 130mg malegra dxt overnight delivery, or lockjaw erectile dysfunction medicine pakistan cheap malegra dxt 130 mg on line, is caused by Clostridium Soremouth is transmitted by direct contact with tetani erectile dysfunction drug coupons best malegra dxt 130mg, when the bacteria gains entry to erectile dysfunction help discount malegra dxt 130mg overnight delivery the body affected animals or contact with equipment, fences, through a contaminated break in the skin. They would then only need one annual booster in subsequent years about 30 days before lambing/kidding. The vaccination 30 days before parturition will confer passive immunity to the offspring via the colostrum. Lambs and kids should then be vaccinated at six to eight weeks, and given a booster shot two to four weeks later. It can cause painful and contagious excessively high parasite levels are often detrimental lesions on the skin, very often on the hands or fngers. The most common Care should be taken when handling animals with internal parasite is the roundworm that lives in the soremouth, handling animals that have been recently abomasum and small intestine of sheep and goats. There are several types of roundworms that infect the vaccine is a live virus that, when applied, sheep and goats, including Telodorsagia (Ostertagia) actually causes the disease locally. The live vaccine for circumcincta, Haemonchus contortus, soremouth will cause soremouth lesions at a specifc and Trichostrongylus colubriformis. Clinical if it is already present in the herd, as it will introduce signs include anemia (pale mucous membranes), the virus if it is not already there. Lambs and kids become resistant to tapeworms 573-W on Managing Internal Parasitism in Sheep and quickly, so infections are most common in animals Goats. Animals between one and six months to parasitism are young animals, lactating ewes and of age in feedlots or intensive grazing systems does, and those in late gestation or around the time of are at highest risk for coccidiosis. The animals least susceptible to parasites coccidiosis can be controlled by implementing good are mature, dry ewes. There are challenges associated with using which are not susceptible to insecticides. Keds also cause wool discoloration, which producers observe the color of the conjunctiva of the further reduces the value of the feece. Ked bites lower eyelid to determine the level of anemia that an affect the hide quality as well. Parasites common to sheep or goats skin, causing the sheep and goats to itch, which results include lice, keds, and mites. Pour-on treatments are injectable Ivermectin or topical insecticides can help a common form of management for many external affected animals. Respiratory Problems Respiratory infections, or pneumonia, are a common and serious disease in sheep and goats. Clinical signs of pneumonia include fever with a temperature over 104F, along with a moist, painful cough and dyspnea (diffculty breathing). Anorexia and depression may also be observed in an animal suffering from pneumonia. Because there are different types of pneumonia, it is important to work with a veterinarian to identify the this picture shows a goat with bottle jaw, a symptom of parasitic infection. Making sure advanced cases, the hoof horn becomes under run buildings have adequate ventilation and reducing dust and actually can separate from the hoof wall. Footrot commonly appears on a farm when an Foot Scald / Footrot infected sheep or goat is brought into the herd. Footrot is a bacterial infection prevalent in warm, nodosus bacteria can not live in the environment for moist areas. Footrot is caused mainly by the more than about 14 days, so almost always, the source synergistic action of the bacteria Fusobacterium of the bacteria in an unaffected herd/fock is a carrier necrophorum and Dichelobacter nodosus. Virulent footrot While not as likely as with carrier animals, footrot is much more of a problem, as the bacteria enter the can also be spread on boots, tires, feeders, or handlers hoof and digest the hard, horny tissue of the sole that hands, so care must be taken if footrot is present in protects the feshy tissue of the hoof. To prevent footrot, it is absolutely imperative to avoid the introduction of the disease to a footrot-free herd/fock. Foot soaking baths using zinc sulfate can be constructed to treat footrot in conjunction with systemic treatment. Vaccines are effective 60 to 80 percent of the time, and can be used with other management practices to reduce the prevalence of footrot. A combined treatment plan of foot trimming, foot baths, vaccination, and antibiotic treatment (for the most severe cases), can be effective in controlling the physical clinical signs of footrot. Affected animals are does not treat for existing infections; animals must often culled early and may die. Listeriosis is a bacterial infection caused by the Abscesses, though not painful, grow slowly over time, bacteria Listeria monocytogenes. Listeriosis is also a concern when animals are consuming ensiled forages such as haylage or corn silage. Try to not feed the moldy portion of silage to animals and limit soil contamination when putting up silage, as listeriosis is most prevalent in the soil and in molded areas of silage. Clinical signs of listeriosis include anorexia, depression, disorientation, facial paralysis, excessive salivation, and in severe cases, affected animals may fall on their sides and exhibit this sheep has caseous lymphadenitis. Bacteria have also been isolated carcasses and the bacteria enters a break in the skin. It is important for producers to cover stored feed and Abortive Diseases discourage stray cats from hanging around barns that Abortion refers to a female losing her offspring during house gestating ewes or does. The main infectious agents be consulted if this method is considered, as several that cause abortion in sheep and goats are Vibriosis can be effective. It is generally transmitted when Border disease virus, Cache Valley virus, Listeria, animals come into contact with standing water, such and Salmonella have been known to cause abortion as a lake or pond, with the bacteria. If the abortions are due to an infection by abortion, especially in goats, but also in sheep. It is Campylobacter bacteria, infected animals are often caused by the bacteria Coxiella burnetii, which are responsive to either tetracycline or sulfa drugs to shed in milk, urine, feces, placental tissue and amniotic prevent further abortions. Clinical Chlamydia infections cause abortions during the signs in ruminants include anorexia, abortion, and last 2 to 3 weeks of gestation, resulting in stillbirths lesions. Ewes and does infected by from an infected placenta, which will be covered with this bacterium rarely abort more than once, but can a gray-brown secretion. Outbreaks can be managed by continue to shed the bacteria from their reproductive administration of oral tetracycline, separating pregnant tract, infecting other herd members. It is likely the animals inside from the rest of the herd, and burning infectious agent is Chlamydia bacteria if the abortions or burying reproductive waste. Feeding high doses in animals with normal temperatures, or lesions are of tetracycline prior to lambing or kidding has been found during necropsy. There is, however, no vaccine for toxoplasmosis available in the United Mastitis States. Losses conditions, systemic infection, or trauma inficted by are most often sustained in animals on a high plane of offspring. In the acute form, lambs are found at a sample of milk from an affected gland on a strip dead or comatose, experiencing involuntary muscle cup against a black background. Body temperature is not mammary glands are warm, swollen, and painful, and affected. If mastitis is a Pregnancy toxemia (ketosis) affects ewes or does chronic problem in an operation, then the causative during late gestation. During early gestation, the dams White Muscle Disease increased appetite is enough to encourage her to White muscle disease is a degenerative muscle disease compensate for the increased nutrient needs. It is caused by a defciency gestation however, the growing feti are taking up of selenium and/or vitamin E. Selenium defciency more space in the dams abdomen, and she is often is associated with areas where the soil is defcient in physically incapable of eating enough to meet her selenium, while a vitamin E defciency refects poor needs unless more nutrient-dense feeds are provided. When the heart where excess ketones are present in the bloodstream, muscle becomes affected, the animal may present with known as ketosis, results in depression and anorexia diffculty breathing; fever; and frothy, blood-stained until the ewe or doe becomes too weak to stand. They can also be ultrasounded during White muscle disease can be treated with an pregnancy to determine fetal number, and animals injection of both vitamin E and selenium since the gestating multiples can be fed and managed differently condition may be caused by a defciency in one or than those with singles. Affected animals will usually respond to a should then be divided into two pens and managed single treatment within 24 hours, and a second dose differently during gestation to minimize their risk of of vitamin E (though not selenium) may be given if toxemia. Ingested copper is Ruminal lactic acidosis, often referred to as grain bound very tightly in the liver. Be or goats with the condition demonstrate symptoms of wary of beef and dairy products as they may contain discomfort, anorexia, teeth grinding, muscle twitching, high levels of copper. Forages should be used neutralize acid present in the rumen and keep appetite as much as possible when feeding sheep and goats, and feed intake high.

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Navigational Note: Epistaxis Mild symptoms; intervention Moderate symptoms; medical Transfusion; invasive Life-threatening Death not indicated intervention indicated health erectile dysfunction causes cheap malegra dxt online visa. Navigational Note: Hoarseness Mild or intermittent voice Moderate or persistent voice Severe voice changes change; fully understandable; changes; may require including predominantly self-resolves occasional repetition but whispered speech understandable on telephone; medical evaluation indicated Definition:A disorder characterized by harsh and raspy voice arising from or spreading to erectile dysfunction natural treatment options cheap malegra dxt 130mg with visa the larynx erectile dysfunction newsletter purchase malegra dxt australia. Navigational Note: Laryngeal fistula Asymptomatic Symptomatic erectile dysfunction causes mental quality 130mg malegra dxt, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the larynx and another organ or anatomic site. Navigational Note: Laryngeal hemorrhage Mild cough or trace Moderate symptoms; Transfusion indicated; Life-threatening Death hemoptysis; laryngoscopic intervention indicated invasive intervention consequences; urgent findings indicated; hospitalization intervention indicated. Navigational Note: Mediastinal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated; radiologic intervention indicated invasive intervention consequences; urgent evidence only indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the mediastinum. Navigational Note: Oropharyngeal pain Mild pain Moderate pain; altered oral Severe pain; severely altered intake; non-narcotics eating/swallowing; narcotics initiated; topical analgesics initiated; requires parenteral initiated nutrition Definition:A disorder characterized by a sensation of marked discomfort in the oropharynx. Navigational Note: Pharyngeal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the pharynx and another organ or anatomic site. Navigational Note: Pulmonary fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the lung and another organ or anatomic site. Navigational Note: Rhinorrhea Present Definition:A disorder characterized by excessive mucous secretions draining from the nose. Navigational Note: Sneezing Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition:A disorder characterized by the involuntary expulsion of air from the nose. Navigational Note: Tracheal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the trachea and another organ or anatomic site. Navigational Note: Hair texture abnormal Present Definition:A disorder characterized by a change in the way the hair feels. Navigational Note: Hirsutism In women, increase in length, In women, increase in length, thickness or density of hair in thickness or density of hair in a male distribution that the a male distribution that patient is able to camouflage requires daily shaving or by periodic shaving, bleaching, consistent destructive means or removal of hair of hair removal to camouflage; associated with psychosocial impact Definition:A disorder characterized by the presence of excess hair growth in women in anatomic sites where growth is considered to be a secondary male characteristic and under androgen control (beard, moustache, chest, abdomen). Older lesions are usually a darker purple color and eventually become a brownish-yellow color. Navigational Note: Skin ulceration Combined area of ulcers <1 Combined area of ulcers 1 2 Combined area of ulcers >2 Any size ulcer with extensive Death cm; nonblanchable erythema cm; partial thickness skin loss cm; full-thickness skin loss destruction, tissue necrosis, or of intact skin with associated involving skin or involving damage to or damage to muscle, bone, or warmth or edema subcutaneous fat necrosis of subcutaneous supporting structures with or tissue that may extend down without full thickness skin loss to fascia Definition:A disorder characterized by a circumscribed, erosive lesion on the skin. The syndrome is thought to be a hypersensitivity complex affecting the skin and the mucous membranes. Navigational Note: Hematoma Mild symptoms; intervention Minimally invasive evacuation Transfusion; invasive Life-threatening Death not indicated or aspiration indicated intervention indicated consequences; urgent intervention indicated Definition:A disorder characterized by a localized collection of blood, usually clotted, in an organ, space, or tissue, due to a break in the wall of a blood vessel. Navigational Note: Lymph leakage Symptomatic; medical Severe symptoms; invasive Life-threatening Death intervention indicated intervention indicated consequences; urgent intervention indicated Definition:A disorder characterized by the loss of lymph fluid into the surrounding tissue or body cavity. Navigational Note: Superficial thrombophlebitis Present Definition:A disorder characterized by a blood clot and inflammation involving a superficial vein of the extremities. Date of Revision: 2920 Matheson Boulevard East May 27, 2015 Mississauga, Ontario L4W 5R6. During treatment, patients are advised to use non-hormonal methods of contraception (eg, barrier method) if contraception is required. Cigarette smoking increases the risk of serious adverse effects on the heart and blood vessels. Any irregularity or anomaly of the breast should be adequately investigated (eg, by mammography or ultrasound). In isolated cases, these tumors have led to life-threatening intra-abdominal hemorrhages. Cardiovascular From epidemiological studies, there is little evidence for an association between progestin-only preparations and an increased risk of myocardial infarction or cerebral thromboembolism. The risk of cardiovascular and cerebral events is rather related to increasing age, hypertension, and smoking. In women with hypertension the risk of stroke may be slightly increased by progestin-only preparations. Some studies indicate that there may be a slightly, but not statistically significant, increased risk of venous thromboembolism (deep venous thrombosis, pulmonary embolism) associated with the use of progestin-only preparations. If contraception is required, a non-hormonal method (eg, barrier method) should be used. Pregnancies that occur among users of progestin-only preparations for contraception are more likely to be ectopic than are pregnancies among users of combined oral contraceptives. Most of these follicles are asymptomatic, although some may be accompanied by pelvic pain. If bleeding is heavy and continues over time, this may lead to anemia (severe in some cases). This may result in reduced endometrial thickness and an atrophic endometrium during treatment. Abnormal vaginal bleeding (eg, prolonged and/or heavy) should be thoroughly investigated by pelvic ultrasound, endometrial biopsy or hysteroscopy. Chloasma may occasionally occur, especially in women with a history of chloasma gravidarum. The data from a limited number of cases of exposure during pregnancy demonstrate that dienogest does not show adverse effects on pregnancy or on the health of the fetus/newborn. Clinical Trial Adverse Drug Reactions Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Synonyms or related conditions are not listed, but should be taken into account as well. During the fourth reference period (day 271 to day 360), the following bleeding patterns were observed (n = 149): amenorrhea (28. Changes in menstrual bleeding patterns were only occasionally reported as adverse events by the patients. In general, bleeding patterns were well tolerated and the discontinuation rate due to changes in bleeding pattern was below 1%. Metabolism and nutrition disorders: Increased appetite Psychiatric disorders: Anxiety, depression, mood altered, mood swings. Nervous system disorders: Autonomic nervous system imbalance, disturbance in attention. Gastrointestinal disorders: Abdominal discomfort, constipation, diarrhea, flatulence, gastrointestinal inflammation, vomiting. Skin and subcutaneous tissue disorders: Dermatitis, dry skin, onychoclasis, photosensitivity reaction, pigmentation disorder, pruritus. Musculoskeletal and connective tissue disorders: Back pain, bone pain, heaviness in extremities, muscle spasms, pain in extremity. Reproductive system and breast disorders: Breast induration, breast mass, fibrocystic breast disease, genital discharge, hot flush, pelvic pain, vaginal candidiasis, vulvovaginal dryness. Drug-Drug Interactions Substances increasing the clearance of sex hormones (diminished efficacy by enzyme induction) Substances increasing the clearance of sex hormones include phenytoin, barbituates, primidone, carbamazepine, rifampicin, and possibly also oxcarbazepine, topiramate, felbamate, griseofulvin and products containing St. After the cessation of drug therapy, enzyme induction may be sustained for about 4 weeks. Antifungal: T vdienogest Induction of hepatic microsomal enzymes may decrease griseofulvin plasma levels of dienogest. Sedatives and hypnotics: T vdienogest Induction of hepatic microsomal enzymes may decrease benzodiazepines plasma levels of dienogest. Drug-Laboratory Interactions the use of progestins may influence the results of certain laboratory tests (eg, gonadotropin, endogenous hormones). The results of certain endocrine and liver function tests may be affected by progestin-containing products: Impaired glucose tolerance; Reduced serum folate concentration; Change in plasma lipoprotein levels. The results of the above laboratory tests should not be considered reliable unless therapy has been discontinued for 2 to 4 weeks. Special Populations Renal Impairment There are no data suggesting the need for a dosage adjustment in patients with renal impairment. Missed Dose In the event of a missed tablet, a patient should take 1 tablet only as soon as possible and then continue to take the next tablet at her usual time the next day. A tablet not absorbed due to vomiting or diarrhea should likewise be replaced by 1 tablet. For management of a suspected overdose please contact your regional Poison Control Centre. Despite its low affinity to the progesterone receptor, dienogest has a strong progestogenic effect in vivo.

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However erectile dysfunction treatment in bangladesh purchase genuine malegra dxt on-line, 365 many women will discontinue use of a method regardless of service quality improvements erectile dysfunction with age statistics purchase malegra dxt 130 mg with amex. The need then is strong for a method that both has high user satisfactionand erectile dysfunction 40s order malegra dxt with visa, in particular impotence from diabetes buy malegra dxt american express, does not have side effects or prompt health concernsand is effective, two key indicators of continuation. Women should not have to settle for coping with a methods side effects for years while they attempt to avoid pregnancy. Reassurance from health the need then is strong for a method that care providers does not eliminate the both has high user satisfactionand, in side effects. For women who want to achieve pregnancy, it does not 366 require waiting for months for fertility to return after discontinuation, unlike other methods. Women can switch from attempting to avoid pregnancy to attempting to achieve pregnancy in the next cycle. To make an informed choice, women must be informed during family planning counseling about how long the return to fertility for each method is given that the timing of 367 pregnancy is important for professional, economic, and social reasons. Further, a woman who stops contraceptive use because she does not like it is not prepared if she wants to avoid pregnancy. Providers have been reluctant to remove implants for minor side effects because of the 373 costliness of the procedure or because they perceive the patients reasons for desiring Recommendations. College of Obstetricians and Gynecologists, Committee Opinion, Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices, No. See also Alexandra, Guest post: the freedom not to use birth control, Feministing, feministing. See Janine Barden-OFallon & Ilene Speizer, What Differentiates Method Stoppers from Switchers See Planned Parenthood, Birth Control Implant (Implanon and Nexplanon). One doctor urges providers, Keep your eye on the 375 prize, despite failed insertions and higher rates of expulsion/removal. The need for hormonal health education Empowering a woman to take care of her hormonal health is multifaceted. It entails educating her to observe events throughout her cycle and to note any irregularities that require health care consultation. Without knowledge about the hormonal interplay of her cycle, a womans ability to make empowered, informed sexual Without knowledge about the and reproductive decisions is hindered, as it hormonal interplay of her cycle, a renders her own health and fertility womans ability to make empowered, confusing. Every woman should understand informed sexual and reproductive how her body works in order to equip her to decisions is hindered, as it renders her make the choice that is best for her. Hormonal health knowledge also includes fertility literacy, or awareness of the behaviors that affect her reproductive health over the course of her lifetime. Understanding of menstruation also is key, as it protects a woman from the stigma and shame that surround menstruation in many cultures. Knowledge of fertile period At the most basic level, every woman should understand how ovulation works, what the signs of ovulation are, and that ovulation is a sign of health. A womans accurate perception of when she ovulates is critical for recognizing whether she has any abnormalities that indicate a 379 potential underlying health problem warranting medical consultation, and for understanding 380 when she can and cannot become pregnant. Although identification of ovulation is a tool that helps both women trying to avoid pregnancy and women trying to achieve pregnancy, data indicate that most women cannot accurately identify when they ovulate and when they are fertile. Further, lack of knowledge about the relationship between fertility and age hinders a womans ability to make informed decisions about her plans for a family. In most countries, fewer than 20 percent of all respondents can identify the fertile period. Even in the two countries with the 384 385 highest correct identification of the fertile period, Jordan and Ukraine, nearly 40 percent of the female respondents could not identify the fertile period, although 77. Halfway between cycles is the approximate point at which most women with regular cycles ovulate. It is not the same for all women, and is not necessarily on the same day of every cycle for each woman. For estimates of the range of normal variability of the menstrual cycle, see Laurence A. Developed countries the inability to identify the fertile period is also prevalent in the United States and other developed countries. Data from the National Survey of Reproductive and Contraceptive Knowledge reveal that few young adults in the U. Only 34 percent of respondents42 percent of women and 27 percent of men 386 had this knowledge. Only 23 percent and 27 percent, respectively, of black and Hispanic young adults could identify a womans fertile period accurately, as compared to 38 percent of 387 whites. Womens knowledge of fertility 389 increased with age while mens did not improve. Prior sexual activity, prior participation in a sex education program, prior receipt of sexual health services at a doctors office or clinic, and 390 prior pregnancy each had no bearing on the accuracy of young adults fertility knowledge. Those men and women who had used traditional methods of birth controldefined in the study as withdrawal and natural family planninghad more accurate knowledge of a womans fertile period, but still at low numbers: 29 percent of the 53 percent of young adult men who had used withdrawal could identify a womans fertile period, as compared to 23 percent of the men who had not used withdrawal, and 58 percent of the 8 percent of young adult women who had used natural family planning methods could identify a womans fertile period, as compared 391 to 41 percent of the women who had not used natural family planning methods. Despite these numbers, 90% believe (and 66% strongly believe) they have all the knowledge they need 392 to avoid an unplanned pregnancy. Yet another study evaluated the accuracy of the ovulation predictions of women by testing their urine and found that only 28 percent of respondents correctly identified ovulation, and 48. The researchers estimated that only 14% of women in 396 a general population know when they ovulate. Interviews of Latina and black women in the United States using fertility awareness methods found that most women abstained from sexual intercourse when they perceived they were 398 fertile, but that only half accurately perceived when they were fertile. Many had not received 399 accurate information from health care providers or family members. Even women who are actively trying to become pregnant do not know when they ovulate. In a 1997 study in Auckland, New Zealand, only 26 percent of the 80 women struggling with infertility in the study had adequate fertility awareness, and 46 percent did not understand the symptoms of fertility or their meaning, despite the fact that all had been trying 401 to conceive for at least two years. However, 80 percent of women who had received natural 402 family planning instruction previously had adequate fertility awareness knowledge. Likewise, a 2012 study of 204 women who visited fertility clinics in Melbourne, Australia, over 83 percent of whom had attempted to get pregnant for at least one year, found that only 12. Dubois, Validating Signals of Ovulation: Do Women Who Think They Know, Really Know Health and fertility literacy Fertility literacy is important for Many lifestyle factors affect fertility, improving reproductive health, including cigarette smoking, caffeine pregnancy outcomes, and chronic consumption, exercise, body mass index 406 disease prevention. A number of significant impact on fertility and risk of modifiable factors have a significant pregnancy and delivery complications for negative impact on fertility, and thus it both mother and baby. Many lifestyle factors affect fertility, including cigarette smoking, caffeine 409 410 411 412 consumption, exercise, body mass index (being underweight or overweight), stress, 413 and rotating shift work. Age also has a significant impact on fertility and risk of pregnancy 414 and delivery complications for both mother and baby. Women, university-educated people, and people from very high Human Development Index countries fared better, and results suggest that education plays a greater role in fertility knowledge than 416 fertility and parenting experiences. The Australian study on women and men of reproductive age found that more than 40 percent did not know the fertility risks associated with smoking 417 and obesity in women. Age-related misconceptions about fertility are very common, even among highly educated individuals, and are becoming more prominent as postponing childbearing grows, especially in the West. A survey of American women aged 2535 years who had not yet had children revealed that most thought they would have a relatively easy time conceiving, and most overestimated the likelihood of getting pregnant over a month of unprotected intercourse and 420 underestimated how long it takes to get pregnant. Most of the women visited an Ob/Gyn regularly and preferred the Ob/Gyn as a source of information about fertility, but 52 percent had never discussed pregnancy plans with their Ob/Gyns and 78 percent had never discussed 421 age as an infertility risk factor; most discussed contraception during their visits. A study of 422 Canadian women found similar results about incorrect fertility knowledge. In a survey of American undergraduates, 32 percent of women and 36 percent of men overestimated the age 415 See Laura Bunting et al. A Finnish study of university students likewise found that more than half of the men and one-third of the women thought that a womans fertility declines markedly after the age of 45, and more than half of men and 43 percent of women 424 overestimated a womans chance of becoming pregnant between the ages of 34 and 40. Even female health care professionals believe they 429 can safely postpone childbearing due to overestimation of fertility at advanced ages. Knowledge of and feelings toward menstruation A womans awareness about her cycle should not just be limited to ovulation. Menstruation is 430 another important event that indicates the healthy functioning of the body.