Pessary

Last updated
Gold-plated stem pessary (intrauterine device) from 1920 Gold-Plated Stem Pessary Intrauterine Device 2017.020.jpg
Gold-plated stem pessary (intrauterine device) from 1920

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. [1] It can also be used to administer medications locally in the vagina or as a method of contraception.

Contents

Pessaries come in different shapes and sizes, so it is important that individuals be fitted for them by health care professionals to avoid any complications. [1] However, there are a few instances and circumstances that allow pessaries to be purchased without a prescription or without seeking help from a health care professional. [2] Some side effects may occur if pessaries are not sized properly or regularly maintained, but with the appropriate care, pessaries are generally safe and well tolerated. [3]

History

An assortment of pessaries Pessaries.JPG
An assortment of pessaries

Early use of pessaries dates back to the ancient Egyptians, as they described using pessaries to treat pelvic organ prolapse. [3] The term 'pessary' itself, is derived from the Ancient Greek word 'pessós', meaning round stone used for games. [4] [5] Pessaries are even mentioned in the oldest surviving copy of the Greek medical text, Hippocratic Oath, as something that physicians should never administer for the purposes of an abortion: "Similarly I will not give to a woman a pessary to cause abortion." [6] The earliest documented pessaries were natural products. For example, Greek physicians Hippocrates and Soranus described inserting half of a pomegranate into the vagina to treat prolapse. [3] It was not until the 16th century that the first purpose-made pessaries were made. [5] For instance, in the late 1500s, Ambroise Paré was described as making oval pessaries from hammered brass and waxed cork. Nowadays, pessaries are generally made from silicone and are well tolerated and effective among patients who need them. [3]

Medical uses

Pelvic organ prolapse

The most common use for pessaries is to treat pelvic organ prolapse. A pelvic organ prolapse can occur when the muscles and tissues surrounding the bladder, uterus, vagina, small bowel, and rectum stop working properly to hold the organs in place and the organs begin to drop outside the body. The most common cause of such prolapse is childbirth, usually multiple births. Obesity, long-term respiratory problems, constipation, pelvic organ cancers, and hysterectomies can all be causes for pelvic organ prolapses as well. [7] Some signs and symptoms include feeling pressure in the pelvic area, lower back pain, painful intercourse, urinary incontinence, a feeling that something is out of place, constipation, or bleeding from the vagina. [7] Pessaries are manual devices that are inserted into the vagina to help support and reposition descended pelvic organs, which helps to prevent the worsening of prolapse, helps with symptom relief, and can delay or prevent the need for surgery. [3] [5] Further, pessaries can be used for surgery preparation as a way to maintain prolapse without progression. [3] This is especially useful when a surgery may need to be delayed. [3]

Stress urinary incontinence

Stress urinary incontinence is leakage of urine that is caused by sudden pressure on the bladder. It occurs during activities that increase the amount of pressure on the bladder such as coughing, sneezing, laughing, and exercising. [8] The pressure causes opening of the sphincter muscles which usually help prevent urine leakage. Stress urinary incontinence is a common medical problem especially in women as about 1 in 3 women are affected by this condition at some point in their lives. [8] Pessaries are considered a safe non-surgical treatment option for stress urinary incontinence as it can control the urine leakage by pushing the urethra closed. Pessaries can be removed any time. [8] [9]

Other

Some additional uses for pessaries are for an incarcerated uterus, prevention of preterm birth and an incompetent cervix. [3] [10] In early pregnancy the uterus can be displaced, which can lead to pain and rectal and urinary complications. [3] A pessary can be used to treat this condition and support the uterus. [3] Preterm birth is when babies are born prematurely, which puts the baby at increased risk for complications and even death. Currently, the use of pessaries to help prevent preterm birth is an ongoing area of research. [10] The use of pessaries for an incompetent cervix is not commonly practiced today, but they have been used in the past. [3] Specifically, an incompetent cervix is when the cervix begins to open up prematurely. [11] This can lead to a preterm birth or even a miscarriage. Pessaries can be used to correctly position the cervix, increasing the success of pregnancy. [3]

Managing your pessary

It is imperative that throughout the process you are following up with your provider when they recommend it. Initially, it may be somewhat frequent to determine that your pessary is serving your needs and that your body is tolerating the device, and then less frequent as you become accustomed to it. [12]

Types of pessaries

Different types of pessaries Pessary.png
Different types of pessaries

Therapeutic pessaries

A therapeutic pessary is a medical device similar to the outer ring of a diaphragm. Therapeutic pessaries are used to support the uterus, vagina, bladder, or rectum. [13] Pessaries are most commonly used for pelvic organ prolapse and considered a good treatment option for women who need or desire non-surgical management or future pregnancy. [13] It is used to treat prolapse of uterine, vaginal wall (vaginal vault), bladder (cystocele), rectum (rectocele), or small bowel (enterocele). It is also used to treat stress urinary incontinence. [14]

There are different types of pessaries but most of them are made out of silicone—a harmless and durable material. [15] Pessaries are mainly categorized into two types, supporting pessaries and space-occupying pessaries. [5] Support pessaries function by supporting the prolapse and space-occupying pessaries by filling the vaginal space. [3] There are also lever type pessaries. [16]

Support pessary

Ring with support pessaries are the supporting type. [5] These are often used as a first-line treatment and used for earlier stage prolapse since individuals can easily insert and remove them on their own without a doctor's help. These can be easily folded in half for insertion. [13] [15]

Gellhorn pessaries are considered a type of supporting and space-occupying pessary. [5] These resemble the shape of a mushroom and are used for more advanced pelvic organ prolapse. [5] [15] These are less preferred than ring with support pessary due to difficulty with self-removal and insertion. [15]

Marland pessaries are another type of supporting pessary. [13] These are used to treat pelvic organ prolapse as well as stress urinary incontinence. [13] These pessaries have a ring at their base and a wedge-shaped ridge on one side. [15] Although these pessaries are less likely to fall out than standard ring with support pessaries, individuals find it difficult to insert or remove them on their own. [15]

Space-occupying pessary

Donut pessaries are considered space-occupying pessaries. [5] These are used for more advanced pelvic organ prolapse including cystocele or rectocele as well as a second or third-degree uterine prolapse. [13] Due to its shape and size, it is one of the hardest ones to insert and remove. [15]

Cube pessaries are space-occupying pessaries in the shape of a cube that are available in 7 sizes. The pessary is inserted into the vagina and kept in place by the suction of its 6 surfaces to the vaginal wall. Cube pessaries must be removed before sexual intercourse and replaced daily. [5] Cube pessaries are generally used as a last resort only if the individuals cannot retain any other pessaries. [3] This is due to undesirable side effects such as vaginal discharge and erosion of the vaginal wall. [3] [5] In order to remove the cube pessary, the suction must be broken by grasping the device. [3]

Gehrung pessaries are space-occupying pessaries that are similar to the Gellhorn pessaries. [3] They are silicone devices that are placed into the vagina and used for second or third degree (more severe) uterine prolapse. These contain metal and should be removed prior to any MRI, ultrasound or X-rays. They can also be used to help with stress urinary incontinence such as urine leaks during exercising or coughing. These types of pessaries need to be fitted by a health care professional to ensure proper size. Once placed it should not move when standing, sitting, or squatting. It should be cleaned with mild soap and warm water every day or two. [17]

Lever pessary

Hodge pessaries are a type of lever pessary. Although these can be used for mild cystocele and stress urinary incontinence, they are not commonly used. Smith, and Risser pessaries are other types of lever pessaries and they differ in shape. [15] [16]

Pharmaceutical pessaries

Treating vaginal yeast infections is one of the most common uses of pharmaceutical pessaries. They are also known as vaginal suppositories, which are inserted into the vagina and are designed to dissolve at body temperature. They usually contain a single use antifungal agent such as clotrimazole. Oral antifungal agents are also available. [18]

Pessaries can also be used in a similar way to help induce labor for women who have overdue expected delivery dates or who experience premature rupture of membranes. Prostaglandins are usually the medication used in these kinds of pessaries in order to relax the cervix and promote contractions. [19]

According to Pliny the Elder, pessaries were used as birth control in ancient times. [20]

Occlusive pessaries

Occlusive pessaries are most commonly used for contraception. Also known as a contraceptive cap, they work similar to a diaphragm as a barrier form of contraception. They are inserted into the vagina and block sperm from entering the uterus through the cervix. The cap must be used in conjunction with a spermicide in order to be effective in preventing pregnancy. When used correctly the cap is thought to be 92–96% effective. These caps are reusable but come in different sizes. It is recommended for anyone attempting this form of contraception to be fitted for the correct size by a trained health care professional. [21]

Stem pessary

The stem pessary, a type of occlusive pessary, was an early form of the cervical cap. Shaped like a dome, it covered the cervix, and a central rod or "stem" entered the uterus through the external orifice of the uterus, also known as the cervical canal or the os, to hold it in place. [22]

Side effects and complications

Pessary covered in phosphate after being left in the vagina for an extended time Gould Pyle 227.jpg
Pessary covered in phosphate after being left in the vagina for an extended time

When pessaries are used correctly, they are tolerated well for pelvic organ prolapse or stress urinary incontinence. [23] However, pessaries are still a foreign device that is inserted into the vagina, so side effects can occur. [24] Some more common side effects include vaginal discharge and odor. [13] Vaginal discharge and odor may be associated with bacterial vaginosis, characterized by an overgrowth of naturally occurring bacteria in the vagina. [25] These symptoms can be treated with the appropriate medications.

More serious side effects include fistula formation between the vagina and rectum or the vagina and bladder, or erosion, or thinning, of the vaginal wall. [13] Fistula formation is rare, but erosion of the vaginal wall occurs more frequently. Low estrogen production can also increase the risk of vaginal wall thinning. [26] For individuals with pessaries that are not fitted for them, herniations of the cervix and uterus can occur through the opening of the pessary. This can lead to tissue necrosis in the cervix and uterus. [24] To prevent these side effects, individuals can be fitted properly for their pessaries and undergo routine follow-up visits with their health care professionals to ensure the individual has the correct pessary size and no other complications. [13] In addition, those with an increased risk of vaginal wall thinning can be prescribed estrogen to prevent erosion and prevent these complications. [3]

If pessaries are not used properly or not maintained periodically, more serious complications can occur. For example, the pessary can become embedded into the vagina, which makes it harder to remove. Estrogen can decrease the inflammation of the vaginal walls and promote skin cells in the vagina to mature, so use of estrogen cream can allow removal of the pessary more easily. [24] In rare cases, pessaries would need to be removed through surgical procedures. [3]

To prevent complications, individuals should not use pessaries if they have characteristics that exclude them from this method of therapy. Contraindications to pessary use include current infections in the pelvis or vagina, or allergies to the material of the pessary (which can be silicone or latex). [14] In addition, individuals should not be fitted for a pessary if they are less likely to properly maintain their pessary.

See also

Related Research Articles

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

<span class="mw-page-title-main">Kegel exercise</span> Pelvic floor exercise

Kegel exercise, also known as pelvic floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many times a day, for several minutes at a time but takes one to three months to begin to have an effect.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Pelvic organ prolapse</span> Descent of the pelvic organs from their normal positions

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

<span class="mw-page-title-main">Pelvic exenteration</span> Surgical removal of all pelvic organs

Pelvic exenteration is a radical surgical treatment that removes all organs from a person's pelvic cavity. It is used to treat certain advanced or recurrent cancers. The urinary bladder, urethra, rectum, and anus are removed. In women, the vagina, cervix, uterus, Fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed. The procedure leaves the person with a permanent colostomy and urinary diversion.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

<span class="mw-page-title-main">Pelvic examination</span> Physical medical examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma. It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles. In this case, the term used is cystourethrocele.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

<span class="mw-page-title-main">Vaginal cysts</span> Benign growths of the vaginal epithelium

Vaginal cysts are uncommon benign cysts that develop in the vaginal wall. The type of epithelial tissue lining a cyst is used to classify these growths. They can be congenital. They can present in childhood and adulthood. The most common type is the squamous inclusion cyst. It develops within vaginal tissue present at the site of an episiotomy or other vaginal surgical sites. In most instances they do not cause symptoms and present with few or no complications. A vaginal cyst can develop on the surface of the vaginal epithelium or in deeper layers. Often, they are found by the woman herself and as an incidental finding during a routine pelvic examination. Vaginal cysts can mimic other structures that protrude from the vagina such as a rectocele and cystocele. Some cysts can be distinguished visually but most will need a biopsy to determine the type. Vaginal cysts can vary in size and can grow as large as 7 cm. Other cysts can be present on the vaginal wall though mostly these can be differentiated. Vaginal cysts can often be palpated (felt) by a clinician. Vaginal cysts are one type of vaginal mass, others include cancers and tumors. The prevalence of vaginal cysts is uncertain since many go unreported but it is estimated that 1 out of 200 women have a vaginal cyst. Vaginal cysts may initially be discovered during pregnancy and childbirth. These are then treated to provide an unobstructed delivery of the infant. Growths that originate from the urethra and other tissue can present as cysts of the vagina.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

References

  1. 1 2 "Pessaries - Treatments". Voices for PFD. Retrieved 2020-07-28.
  2. ↑ "Cystoceles, Urethroceles, Enteroceles, and Rectoceles - Gynecology and Obstetrics - Merck Manuals Professional Edition". Merck Manuals Professional Edition. Retrieved 2017-12-29.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 "Contemporary Use of the Pessary | GLOWM". www.glowm.com. Retrieved 2020-07-31.
  4. ↑ "Pessary - Define Pessary at Dictionary.com". dictionary.com. Retrieved 9 April 2018.
  5. 1 2 3 4 5 6 7 8 9 10 Oliver, Reeba; Thakar, Ranee; Sultan, Abdul H. (June 2011). "The history and usage of the vaginal pessary: a review". European Journal of Obstetrics & Gynecology and Reproductive Biology. 156 (2): 125–130. doi:10.1016/j.ejogrb.2010.12.039. ISSN   0301-2115. PMID   21255901.
  6. ↑ Hippocrates of Cos (1923). "The Oath". Loeb Classical Library. 147: 298–299. doi:10.4159/DLCL.hippocrates_cos-oath.1923. retrieved 18 September 2018
  7. 1 2 "What Is Pelvic Organ Prolapse?". WebMD. Retrieved 2020-08-28.
  8. 1 2 3 "Stress Urinary Incontinence (SUI): Symptoms, Diagnosis & Treatment - Urology Care Foundation". www.urologyhealth.org. Retrieved 2020-08-05.
  9. ↑ Rovner, Eric S; Wein, Alan J (2004). "Treatment Options for Stress Urinary Incontinence". Reviews in Urology. 6 (Suppl 3): S29–S47. ISSN   1523-6161. PMC   1472859 . PMID   16985862.
  10. 1 2 Berghella, Vincenzo (December 1, 2016). "Can pessaries prevent preterm birth?". Contemporary Ob/Gyn Journal. Vol 65 No 08. 64 (8). Retrieved August 5, 2020.
  11. ↑ "Incompetent Cervix". American Pregnancy Association. 2012-04-27. Retrieved 2020-08-28.
  12. ↑ "Have You Heard Of A Pessary? - Up and Running Physical Therapy". upandrunningpt.com. 2023-03-03. Retrieved 2023-12-04.
  13. 1 2 3 4 5 6 7 8 9 Jones, Keisha A; Harmanli, Oz (2010). "Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence". Reviews in Obstetrics and Gynecology. 3 (1): 3–9. ISSN   1941-2797. PMC   2876320 . PMID   20508777.
  14. 1 2 Viera, Anthony J.; Larkins-Pettigrew, Margaret (2000). "Practical Use of the Pessary". American Family Physician. 61 (9): 2719–2726. ISSN   0002-838X. PMID   10821152.
  15. 1 2 3 4 5 6 7 8 Culligan, Patrick J. (2012). "Nonsurgical Management of Pelvic Organ Prolapse". Obstetrics & Gynecology. 119 (4): 852–860. doi:10.1097/AOG.0b013e31824c0806. ISSN   0029-7844. PMID   22433350. S2CID   21218937.
  16. 1 2 Tam, Theresa; Davies, Matthew (December 2013). "Pessaries for vaginal prolapse: Critical factors to successful fit and continued use". www.mdedge.com. 25. OBG Management: 42–44, 48–52, 59. Retrieved 2020-08-03.
  17. ↑ "Medline Gehrung Pessary | Pessary". www.healthproductsforyou.com. Retrieved 2020-07-31.
  18. ↑ Vaginal yeast infections (thrush): What helps?. Institute for Quality and Efficiency in Health Care (IQWiG). 2019-06-19.
  19. ↑ Thomas, Jane; Fairclough, Anna; Kavanagh, Josephine; Kelly, Anthony J (2014-06-19). "Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term". Cochrane Database of Systematic Reviews. 2014 (6): CD003101. doi:10.1002/14651858.cd003101.pub3. ISSN   1465-1858. PMC   7138281 . PMID   24941907.
  20. ↑ "Pliny the Elder, the Natural History, Book XXII. The Properties of Plants and Fruits, Chap. 49.—Laser: Thirty-Nine Remedies".
  21. ↑ "The different types of contraception". www.nhsinform.scot. Retrieved 2020-07-30.
  22. ↑ "Contraceptive Stem Pessary in Aluminium - Phisick - Medical Antiques". www.phisick.com. Retrieved 9 April 2018.
  23. ↑ "Pessary". Northwestern Medicine. Retrieved 2020-07-30.
  24. 1 2 3 Viera, Anthony J.; Larkins-Pettigrew, Margaret (2000-05-01). "Practical Use of the Pessary". American Family Physician. 61 (9): 2719–2726. ISSN   0002-838X. PMID   10821152.
  25. ↑ "Bacterial vaginosis - Symptoms and causes". Mayo Clinic. Retrieved 2020-07-31.
  26. ↑ "Vaginal atrophy - Symptoms and causes". Mayo Clinic. Retrieved 2020-07-31.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.