The apex of the urinary bladder is the anterior end of the bladder; thus, it cannot be palpated. The terminal part of the round ligament of the uterus emerges from the superficial inguinal ring and becomes lost in the subcutaneous tissue of the labium majus. The anterior surface of the ovary is attached to the posterior surface of the broad ligament of the uterus. The ureter descends retroperitoneally on the lateral pelvic wall but is crossed by the uterine artery in the base (in the inferomedial part) of the broad ligament. The terminal part of the round ligament of the uterus becomes lost in the subcutaneous tissue of the labium majus. The suspensory ligament of the ovary is a band of peritoneum that extends superiorly from the ovary to the pelvic wall. In the male, the pelvic part of Chapter 6 Perineum and Pelvis 293 the ureter lies lateral to the ductus deferens and enters the posterosuperior angle of the bladder, where it is situated anterior to the upper end of the seminal vesicle, and thus, it cannot be palpated during rectal examination. However, in the female, the ureter can be palpated during vaginal examination because it runs near the uterine cervix and the lateral fornix of the vagina to enter the posterosuperior angle of the bladder. The testes are examined during a routine annual checkup but obviously not during a rectal examination. Parasympathetic preganglionic fibers in the pelvic splanchnic nerve are responsible for erection of the penis. Sympathetic preganglionic fibers in the sacral splanchnic nerve are responsible for ejaculation. The dorsal nerve of the penis is a terminal branch of the pudendal nerve and supplies sensation of the penis. The posterior scrotal nerves are superficial branches of the perineal nerve and supply sensory fibers to the scrotum. The pelvic inlet (pelvic brim) is bounded by the promontory and the anterior border of the ala of the sacrum, the arcuate line of the ilium, the pectineal line, the pubic crest, and the superior margin of the pubic symphysis. The skin of the urogenital triangle is innervated by the pudendal nerve, perineal branches of the posterior femoral cutaneous nerve, anterior scrotal or labial branches of the ilioinguinal nerve, and the genital branch of the genitofemoral nerve. The pubic arcuate ligament, tip of the coccyx, ischial tuberosities, and sacrotuberous ligament all form part of the boundary of the perineum. The scrotum is innervated by branches of the ilioinguinal, genitofemoral, pudendal, and posterior femoral cutaneous nerves. The scrotum receives blood from the posterior scrotal branches of the internal pudendal arteries and the anterior scrotal branches of the external pudendal arteries, but it does not receive blood from the testicular artery. Similarly, the scrotum is drained by the posterior scrotal veins into the internal pudendal vein. The lymph vessels from the scrotum drain into the superficial inguinal nodes, whereas the lymph vessels from the testis drain into the upper lumbar nodes. The cardinal (transverse cervical) ligament provides the major ligamentous support for the uterus. The broad and round ligaments of the uterus provide minor supports for the uterus. An obstetrician should avoid incising the levator ani and the external anal sphincter. The levator ani is the major part of the pelvic diaphragm, which forms the pelvic floor and supports all of the pelvic organs. The lumbosacral trunk is formed by part of the ventral ramus of the fourth lumbar nerve and the ventral ramus of the fifth lumbar nerve. This trunk contributes to the formation of the sacral plexus by joining the ventral ramus of the first sacral nerve in the pelvic cavity and does not leave the pelvic cavity. The sphincter urethrae is found in the deep perineal space, whereas the other structures are located in the superficial perineal space. Lymphatic vessels from the testis and epididymis ascend along the testicular vessels in the spermatic cord through the inguinal canal and continue upward in the abdomen to drain into the upper lumbar nodes. The lymph from the other structures drains into the superficial inguinal lymph nodes.
The mean sac diameter is determined by adding the three orthogonal dimensions of the chorionic sac and dividing by 3. The amnion and smooth chorion have been cut and reflected to show their relationship to each other and the decidua parietalis. The shape of the placenta is determined by the persistent area of chorionic villi. As the chorionic villi invade the decidua basalis, decidual tissue is eroded to enlarge the intervillous space. This erosion produces several wedge-shaped areas of decidua, placental septa, that project toward the chorionic plate, the part of the chorionic wall related to the placenta. The placental septa divide the fetal part of the placenta into irregular convex areas-cotyledons. Each cotyledon consists of two or more stem villi and their many branch villi. By the end of the fourth month, the decidua basalis is almost entirely replaced by the cotyledons. Expression of the transcription factor Gcm1 (glial cells missing-1) in trophoblast stem cells regulates the branching process of the stem villi to form the vascular network in the placenta. The decidua capsularis, the layer of decidua overlying the implanted chorionic sac, forms a capsule over the external surface of the sac. As the conceptus enlarges, the decidua capsularis bulges into the uterine cavity and becomes greatly attenuated. Eventually the decidua capsularis contacts and fuses with the decidua parietalis, thereby slowly obliterating the uterine cavity. By 22 to 24 weeks, the reduced blood supply to the decidua capsularis causes it to degenerate and disappear. After disappearance of the decidua capsularis, the smooth part of the chorionic sac fuses with the decidua parietalis. This fusion can be separated and usually occurs when blood escapes from the intervillous space. The collection of blood (hematoma) pushes the chorionic membrane away from the decidua parietalis, thereby reestablishing the potential space of the uterine cavity. Maternal blood flows into the intervillous space in funnel-shaped spurts from the spiral endometrial arteries, and exchanges occur with the fetal blood as the maternal blood flows around the branch villi. It is through these villi that the main exchange of material between the mother and embryo/fetus occurs. The inflowing arterial blood pushes venous blood out of the intervillous space into the endometrial veins, which are scattered over the surface of the decidua basalis. Note that the umbilical arteries carry poorly oxygenated fetal blood (shown in blue) to the placenta and that the umbilical vein carries oxygenated blood (shown in red) to the fetus. Note that the cotyledons are separated from each other by placental septa, projections of the decidua basalis. In this drawing, only one stem villus is shown in each cotyledon, but the stumps of those that have been removed are indicated. The intervillous space of the placenta, which contains maternal blood, is derived from the lacunae that developed in the syncytiotrophoblast during the second week of development (see Chapter 3). This large blood-filled space results from the coalescence and enlargement of the lacunar networks. The intervillous space of the placenta is divided into compartments by the placental septa; however, there is free communication between the compartments because the septa do not reach the chorionic plate. Maternal blood enters the intervillous space from the spiral endometrial arteries in the decidua basalis. The spiral arteries pass through gaps in the cytotrophoblastic shell and discharge blood into the intervillous space. This large space is drained by endometrial veins that also penetrate the cytotrophoblastic shell. The blood in this space carries oxygen and nutritional materials that are necessary for fetal growth and development. The maternal blood also contains fetal waste products such as carbon dioxide, salts, and products of protein metabolism. As a result, the amnion and smooth chorion soon fuse to form the amniochorionic membrane. This composite membrane fuses with the decidua capsularis and, after disappearance of this capsular part of the decidua, adheres to the decidua parietalis.
The anterior two-thirds of the tongue is formed from the lingual swellings and the tuberculum impar. The posterior one-third of the tongue is formed by the cranial part of the hypobranchial eminence. It is derived partly from the stomatodeum (ectodermal) and partly from the cranial part of the foregut (endodermal). Hence its epithelial lining is partly ectodermal and partly endodermal and the demarcation between the two is buccopharyngeal membrane. After disappearance of the buccopharyngeal membrane (4th week), both become continuous with each other and the line of junction between the ectoderm and endoderm is difficult to define. Primitive Oral Cavity the stomatodeum is divided into two parts by developing primitive and definitive palate. The derivatives of oral part can be subdivided into those from ectoderm and those from endoderm. Floor of mouth: In the region of the floor of the mouth, the mandibular processes take part in the formation of three structures. Soon the tongue forms a recognizable swelling, which is separated laterally from the rest of the mandibular process by the linguogingival sulcus. This sulcus deepens rapidly and the tissues of the mandibular arch lateral to it form the lower lip (or cheek). With the deepening of these two sulci, the area lying between them becomes a raised alveolar process. The tongue, the alveolar process (or jaw) and the lips (or cheeks) are thus separated from one another. The alveolar process of the upper jaw is separated from the upper lip and cheek by appearance of a labiogingival furrow, just as in the lower jaw. The medial margin of the alveolus becomes defined when the palate becomes highly arched. The epithelium overlying the convex border of this process becomes thickened and projects into the underlying mesoderm. The dental lamina is, in fact, apparent even before the alveolar process itself is defined. The dental lamina now shows a series of local thickenings, each of which is destined to form one milk tooth. There are 10 such enamel organs (five on each side) in each alveolar process. As already stated each enamel organ is formed by localized proliferation of the cells of the dental lamina (Figs 12. The dental lamina, seen in the alveolar process, gives origin to teeth (Also see. The cup comes to be occupied by a mass of mesenchyme called the dental papilla (According to some authorities, this mesenchyme is of neural crest origin). At this stage the developing tooth looks like a cap: it is, therefore, described as the cap stage of tooth development. Bell stage: Mesodermal cells of the papilla that are adjacent to the ameloblasts arrange themselves as a continuous epithelium like layer. Apposition stage: Ameloblasts lay down enamel on the superficial (outer) surface of the basement membrane. The process of laying down of enamel and of dentine is similar to that of formation of bone by osteoblasts. As layer after layer of enamel and dentine are laid down, the layer of ameloblasts and the layer of odontoblasts move away from each other. After the enamel is fully formed the ameloblasts disappear leaving a thin membrane, the dental cuticle, over the enamel. The odontoblasts, however, continue to separate the dentine from the pulp throughout the life of the tooth.
The developing corpus striatum soon becomes subdivided into medial and lateral subdivisions, which increase in thickness. Meanwhile, the cerebral cortex is developing and numerous axons, which are Cerebral Cortex the cerebral cortex is formed by migration of cells from the mantle layer into the overlying marginal layer. These cells divide, and subdivide, leading to considerable thickening of the cortex. Simultaneously, there is considerable side-toside expansion of the cortex as a result of which its surface area is greatly increased. As the surface expansion is at a greater rate than that of the hemisphere as a whole, the cortex becomes folded on itself. The region of the insula is relatively slow in growth, and is gradually overgrown by adjacent areas, which form the opercula of the insula. The region of the developing corpus striatum is divided (longitudinally) into deep and superficial parts (by nerve fibers growing downwards through it). It undergoes very great expansion and forms the whole of the cerebral cortex seen on the superolateral and medial surfaces of the cerebral hemisphere, and the cortex of the inferior surface excluding the pyriform area (Figs 17. The pyriform cortex gives rise to the part of the cerebral cortex that receives olfactory sensations. It forms the uncus, the anterior part of the parahippocampal gyrus, and the anterior perforated substance. The hippocampal cortex develops in the medial wall, the pyriform cortex in the marginal layer superficial to the corpus striatum, and the neocortex in the superolateral region. With the establishment of the inferior horn of the lateral ventricle, the hippocampal cortex follows the curve of the choroid fissure and thus, assumes a ringlike configuration. However, the superior part of the hippocampal cortex is soon separated from the fissure by the formation of the corpus callosum. The lower part of the hippocampal cortex undergoes relatively greater development and becomes the hippocampus and the dentate gyrus. With the expansion of the neocortex, these structures are pushed into the cavity of the inferior horn of the lateral ventricle. White Matter of Cerebrum the bulk of the cerebrum is constituted by its white matter. The internal capsule passes through the interval between the lentiform nucleus laterally and the caudate nucleus and thalamus medially A B C. The hippocampal cortex forms the hippocampus and the indusium griseum Cerebral Commissures the part of the wall of the neural tube that closes the cranial end of the prosencephalon is called the lamina terminalis (Figs 17. After the appearance of the telencephalic vesicles, the lamina terminalis lies in the anterior wall of the third ventricle. Any neuron growing from one hemisphere to the other must pass through this lamina. To facilitate this passage, the lamina terminalis becomes thickened to form the commissural plate. It, at first, lies anterior to the diencephalon, but because of rapid increase in its size, it extends backwards and roofs over this region (Figs 17. The part of lamina terminalis that stretches between corpus callosum and fornix persists as septum pellucidum. Clinical correlation Anomalies of brain and spinal cord Neural tube defects (NtdS) these are a group of conditions where due to non-approximation of neural folds, they result in an opening in the spinal cord or brain or both from the early human development. It results when the brain and/or spinal cord are exposed at birth through a defect in the skull or vertebrae. Outward bulging of neural tube and covering membranes As a result of non-fusion of the neural tube, or of overlying bones.
With the huge demand for social networking, and the necessity for collaboration among scientists, we see this as a crucial time and opportunity for all scientists and science companies to get involved. This free, online network is comprised of scientists and engineers from around the world. When you join, you create a profile that summarizes your research, experience, and accomplishments. Once registered, you create a profile detailing your education, experience, and research interests. This ensures that you receive news and information relevant to you; including breaking news of discoveries and advancements in your field, relevant events, publications, jobs, reviews, and other research you should know. Share Your Expertise Your knowledge is important and at LabRoots you are free to share your accomplishments, expertise, and opinions with others. This includes participating in relevant blogs, answering questions from others, and rating companies and products that you use in your work. Discover New Networks LabRoots is a forum for the free exchange of ideas between all scientists, irrespective of geographic boundaries or fields of study. LabRoots brings together scientists from life science, clinical science, chemistry, physics, earth science, environmental science, space science, physical science, computer science, mathematics, engineering, medical, health and social science. This allows a unique opportunity to find and connect with others that can broaden your vision, and enable discovery of ideas you never thought possible. Interact Keeping track of colleagues and friends and meeting new ones has never been easier. Nominating Contact Person Name: Heidi Bullock Title: Director of Marketing Tel: 650. User Organization Contact Person Name: Cesar Paredes Title: Product Manager Tel: 3142867605 Email: Ces. Project Project Title: Your Favorite Gene powered by Ingenuity Team Leader Name: Cesar Paredes Title: Product Manager Tel: 3142867605 Email: Ces. The new Your Favorite Gene-Powered by Ingenuity enables scientists to find more relevant products from the Sigma-Aldrich web site by using a biological vocabulary that ties biological concepts to product identifiers and descriptions. With access to more than 75,000 pages of biological information, scientists can explore biological pathways and molecular networks to validate their product selection and to identify additional products relevant to their experiment. Introduction Sigma-Aldrich approached Ingenuity with a goal of organizing its vast product suite in a convenient and logical manner by linking reagents and kits to related biological knowledge. The life sciences community faces the challenge of keeping up to date on a continually proliferating amount of biological data generated from research projects and industry advancements. Though much of this information is available to the public, most of it is unorganized and is not centrally located. Sigma-Aldrich envisioned presenting its product suite within an organized network of Knowledge Management biological knowledge to provide its customers with a richer and more targeted search and purchasing experience. Ingenuity also contributed to the technical solution by providing visualization software to help users navigate pathways and interaction networks that are dynamically generated based on a specific search term. This software provides visualization tools such as zoom, pan, and highlight so scientists can easily focus on areas of interest. The visualization software also enables scientists to easily change the members of a particular gene network or select the best layout in order to navigate and explore the vast biological database. Results Your Favorite Gene-Powered by Ingenuity enables researchers to generate more relevant search results and explore gene pathways and molecular interaction networks to quickly understand alternative product and experimental design options. The solution is designed to be user-friendly by supporting searches on more than just gene names; users can search on a variety of topics including genes, proteins, diseases, small molecules and more. The pathways available through Your Favorite Gene-Powered by Ingenuity are fully interactive: users can search, filter, highlight and drill down on specific molecules or interactions to access underlying information and, most importantly, view products relevant to those molecules or interactions. Your Favorite GenePowered by Ingenuity also provides fully interactive molecular networks that allow researchers to observe what is upstream or downstream from a gene and find related products necessary for their experiments. Conclusion (800 Characters max: Currently at 718) the ability to efficiently and easily navigate through the vast amount of biological data in order to design better experiments has long been a goal of researchers seeking to understand complex chemical and biological networks. Your Favorite Gene-Powered by Ingenuity enables scientists to understand complex systems at multiple levels of detail through a vivid, interactive platform. These dynamic interaction platforms provide researchers with greater scientific insight and help them better model their experiments, while the life sciences industry vendors can provide their customers with more convenient and targeted access to relevant products.
Chapter 8 Head and Neck 347 Danger area of the face is the area of the face near the nose drained by the facial veins. Pustules (pimples) or boils or other skin infections, particularly on the side of the nose and upper lip, may spread to the cavernous venous sinus via the facial vein, pterygoid venous plexus, and ophthalmic veins. Septicemia (blood infection) is a systemic disease caused by the presence of pathogenic organisms or their toxins in the bloodstream and is often associated with severe infections, leading to meningitis and cavernous sinus thrombosis, both of which may cause neurologic damage and may be life-threatening. Divides into an anterior branch, which joins the facial vein to form the common facial vein, and a posterior branch, which joins the posterior auricular vein to form the external jugular vein. Is composed of dense connective tissue, which contains numerous blood vessels and nerves, sweat glands, and hair follicles. The arteries nourish the hair follicles and anastomose freely and are held by the dense connective tissue around them, and thus, they tend to remain open when cut, causing profuse bleeding. Aponeurosis Epicranialis (Galea Aponeurotica) Is a tendinous sheet that covers the vault of the skull and unites the occipital and frontal bellies of the occipitofrontal muscles. Loose Connective Tissue Forms the loose and scanty subaponeurotic space and contains the emissary veins. Is termed a dangerous area because infection (blood and pus) can spread easily in it or from the scalp to the intracranial sinuses by way of the emissary veins. Scalp hemorrhage results from laceration of arteries in the dense connective tissue layer that is unable to contract or retract and thus remain open, leading to profuse bleeding. Deep scalp wounds gape widely when the epicranial aponeurosis is lacerated in the coronal plane because of the pull of the frontal and occipital bellies of the epicranius muscle in opposite directions. Scalp infection localized in the loose connective tissue layer spreads across the calvaria to the intracranial dural venous sinuses through emissary veins, causing meningitis or septicemia. Is supplied by the supratrochlear and supraorbital branches of the internal carotid and by the superficial temporal, posterior auricular, and occipital branches of the external carotid arteries. Infratemporal Fossa (Figures 8-17 and 8-18) Contains the lower portion of the temporalis muscle, the lateral and medial pterygoid muscles, the pterygoid plexus of veins, the mandibular nerve and its branches, the maxillary artery and its branches, the chorda tympani, and the otic ganglion. Temporal Fossa (See Figures 8-17 and 8-18) Contains the temporalis muscle, the deep temporal nerves and vessels, the auriculotemporal nerve, and the superficial temporal vessels. Anterior: zygomatic process of the frontal bone and the frontal process of the zygomatic bone. Floor: parts of the frontal, parietal, temporal, and greater wing of the sphenoid bone. Temporalis muscle Lateral pterygoid muscle Sphenopalatine artery Descending palatine artery Infraorbital artery Posterior-superior alveolar artery Buccal artery and nerve Buccinator muscle Mandible Chapter 8 a b l e Muscle Temporalis Masseter Head and Neck 351 8-4 Origin Muscles of Mastication* Insertion Coronoid process and ramus of mandible Lateral surface of coronoid process, ramus and angle of mandible Neck of mandible; articular disk and capsule of temporomandibular joint Medial surface of angle and ramus of mandible Nerve Trigeminal Trigeminal Action on Mandible Elevates; retracts Elevates (superficial part); retracts (deep part) Depresses (superior head); protracts (inferior head) Elevates; protracts Temporal fossa Lower border and medial surface of zygomatic arch Superior head from infratemporal surface of sphenoid; inferior head from lateral surface of lateral pterygoid plate of sphenoid Tuber of maxilla (superficial head); medial surface of lateral pterygoid plate; pyramidal process of palatine bone (deep head) Lateral pterygoid Trigeminal Medial pterygoid Trigeminal *The jaws are opened by the lateral pterygoid muscle and are closed by the temporalis, masseter, and medial pterygoid muscles. Mandibular Division of the Trigeminal Nerve Passes through the foramen ovale and innervates the tensor veli palatini and tensor tympani muscles, muscles of mastication (temporalis, masseter, and lateral and medial pterygoid), anterior belly of the digastric muscle, and the mylohyoid muscle. Provides sensory innervation to the lower teeth and gum and to the lower part of the face below the lower lip and the mouth. Meningeal Branch Accompanies the middle meningeal artery, enters the cranium through the foramen spinosum, and supplies the meninges of the middle cranial fossa. Innervates skin and fascia on the buccinator muscle and penetrates this muscle to supply the mucous membrane of the cheek and gums. It can occur after parotid surgery and may be treated by cutting the tympanic plexus in the middle ear. Lies anterior to the inferior alveolar nerve on the medial pterygoid muscle, deep to the ramus of the mandible. Crosses lateral to the styloglossus and hyoglossus muscles, passes deep to the mylohyoid muscle, and descends lateral to and loops under the submandibular duct. Passes deep to the lateral pterygoid muscle and then between the sphenomandibular ligament and the ramus of the mandible. Enters the mandibular canal through the mandibular foramen and supplies the tissues of the chin and lower teeth and gum. Mylohyoid nerve, which innervates the mylohyoid and the anterior belly of the digastric muscle. Otic Ganglion Lies in the infratemporal fossa, just below the foramen ovale between the mandibular nerve and the tensor veli palatini. Receives preganglionic parasympathetic fibers that run in the glossopharyngeal nerve, tympanic nerve and plexus, and lesser petrosal nerve and synapse in this ganglion. Contains cell bodies of postganglionic parasympathetic fibers that run in the auriculotemporal nerve to innervate the parotid gland.
Hence, it is essential to take note of the increasing demand for English in the job market. It also considered the need to evaluate the utility of the existing Arts and Science courses and link them to employment opportunities. Many international companies have created their call centres and branches in India because of the easy availability of a large and relatively inexpensive, skilled. This underscores the fact that there is a phenomenal increase in career opportunities for the graduates proficient in English. Studies on English Language Needs of the Employment Sector Nowadays in most of the sectors English is a prime requirement for business communication. There are quite a few studies that explore the English language needs of the corporate world. Praveen Kumar (1997) has tried to study the perspectives of teachers and employers on the Functional English syllabus. Mohan and Banerji (2003) carried out a questionnaire-based survey of the needs for English in the professional world. In this study it was discovered that all the 32 language tasks listed in the questionnaire and the related sub-tasks identified by the researchers as relevant for professional purposes were actually performed with varying degrees of frequency. The study stresses the need to take into account the specific needs of the learners in India while planning the language courses. These studies by Praveen Kumar (1997) and Mohan and Banerji (2003) are related to Functional English syllabus and General English course respectively. Among these twenty respondents, one employer was from a Multinational Company (05%), two were of the organizations run by trusts (10%), eight were proprietors (40%) of their firms, while five represented public limited companies (25%) and four belonged to private limited companies (20%). Thus employment specific vocabulary and writing and presentation skills are required from the prospective employees. This means advanced composition skills and e-reference skills matter most for employers. This implies that listening skills should have a prominent place in the courses in English. Along with fluency in spoken English, presentation skills are must to seek an employment. It indicates that there is no need of overemphasis on activity like writing a news report. They expect that the employees should be able to use business jargons for effective communication. Discussion Mohan and Banerji (2003:20) state: "The needs of the professions which university graduates enter are not determined by the kind of input but by the nature of expected output. The employer does not look at the past, to what the entrant to his organization has learnt, but to the future, to what the entrant can do. Some of the skills mentioned in this survey are included in the General / Compulsory English courses offered in the degree programmes in the universities in India. However, based on their significance to the employment sector their weighting needs to be changed. Even though some of the books include the units on vocabulary, in the syllabi of Compulsory English in Indian universities enough attention is not paid towards vocabulary development. The present survey indicates to incorporate employment specific vocabulary in the course books. Most significant outcome of this survey may be the need to give enough training to our students to listen to English carefully and develop the skill of note-taking. Listening and speaking skills have less weighting in the General English courses offered in conventional degree programmes. The emphasis of the employers to develop spoken English of our graduates needs to be taken seriously.
Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. Rationale for a preoperative, -month experience of living in an identity-congruent gender role: the criterion noted above for some types of genital surgeries-i. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. It is preferable that this mental health professional be familiar with the patient. It is usually performed through implantation of breast prostheses and occasionally with the lipofilling technique. Infections and capsular fibrosis are rare complications of augmentation mammoplasty in MtF patients (Kanhai, Hage, Karim, & Mulder,). If the objectives of phalloplasty are a neophallus of good appearance, standing micturition, sexual sensation, and/or coital ability, patients should be clearly informed that there are several separate stages of surgery and frequent technical difficulties, which may require additional operations. Metoidioplasty results in a micropenis, without the capacity for standing urination. For this reason, many FtM patients never undergo genital surgery other than hysterectomy and salpingo-oophorectomy (Hage & De Graaf,). Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective. Postoperative patients should undergo regular medical screening according to recommended guidelines for their age. While hormone providers and surgeons play important roles in preventive care, every transsexual, transgender, and gender-nonconforming person should partner with a primary care provider for overall health care needs (Feldman,). However, in areas such as cardiovascular risk factors, osteoporosis, and some cancers (breast, cervical, ovarian, uterine, and prostate), such general guidelines may either over- or underestimate the cost-effectiveness of screening individuals who are receiving hormone therapy. For patients who take masculinizing hormones, despite considerable conversion of testosterone to estrogens, atrophic changes of the vaginal lining can be observed regularly and may lead to pruritus or burning. Gynecologists treating the genital complaints of FtM patients should be aware of the sensitivity that patients with a male gender identity and masculine gender expression might have around having genitals typically associated with the female sex. People should not be discriminated against in their access to appropriate health care based on where they live, including institutional environments such as prisons or long-/intermediate-term health care facilities (Brown,). If the in-house expertise of health professionals in the direct or indirect employ of the institution does not exist to assess and/or treat people with gender dysphoria, it is appropriate to obtain outside consultation from professionals who are knowledgeable about this specialized area of health care. A "freeze frame" approach is not considered appropriate care in most situations (Kosilek v. Infertility may already be present due to either early gonadal failure or to gonadectomy because of a malignancy risk. Much of this literature has been produced by high-level specialists in pediatric endocrinology and urology, with input from specialized mental health professionals, especially in the area of gender. The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals. A parentreport gender identity questionnaire for children: A cross-national, cross-clinic comparative analysis. Unprincipled exclusions: the struggle to achieve judicial and legislative equality for transgender people. Long-term maintenance of fundamental frequency increases in male-to-female transsexuals. Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: A crosssectional survey. Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges.
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