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Menstrual disordersDysmenorrhea; Menorrhagia; Amenorrhea; Cramps; Heavy menstrual bleeding
An in-depth report on the causes, treatment, and prevention of menstrual cramps.
Menstrual Disorders
Menstrual disorders include:
- Dysmenorrhea refers to painful cramps during menstruation. Primary dysmenorrhea is caused by menstruation itself. Secondary dysmenorrhea is triggered by another condition, such as endometriosis or uterine fibroids.
- Menorrhagia is heavy bleeding including prolonged menstrual periods or excessive bleeding during a normal-length period.
- Amenorrhea is the absence of menstruation. Primary amenorrhea is considered when a girl does not begin to menstruate by the age of 16. Secondary amenorrhea occurs when periods that were previously regular stop for at least 3 months.
- Oligomenorrhea refers to light or infrequent menstrual periods that occur more than 35 days apart. It usually is not a cause for concern, except if periods occur more than 3 months apart.
Treatment for Menstrual Disorders
Treatment options for menstrual disorders include:
- Acetaminophen (Tylenol, generic) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, generic) and naproxen (Aleve, generic) can help provide pain relief for cramps.
- Oral contraceptives (birth control pills)can help regulate menstrual periods and reduce heavy bleeding. Newer continuous-dosing oral contraceptives reduce or eliminate menstrual periods. Progesterone injections with Depo-Provera are another option. The LNG-IUS (Mirena), a progesterone intrauterine device (IUD), is often recommended as a first-line treatment for heavy bleeding
- Endometrial ablation is a surgical option. In some cases, hysterectomy may be considered.
Research News
The levonorgestrel-releasing intrauterine system (LNG-IUS) works better for improving quality of life for women with heavy bleeding than medical treatments with oral estrogen-progesterone contraceptives or progesterone injections, suggests a 2013 study published in the New England Journal of Medicine.
Menstrual disorders are problems that affect a woman's normal menstrual cycle. They include painful cramps during bleeding, abnormally heavy bleeding, or not having any bleeding.
Menstruation occurs during the years between puberty and menopause. Menstruation, also called a "period," is the monthly flow of blood from the uterus through the cervix and out through the vagina.
- The uterus is a pear-shaped organ located between the bladder and lower intestine.
- The cervix is the lower portion of the uterus. It has a narrow opening called the os, which connects to the vagina and allows menstrual blood to flow out of the uterus into the vagina.
- The fallopian tubes connect the uterus and ovaries. Ovaries are egg-producing organs that hold 200,000 - 400,000 follicles (from folliculus, meaning "sack" in Latin). These cellular sacks contain the materials needed to produce ripened eggs, or ova. An egg develops within the follicle.
- The endometrium is the inner lining of the uterus. During pregnancy it thickens and becomes enriched with blood vessels to house and nourish the growing fetus.
- If pregnancy does not occur, the endometrium is shed and a woman starts menstruating. Menstrual flow also consists of blood and mucus from the cervix and vagina.
The Menstrual Cycle
The menstrual cycle is regulated by the complex surge and fluctuations in many different reproductive hormones, which work together to prepare a women's body for pregnancy. The hypothalamus (an area in the brain) and the pituitary gland control six important hormones:
- Gonadotropin-releasing hormone (GnRH) is released by the hypothalamus.
- GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
- Estrogen, progesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH.
The menstrual cycle begins with the first day of bleeding. The menstrual cycle is divided into three phases:
- Follicular. The follicular phase begins with menstrual bleeding. At the start of this phase, estrogen and progesterone levels are at their lowest point, which causes the uterine lining to break down and shed. At the same time, the hypothalamus produces GnRH which stimulates production of FSH and LH. As FSH levels increase, they signal the ovaries to produce follicles. Each follicle contains an egg. As FSH levels surge and decline, only one follicle and its egg continues to develop. The maturing follicle releases estrogen, which signals that an egg is mature and ready for egg release (ovulation).
- Ovular. Ovulation marks the halfway point in the menstrual cycle. The ovular phase begins with a surge in LH and FSH levels. Ovulation occurs about 12- 36 hours after LH levels surge. The follicle bursts and releases the egg, which travels down the fallopian tube to the uterus. (Some women experience a quick dull abdominal pain called mittelschmerz ["middle pain" because it occurs in the middle of the monthly cycle] when the follicle ruptures.) A woman is most likely to get pregnant in the 3 - 5 days before ovulation or the day of ovulation. The egg can live for up to 24 hours after being released.
- Luteal. After releasing the egg, the ruptured follicle closes and forms corpus luteum, a yellow mass of cells that provide a source of estrogen and progesterone during pregnancy.These hormones help the uterine lining to thicken and prepare for the egg's fertilization. If the egg is fertilized by a sperm cell, it implants in the uterus and pregnancy begins. If fertilization does not occur, the egg breaks apart. The corpus luteum degenerates, and estrogen and progesterone levels drop. Finally, the thickened uterine lining sloughs off and is shed along with the unfertilized egg during menstruation and the menstrual cycle begins again.
Typical Menstrual Cycle
Menstrual Phases
Typical No. of Days
Hormonal Actions
Follicular (Proliferative) Phase
Cycle Days 1 - 6: Beginning of menstruation to end of blood flow.
Estrogen and progesterone start out at their lowest levels.
FSH levels rise to stimulate maturity of follicles. Ovaries start producing estrogen and levels rise, while progesterone levels remains low.
Cycle Days 7 - 13: The endometrium thickens to prepare for the egg implantation.
Cycle Day 14:
Surge in LH. Largest follicle bursts and releases egg into fallopian tube.
Luteal (Secretory) Phase, also known as the Premenstrual Phase
Cycle Days 15 - 28:
Ruptured follicle develops into corpus luteum, which produces progesterone. Progesterone and estrogen stimulate blanket of blood vessels to prepare for egg implantation.
If fertilization occurs:
Fertilized egg attaches to blanket of blood vessels that supplies nutrients for the developing placenta. Corpus luteum continues to produce estrogen and progesterone.
If fertilization does not occur:
Corpus luteum deteriorates. Estrogen and progesterone levels drop. The blood vessel lining sloughs off, and menstruation begins.
Features of Menstruation
Onset of Menstruation (Menarche). The onset of menstruation, called the menarche, typically begins between the ages of 12 - 13 years. Menarche generally occurs 2 - 3 years after initial breast development (breast budding). African-American and Hispanic girls tend to mature slightly earlier than Caucasian girls. A higher body mass index (BMI) during childhood is associated with earlier puberty and menarche. Environmental factors and nutrition may also affect when menstruation begins.
Length of Monthly Cycle. The average menstrual cycle is about 28 days but anywhere from 21 days to 35 days is considered normal. Cycles tend to be longer during the teenage years and they also lengthen when a woman reaches her 40s. Cycle length is most irregular around the time that girls first start menstruating (menarche) and when women stop
Duration of Periods. Most women bleed for around 3- 5 days but a normal period can last anywhere from 2- 7 days.
Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:
- Menstruation stops during pregnancy. Some women continue to have irregular bleeding during the first trimester. This bleeding may indicate a miscarriage and requires immediate attention by the doctor.
- When women breast-feed they are unlikely to ovulate. After that time, menstruation usually resumes, and they are fertile again.
- Perimenopause (transition to menopause) starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation). Menopause usually occurs at about age 51, although smokers often go through menopause earlier.
Menstrual Disorders
There areseveral typesof menstrual disorders. Problems can range from heavy, painful periods to no periods at all. There are many variations in menstrual patterns, but in general women should be concerned when periods come fewer than 21 days or more than 3 months apart, or if they last more than 10 days. Such events may indicate ovulation problems or other medical conditions.
Dysmenorrhea (Painful Cramps)
Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs. Dysmenorrhea is usually referred to as primary or secondary.
Primary dysmenorrhea. Primary dysmenorrhea is cramping pain caused by menstruation. The cramps occur from contractions in the uterus and are usually more severe during heavy bleeding.
Secondary dysmenorrhea. Secondary dysmenorrhea is menstrual-related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids.
Menorrhagia (Heavy Bleeding)
During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood. Most women change their tampons or pads around 3 - 6 times per day. Menorrhagia is the medical term for significantly heavier periods. Menorrhagia can be caused by a number of factors.
Women often overestimate the amount of blood lost during their periods. Clot formation is fairly common during heavy bleeding and is not a cause for concern. However, women should consult their doctor if any of the following occurs:
- Soaking through at least one pad or tampon every 1 - 2 hours for several hours
- Heavy periods that regularly last 10 or more days
- Bleeding between periods or during pregnancy. Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women, but it is still a good idea to speak with a doctor. Women who experience any post-menopausal bleeding should definitely contact their doctors.
Menorrhagia is menstrual flow that lasts longer and is heavier than normal. The bleeding occurs at regular intervals (during periods). It usually lasts more than 7 days and women lose an excessive (more than 80 mL) amount of blood. Menorrhagia is often accompanied by dysmenorrhea because passing large clots can cause painful cramping.
Menorrhagia is a type of abnormal uterine bleeding. Other types of abnormal bleeding are:
- Metrorrhagia, also called breakthrough bleeding, refers to bleeding that occurs at irregular intervals and with variable amounts. The bleeding occurs between periods or is unrelated to periods.
- Menometrorrhagia refers to heavy and prolonged bleeding that occurs at irregular intervals. Menemetrorrhagia combines features of menorrhagia and metrorrhagia. The bleeding can occur at the time of menstruation (like menorrhagia) or in between periods (like metrorrhagia).
- Dysfunctional uterine bleeding (DUB) is a general term for abnormal uterine bleeding that usually refers to extra or excessive bleeding caused by hormonal problems, usually lack of ovulation (anovulation). DUB tends to occurs either when girls begin to menstruate or when women approach menopause, but it can occur at any time during a woman's reproductive life.
- Other types of abnormal uterine bleeding include bleeding after sex and bleeding after menopause.
Amenorrhea (Absence of Menstruation)
Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea. These terms refer to the time when menstruation stops:
- Primary amenorrhea occurs when a girl does not begin to menstruate by age 16. Girls who show no signs of sexual development (breast development and pubic hair) by age 13 should be evaluated by a doctor. Any girl who does not have her period by age 15 should be evaluated for primary amenorrhea.
- Secondary amenorrhea occurs when periods that were previously regular stop for at least 3 months.
Oligomenorrhea (Light or Infrequent Menstruation)
Oligomenorrhea is a condition in which menstrual cycles are infrequent,occurring morethan 35 days apart. It is very common in early adolescence and does not usually indicate a medical problem.
When girls first menstruate they often do not have regular cycles for several years. Even healthy cycles in adult women can vary by a few days from month to month. Periods may occur every 3 weeks in some women, and every 5 weeks in others. Flow also varies and can be heavy or light. Skipping a period and then having a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage.
Premenstrual Syndrome (PMS)
Premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week before menstruation) in most cycles. The symptoms typically do not start until at least day 13 in the cycle, and resolve within 4 days after bleeding begins. Women may begin to have premenstrual syndrome symptoms at any time during their reproductive years, but it usually occurs when they are in their late 20s to early 40s. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle.
Causes of Dysmenorrhea (Painful Periods)
Primary dysmenorrhea is caused by prostaglandins, hormone-like substances that are produced in the uterus and cause the uterine muscle to contract. Prostaglandins also play a role in the heavy bleeding that causes dysmenorrhea.
Secondary dysmenorrhea can be caused by a number of medical conditions. Common causes of secondary dysmenorrhea include:
- Endometriosis. Endometriosis is a chronic and often progressive disease that develops when the tissue that lines the uterus (endometrium) grows onto other areas, such as the ovaries, bowels, or bladder. It often causes chronic pelvic pain.
- Uterine Fibroid. Fibroids are noncancerous growths that grow on the walls of the uterus. They can cause heavy bleeding during menstruation and cramping pain.
- Other Causes. Pelvic inflammatory disease, ovarian cysts, and ectopic pregnancy. The intrauterine device (IUD) contraceptive can also cause secondary dysmenorrhea.
Causes of Menorrhagia (HeavyBleeding)
There are many possible causes for heavy bleeding:
- Hormonal Imbalances. Imbalances in estrogen and progesterone levels can cause heavy bleeding. Hormonal imbalances are common around the time of menarche and menopause.
- Ovulation Problems. If ovulation does not occur (anovulation), the body stops producing progesterone, which can cause heavy bleeding.
- Uterine Fibroids. Uterine fibroids are a very common cause of heavy and prolonged bleeding.
- Uterine Polyps. Uterine polyps (small benign growths) and other structural problems or other abnormalities in the uterus may cause bleeding.
- Endometriosis and Adenomyosis. Endometriosis, a condition in which the cells that line the uterus grow outside of the uterus in other areas, such as the ovaries, can cause heavy bleeding. Adenomyosis, a related condition where endometrial tissue develops within the muscle layers of the uterus, can also cause heavy bleeding and menstrual pain.
- Medications and Contraceptives. Certain drugs, including anticoagulants and anti-inflammatory medications, can cause heavy bleeding. Problems linked to some birth control methods, such as birth control pills or intrauterine devices (IUDs) can cause bleeding.
- Bleeding Disorders. Bleeding disorders that stop blood from clotting can cause heavy menstrual bleeding. Most of these disorders have a genetic basis. Von Willebrand disease is the most common of these bleeding disorders.
- Cancer. Rarely, uterine, ovarian, and cervical cancer can cause excessive bleeding.
- Infection. Infection of the uterus or cervix can cause bleeding.
- Pregnancy or Miscarriage. Spotting is very common during the first 20 weeks of pregnancy. Heavier bleeding may also occur. Heavy bleeding during the first trimester may be a sign of miscarriage or ectopic pregnancy, but it may also be due to less serious causes thatdo not harm the woman or her baby.
- Other Medical Conditions. Systemic lupus erythematosus, diabetes, pelvic inflammatory disorder, cirrhosis, and thyroid disorders can cause heavy bleeding.
Causes of Amenorrhea and Oligomenorrhea (Absent or Light Periods)
Normal causes of skipped or irregular periods include pregnancy, breastfeeding, hormonal contraception, and perimenopause. Skipped periods are also common during adolescence, when it may take a while before ovulation occurs regularly. Consistently absent periods may be due to the following factors:
- Delayed Puberty. A common cause of primary amenorrhea (absence of periods)is delayed puberty due to some genetic factor that delays physical development. Failure of ovarian development is the most common cause of primary amenorrhea.
- Hormonal Changes and Puberty. Oligomenorrhea (light or infrequent menstruation) is commonly experienced by girls who are just beginning to have their periods.
- Weight Loss and Eating Disorders. Eating disorders are a common cause of amenorrhea in adolescent girls. Extreme weight loss and reduced fat stores lead to hormonal changes that include low thyroid levels (hypothyroidism) and elevated stress hormone levels (hypercortisolism). These changes produce a reduction in reproductive hormones.
- Polycystic Ovarian Syndrome (PCOS). PCOS is a condition in which the ovaries produce high amounts of androgens (male hormones), particularly testosterone. Amenorrhea or oligomenorrhea is quite common in women who have PCOS.
- Endometriosis. Endometriosis, and adenomyosis, can cause severe pelvic pain especially during menstruation. In endometriosis, cells from the tissue that lines the uterus grow in sites outside the uterus. In adenomyosis, these endometrial cells grow within and become attached to the muscular walls of the uterus.
- Elevated Prolactin Levels (Hyperprolactinemia). Prolactin is a hormone produced in the pituitary gland that stimulates breast development and milk production in association with pregnancy. High levels of prolactin (hyperprolactinemia) in women who are not pregnant or nursing can reduce gonadotropin hormones and inhibit ovulation, thus causing amenorrhea.
- Premature Ovarian Failure (POF). POF is the early depletion of follicles before age 40. In most cases, it leads to premature menopause. POF is a significant cause of infertility.
- Structural Problems. In some cases, structural problems or scarring in the uterus may prevent menstrual flow. Inborn genital tract abnormalities may also cause primary amenorrhea.
- Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea.
- Athletic Training. Amenorrhea or oligomenorrhea associated with vigorous activity may be related to stress and weight loss. Female athletes who use anabolic steroids will often have amenorrhea or oligomenorrhea. A syndrome known as the female athlete triad is associated with hormonal changes that occur with the combination ofeating disorders, amenorrhea, and osteopenia (loss of bone density that can lead to osteoporosis) in young women who excessively exercise.
- Other Medical Conditions. Epilepsy, thyroid problems, celiac sprue, metabolic syndrome, and Cushing's disease are associated with amenorrhea.
Risk Factors
Age plays a key role in menstrual disorders. Girls who start menstruating at age 11 or younger are at higher risk for severe pain, longer periods, and longer menstrual cycles. Adolescents may develop amenorrhea before their ovulation cycles become regular.
Women who are approaching menopause (perimenopause) may also skip periods. Occasional episodes of heavy bleeding are also common as women approach menopause.
Other risk factors include:
- Weight. Being either excessively overweight or underweight can increase the risk for dysmenorrhea (painful periods) and amenorrhea (absent periods).
- Menstrual Cycles and Flow. Longer and heavier menstrual cycles are definitely associated with painful cramps.
- Pregnancy History. Women who have had a higher number of pregnancies are at increased risk for menorrhagia. Women who have never given birth have a higher risk of dysmenorrhea, while women who first gave birth at a young age are at lower risk.
- Smoking. Smoking can increase the risk for heavier periods.
- Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea.
Menorrhagia (heavy menstrual bleeding)is the most common cause of anemia (reduction in red blood cells) in premenopausal women. A blood loss of more than 80mL (around three tablespoons) per menstrual cycle can eventually lead to anemia. Most cases of anemia are mild. Nevertheless, even mild anemia can reduce oxygen transport in the blood, causing fatigue and a diminished physical capacity. Moderate-to-severe anemia can cause shortness of breath, rapid heart rate, lightheadedness, headaches, ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur in prolonged and severe anemia that is not treated.
Amenorrhea (absent or irregular menstrual periods)caused by reduced estrogen levels is linked to osteopenia (loss of bone density) and osteoporosis (more severe bone loss that increases fracture risk). Conditions that are associated with low estrogen levels include eating disorders, pituitary tumors, and premature ovarian failure. Because bone growth is at its peak in adolescence and young adulthood, losing bone density at that time is very dangerous, and early diagnosis and treatment is essential for long-term health.
Some conditions associated with heavy bleeding, such as ovulation abnormalities, fibroids, or endometriosis, are important contributors to infertility. Many conditions that cause amenorrhea, such as ovulation abnormalities and polycystic ovary syndrome, can also cause infertility. Irregular periods from any cause may make it more difficult to conceive. Sometimes treating the underlying condition can restore fertility. In other cases, specific fertility treatments that use assisted reproductive technologies may be beneficial.
Quality of Life
Menstrual disorders, particularly pain and heavy bleeding, can affect school and work productivity and social activities.
Your medical history can help the doctor determine whether a menstrual problem is caused by another medical condition. For example, non-menstrual conditions that may cause abdominal pain include appendicitis, urinary tract infections, ectopic pregnancy, and irritable bowel syndrome. Endometriosis and uterine fibroids may cause heavy bleeding and pain. Your doctor may ask questions concerning:
- Menstrual cycle patterns -- length of time between periods, number of days that periods last, number of days of heavy or light bleeding
- The presence or history of any medical conditions that might be causing menstrual problems
- Any family history of menstrual problems
- History of pelvic pain
- Regular use of any medications (including vitamins and over-the-counter drugs)
- Diet history, including caffeine and alcohol intake
- Past or present contraceptive use
- Any recent stressful events
- Sexual history
Menstrual Diary. A menstrual diary is a helpful way to keep track of changes in menstrual cycles. You should record whenyour period starts, how long it lasts, and the amount of bleeding and pain that occurs during the course of menstruation.
Pelvic Examination. A pelvic exam is a standard part of diagnosis. A Pap test may be done during this exam.
Blood and Hormonal Tests
Blood tests can help rule out other conditions that cause menstrual disorders. For example,your doctor may test thyroid function to make sure that low thyroid (hypothyroidism) is not present. Blood tests can also check follicle-stimulating hormone, estrogen, and prolactin levels. Patients who have menorrhagia (heavy bleeding) may get tests for bleeding disorders. If patients are losing a lot of blood, they should also get tested for anemia.
Patients who have amenorrhea (absent or missed periods) may need to receive special hormonal tests. The progestational challenge test uses oral or injected progesterone to test for a functional uterine lining (endometrium):
- Bleeding that occurs up to 3 weeks after the progesterone dose suggests that the woman has normal estrogen levels but is not ovulating, particularly if thyroid and prolactin levels are normal. In such cases, the doctor will check for stress, recent weight loss, and any medications. Such results could also suggest polycystic ovaries or stress.
- A failure to bleed could indicate an abnormal uterus that prevents outflow or insufficient estrogen. In such cases, the next step may be to administer estrogen, followed by progestin. If bleeding occurs after that, the cause of amenorrhea is related to low estrogen levels. The doctor will then check for ovarian failure, anorexia, or other causes of low estrogen. If bleeding does not occur, the doctor would check for obstructions that are preventing outflow of menstruation.
Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. Imaging can help diagnose fibroids, endometriosis, or structural abnormalities of the reproductive organs.
Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and finding obstructions in the urinary tract. It uses sound waves to produce an image of the organs. Ultrasound carries no risk and causes very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline (salt water) injected into the uterus to enhance the visualization of the uterus.
Other Diagnostic Procedures
Hysteroscopy. Hysteroscopy is a procedure that can detect the presence of fibroids, polyps, or other causes of bleeding. It may miss cases of uterine cancer, however, and is not a substitute for more invasive procedures, such as dilation and curettage (D&C) or endometrial biopsy, if cancer is suspected.
Hysteroscopyis done in the office setting and requires no incisions. The procedure uses a slender flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber-optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.
Hysteroscopy is non-invasive, but many women find the procedure painful. The use of an anesthetic spray such as lidocaine may help in preventing pain from this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation. Hysteroscopy is also performed as part of surgical procedures.
Laparoscopy. Diagnostic laparoscopy, an invasive surgical procedure, is currently the only definitive method for diagnosing endometriosis, a common cause of dysmenorrhea. It may also be used to treat endometriosis. Laparoscopy normally requires a general anesthetic, although the patient can go home the same day. The procedure involves inflating the abdomen with gas through a small abdominal incision. A fiber optic tube equipped with small camera lenses (the laparoscope) is then inserted. The doctor uses the laparoscope to view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis).
Endometrial Biopsy. When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the doctor's office. This procedure can help identify abnormal cells, which suggest that cancer may be present. It may also help the doctor decide on the best hormonal treatment to use. The procedure is done without anesthesia, or local anesthetic is injected.
- The patient lies on her back with her feet in stirrups. An instrument (speculum) is inserted into the vagina to hold it open and allow the cervix to be viewed.
- The cervix is cleaned with an antiseptic liquid and then grasped with an instrument (tenaculum) that holds the uterus steady. A device called a cervical dilator may be needed to stretch the cervical canal if there is tightness (stenosis). A small, hollow plastic tube is then gently passed into the uterine cavity.
- Gentle suction removes a sample of the lining. The tissue sample and instruments are removed. A specialist called a pathologist examines the sample under a microscope.
Dilation and Curettage (D&C). Dilation and curettage (D&C) is a more invasive procedure:
- A D&C is usually done in an outpatient setting so that the patient can return home the same day, but it sometimes requires a general anesthetic. It may need to be performed in the operating room to rule out serious conditions or treat some minor ones that may be causing the bleeding.
- The cervix (the neck of the uterus) is dilated (opened).
- The surgeon scrapes the inside lining of the uterus and cervix.
The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not useful for most fibroids, which tend to be larger and more firmly attached.
Lifestyle Changes
Dietary Factors
Making dietary adjustments starting about 14 days before a period may help some women with certain mild menstrual disorders, such as cramping. The general guidelines for a healthy diet apply to everyone; they include eating plenty of whole grains, fresh fruits and vegetables, and avoiding saturated fats and commercial junk foods.
Limiting salt (sodium) may help reduce bloating. Limiting caffeine, sugar, and alcohol intake may also be beneficial.
Preventing and Treating Anemia
Dietary Forms of Iron. Women who have heavy menstrual bleeding can sometimes become anemic. Eating iron-rich foods can help prevent anemia. Iron found in foods is either in the form of heme or non-heme iron. Heme iron is better absorbed than non-heme iron.
- Foods containing heme iron are the best sources for increasing or maintaining healthy iron levels. Such foods include (in order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
- Non-heme iron is less well absorbed. A substantial amount of the iron in meat is non-heme (although meat itself helps absorb non-heme iron). Eggs, dairy products, and iron-containing vegetables have only the non-heme form. Such vegetable products include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.
Increasing intake of vitamin C rich foods can enhance absorption of non-heme iron.
Iron Supplements. There are two forms of supplemental iron: ferrous and ferric. Ferrous iron is better absorbed and is the preferred form of iron tablets. Ferrous iron is available in three forms: ferrous fumarate, ferrous sulfate, and ferrous gluconate. Depending on the severity of your anemia, as well as your age and weight, your doctor will recommend a dosage of 60 - 200 mg of elemental iron per day. This means taking one iron pill 2 - 3 times each day.
Other Lifestyle Measures
Exercise. Exercise may help reduce menstrual pain.
Sexual Activity. There have been reports that orgasm reduces the severity of menstrual cramps.
Applying Heat. Applying a heating pad to the abdominal area, or soaking in a hot bath, can help relieve the pain of menstrual cramps.
Menstrual Hygiene. Change tampons every 4 - 6 hours. Avoid scented pads and tampons; feminine deodorants can irritate the genital area. Douching is not recommended because it can destroy the natural bacteria normally present in the vagina. Bathing regularly is sufficient.
Alternative Remedies
Acupuncture and Acupressure. Some studies have reported relief from pelvic pain after acupuncture or acupressure, a technique that applies small pins or pressure to specific points on the body. More research is needed.
Yoga and Meditative Techniques. Yoga and meditative techniques that promote relaxation may help relieve menstrual cramps.
Herbs and Supplements. Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the Food and Drug Administration to sell their products. Just like with drugs, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctor before using any herbal remedies or dietary supplements.
Studies have not generally found herbal or natural remedies to be any more effective than placebos (sugar pills) for reducing menstrual disorders. Natural remedies promoted for menstrual symptoms include:
- Black cohosh (also known as Cimicifuga racemosa or squawroot) contains a plant estrogen and is the most studied herbal remedy for treating menopausal symptoms, including dysmenorrhea, although most studies have indicated it is ineffective. Headaches and gastrointestinal problems are common side effects. It should not be taken for more than 6 months.
- Ginger tea or capsules may help to relieve nausea and bloating.
- Magnesium supplements may be helpful for relieving dysmenorrhea. Some women also report benefit with vitamin B1 (thiamine) supplements.
- Aromatherapy with topically-applied lavender, sage, and rose oils may help ease menstrual cramps, according to some small studies.
- Pycnogenol, an extract from the bark of the French maritime pine tree, may help reduce menstrual pain and discomfort, according to some small studies.
There are a number of different medicines prescribed for menstrual disorders.
Common Pain Relievers for Cramps
Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that increase uterine contractions. They are effective painkillers that also help control the inflammatory factors that may be responsible for heavy menstrual bleeding. Aspirin is the most common NSAID, but there are dozens of others available over the counter or by prescription.
Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS, generic) and naproxen (Aleve, generic), which are both available over-the-counter, and mefenamic acid (Ponstel, generic), which requires a doctor's prescription. Long-term daily use of any NSAID can increase the risk for gastrointestinal bleeding and ulcers, so it's best to just use these drugs for a few days during the menstrual cycle.
Acetaminophen. Acetaminophen (Tylenol, generic) is a good alternative to NSAIDs, especially for women with stomach problems or ulcers. Some products (Pamprin, Premsyn, generic) combine acetaminophen with other drugs, such as a diuretic, to reduce bloating. .
Oral Contraceptives
Oral contraceptives (OCs), commonly called birth controlpills or "the Pill," contain combinations of an estrogen and a progesterone (in a synthetic form called progestin). The estrogen compound used in most combination OCs is estradiol. There are many different progestins, but common types include levonorgestrol, drospirenone, norgestrol, norethindrone, and desogestrel. (Combination contraceptives are also available in other forms, including patches and vaginal rings, but they may increase the risk for menstrual cramping and bleeding.) Natazia, an OC that contains estradiol and the progesterone dienogest, is specifically approved for treatment of heavy bleeding.
OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). Oral contraceptives are as effective for treating pelvic pain from endometriosis as the more potent gonadotropin releasing hormone agonists. They also protect against ovarian and endometrial cancers.
Standard OCs usually come in a 28-pill pack with 21 days of "active" (hormone) pills and 7 days of "inactive" (placebo) pills. Newer "extended-cycle (also called "continuous-use" or "continuous-dosing") oral contraceptives aim to reduce -- or even eliminate -- monthly menstrual periods. These OCs contain a combination of estradiol and the progestin levonorgestrel, but they use extending dosing of active pills.
Extended-cycleoral contraceptives include:
- Seasonale and Seasonique, which reduce periods to about 3 or 4 times a year
- Lybrel, which completely eliminates monthly menstrual periods in many women
Side effects. Common side effects of combination OCs include headache, nausea, bloating, breast tenderness, and bleeding between periods. The estrogen component in combination OCs is usually responsible for these side effects. In general, today's OCs are much safer than OCs of the past because they contain much lower dosages of estrogen.
However, all OCs can increase the risk for migraine, stroke, heart attack, and blood clots. The risk is highest for women who smoke, who are over age 35,or who have a history of heart disease risk factors (such as high blood pressure or diabetes) or past cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for the heart-related complications associated with these pills. Some types of combination OCs contain progestins, such as drospirenone, which have a much higher risk for causing blood clots than levonorgestrel.
Progestins (synthetic progesterone) are used by women with irregular or skipped periods to restore regular cycles. They also reduce heavy bleeding and menstrual pain, and may protect against uterine and ovarian cancers. Progestin-only contraceptives may be a good option for women who are not candidates for estrogen-containing OCs, such as smokers over the age of 35.
Progestins can be delivered in various forms.
Oral. Short-term treatment of anovulatory bleeding (bleeding caused by lack of ovulation) may involve a 21-day course of an oral progestin on days 5 - 26. Medroxyprogesterone (Provera, generic) is commonly used.
Intrauterine Device (Mirena). An intrauterine device (IUD) that releases progestin can be very beneficial for menstrual disorders, regardless of its contraceptive effects. In the United States, a levonorgestrel-releasing intrauterine system, also called an LNG-IUS, is sold under the brand name Mirena. The LNG-IUS has been proven to reduce heavy bleeding and pain in many women who suffer from menorrhagia and dysmenorrhea. It is the only IUD approved by the FDA to treat heavy menstrual bleeding.
Many doctors recommend the LNG-IUS as a first-line treatment for severe heavy menstrual bleeding, particularly for women who may face hysterectomy (removal of uterus) or conservative surgery such as endometrial ablation (destruction of the endometrial lining). This device is considered a good long-term option, especially for women who may desire future pregnancies. Research also indicates that women who choose the LNG-IUS are highly satisfied with the results and experience an improved quality of life equal to those who choose surgery.
The LNG-IUS remains in place in the uterus and releases the progestin levonorgestrel for up to 5 years. Progestin released by an IUD mainly affects the uterus and cervix, and so it causes fewer widespread side effects than progestin pills do. (However, the other type of IUD -- the Copper T -- may increase bleeding.)
After the LNG-IUS is inserted, heaver periods may occur during the first 3 - 6 months as the lining of the uterus is shed. This shedding may also cause irregular periods and light bleeding ("spotting") between menstrual cycles. Eventually, the LNG-IUS results in a shorter period, with little or no blood flow. For many women, the LNG-IUS completely stops menstrual periods.
Common side effects include cramping, acne, back pain, breast tenderness, headache, mood changes, and nausea. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually cause no symptoms and resolve on their own. Women who have a history of pelvic inflammatory disease or who have had a serious pelvic infection should not use the LNG-IUS. Because of the risks associated with pelvic infection, doctors recommend that women who use the LNG-IUS be in a stable monogamous relationship. The LNG-IUS does not protect against sexually transmitted diseases.
Injection (Depo-Provera). Depo-Provera (also called Depo or DMPA) uses the progestin medroxyprogesterone, which is administered by injection once every 3 months. Most women who use Depo-Provera stop menstruating altogether after a year. Depo-Provera may be beneficial for women with heavy bleeding, or pain due to endometriosis. Women who eventually want to have children should be aware that Depo-Provera can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.
Weight gain can be a problem, particularly in women who are already overweight. Women should not use Depo-Provera if they have a history of liver disease, blood clots, stroke, or cancer of the reproductive organs. Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. Because of this, Depo-Provera should not be used for longer than 2 years.
GnRH Agonists
Gonadotropin releasing hormone (GnRH) agonists are sometimes used to treat severe menorrhagia. GnRH agonists block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen.
GnRH agonists include the implant goserelin (Zoladex), a monthly injection of leuprolide (Lupron Depot, generic), and the nasal spray nafarelin (Synarel). Such drugs may be used alone or in preparation for procedures used to destroy the uterine lining. They are not generally suitable for long-term use.
Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.
The most important concern is possible osteoporosis from estrogen loss. Women should not take these drugs for more than 6 months. Add-back therapy, which provides doses of estrogen and progestin that are high enough to maintain bone density but are too low to offset the beneficial effects of the GnRH agonist, may be used.
GnRH treatments used alone do not prevent pregnancy. Furthermore, if a woman becomes pregnant during their use, there is some risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms while on the treatments.
Danazol (Danocrine, generic) is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is occasionally used (sometimes in combination with an oral contraceptive) to help prevent heavy bleeding. It is not suitable for long-term use, and due to its masculinizing side effects it is only used in rare cases. GnRH agonists have largely replaced the use of danazol.
Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and reduced breast size. Danazol may also increase the risk for unhealthy cholesterol levels and it may cause birth defects.
Non-Hormonal Drugs (Lysteda)
Tranexamic acid (Lysteda) is a recently approved medication for treating heavy menstrual bleeding. Approved in 2009, it is the first non-hormonal drug for menorrhagia treatment. Tranexamic acid is given as a pill. It is an antifibrinolytic drug that helps blood to clot. The FDA warns that use of this medication by women who take hormonal contraceptives may increase the risk of blood clots, stroke, or heart attacks. This drug should not be taken by women who have a history of blood clots.
Women with heavy menstrual bleeding, painful cramps, or both have surgical options available to them. Most procedures eliminate or significantly affect the possibility for childbearing, however. Hysterectomy removes the entire uterus while endometrial ablation destroys the uterine lining.
For some women, an intrauterine device (IUD) that releases progestin is proving to be a good medical alternative to surgery. The levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), is increasingly being used instead of surgery to treat heavy menstrual bleeding. Studies have found the LNG-IUS to work just as well as ablation. Women should be sure to ask their doctors about all medical options before undergoing surgical procedures.
Endometrial Ablation
In endometrial ablation, the entire lining of the uterus (the endometrium) is removed or destroyed. For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.
Candidates. Endometrial ablation is not appropriate for women who:
- Have gone through menopause
- Have recently been pregnant
- Would like to have children in the future
- Have certain gynecologic conditions such as cancer of the uterus, endometrial hyperplasia, uterine infection, or an endometrium that is too thin
Considerations. Endometrial ablation significantly decreases the likelihood a woman will become pregnant. However, pregnancy can still occur and this procedure increases the risks of complications, including miscarriage. Women who have this procedure must be committed to not becoming pregnant and to using birth control. Sterilization after ablation is another option.
A main concern of endometrial ablation is that it may delay or make it more difficult to diagnose uterine cancer in the future. (Postmenopausal bleeding or irregular vaginal bleeding can be warning signs of uterine cancer.) Women who have endometrial ablation still have a uterus and cervix, and should continue to have regular Pap smears and pelvic exams.
Types of Endometrial Ablation. Endometrial ablation used to be performed in an operating room using electrosurgery with a resectoscope (a hysteroscope with a heated wire loop or roller ball.) Laser ablation was another older procedure. These types of endometrial ablation have largely been replaced by newer types of procedure that do not use a resectoscope.
The newer procedures can be performed either in an operating room or a doctor's office. They include:
- Radiofrequency. The NovaSure system uses a mesh electrode probe that emits electromagnetic energy to destroy the lining.
- Heated fluid. In the HydroThermAblator system, a saline solution is inserted into the uterus with a hysteroscope and heated until the lining is destroyed. In the thermal balloon method, a balloon inserted into the uterus with hysteroscope is filled with heated fluid and expanded until it touches and destroys the endometrium.
- Freezing. Cryoablation uses liquid nitrogen to freeze the uterine lining.
- Microwave. Microwave endometrial ablation applies very low-power microwaves to the uterus.
Before the Procedure. In preparing for the ablation procedure, the doctor will perform an endometrial biopsy to make sure that cancer is not present. If the woman has an intrauterine device (IUD), it must be removed before the procedure. In some cases, hormonal drugs, such as GnRH analogs, may be given a few weeks before ablation to help thin the endometrial lining.
During the Procedure. Endometrial ablation is an outpatient procedure. The doctor usually applies a local anesthetic around the cervix. (The patient also receives medication for pain and to help her relax.) The doctor will dilate the cervix before starting the procedure. Patients may feel some mild cramping or discomfort, but many of the newer types of endometrial procedures can be performed in under 10 minutes.
After the Procedure. Patients may experience menstrual-like cramping for several days and frequent urination during the first 24 hours. The main side effect is watery or bloody discharge that can last for several weeks. This discharge is especially heavy in the first few days following ablation. (Patients need to wear pads, not tampons during this time, and to wait to have sex until the discharge has stopped.) Patients are generally able to return to work or normal activities within a few days after the procedure.
Complications. Complications of endometrial ablation may include perforation of the uterus, injury to the intestine, hemorrhage, or infection. If heated fluid is used in the procedure, it may leak and cause burns. However, in general, the risk of complications is very low.
Nearly all women have reduced menstrual flow after endometrial ablation, and nearly half of women have their periods stop. Some women, however, may continue to have bleeding problems and ultimately decide to have a hysterectomy.
Hysterectomy is the surgical removal of the uterus.
Heavy bleeding, often from fibroids, and pelvic pain are the reasons for many hysterectomies. However, with newer medical and surgical treatments available, hysterectomies are performed less often than in the past. In its support, hysterectomy, unlike drug treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward. Still, any woman who is uncertain about a recommendation for a hysterectomy to treat fibroids or heavy bleeding should certainly seek a second opinion.
Some women who have hysterectomies have their ovaries removed along with their uterus. Surgical removal of the ovaries is called an oophorectomy. A hysterectomy does not cause menopause but removal of both ovaries (bilateral oophorectomy) does cause immediate menopause.
Doctors may recommend hormone therapy for certain women. Hormone therapy for a woman who has her uterus uses a combination of estrogen and progestin because estrogen alone increases the risk for endometrial (uterine) cancer. However, women who have had their uteruses removed do not have this risk and can take estrogen alone, without the progestin.
Nerve Destruction Techniques for Treating Dysmenorrhea
Some evidence suggests that surgically cutting the pain-conducting nerve fibers leading from the uterus diminishes the pain from dysmenorrhea. Two procedures, laparascopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN), can block such nerves. Some small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea or the chronic pelvic pain associated with endometriosis. Many insurance companies consider these procedures experimental and will not pay for them.
- www.acog.org -- American College of Obstetricians and Gynecologists
- www.resolve.org -- National Infertility Association
- www.asrm.com -- American Society for Reproductive Medicine
- www.endometriosisassn.org -- Endometriosis Association
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Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A. Treatment of menorrhagia. Am Fam Physician. 2007 Jun 15;75(12):1813-9.
Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008 Jun;35(2):219-34.
Chen EC, Danis PG, Tweed E. Clinical inquiries. Menstrual disturbances in perimenopausal women: what's best? J Fam Pract. 2009 Jun;58(6):E3.
Cho SH, Hwang EW. Acupuncture for primary dysmenorrhea: a systematic review. BJOG. 2010 Apr;117(5):509-21. Epub 2010 Feb 17.
Damlo S. ACOG guidelines on endometrial ablation. Am Fam Physician. 2008 Feb 15;77(4):545-549.
Daniels J, Gray R, Hills RK, Latthe P, Buckley L, Gupta J, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009 Sep 2;302(9):955-61.
Espey E. Levonorgestrel intrauterine system--first-line therapy for heavy menstrual bleeding. N Engl J Med. 2013 Jan 10;368(2):184-5.
Gordon CM. Clinical practice. Functional hypothalamic amenorrhea. N Engl J Med. 2010 Jul 22;363(4):365-71.
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Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J; ECLIPSE Trial Collaborative Group. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10;368(2):128-37.
Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2009 May;113(5):1104-16.
Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013 Jan 31;1:CD000400.
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Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection / ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001501.
Lobo RA. Abnormal uterine bleeding. Ovalutory and anovulatory dysfunctional uterine bleeding, management of acute and chronic excessive bleeding. In: Katz VL, Lobo RA, Lentz G, Gershenson D, eds. Comprehensive Gynecology. 5th ed. St. Louis, MO: Mosby; 2007:chap 37.
Lobo RA. Primary and secondary amenorrhea and precocious puberty. Etiology, diagnostic evaluation, management. In: Katz VL, Lobo RA, Lentz G, Gershenson D, eds. Comprehensive Gynecology. 5th ed. St. Louis, MO: Mosby; 2007:chap 38.
Marjoribanks J, Proctor M, Farquhar C, Derks RS. Nonsteroidal anti-inflammatory drugs for dysmenorrhea. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001751.
Matteson KA, Rahn DD, Wheeler TL 2nd, Casiano E, Siddiqui NY, Harvie HS, et al. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013 Mar;121(3):632-43.
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Advanced Studyec
Related Informationec
Review Date: 9/20/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


text:
HOUSTON - The Clippers rarely lose when Jamal Crawford leads the team in scoring.
Crawford insisted it has very little to do with him after his latest such game, one the Clippers played without Chris Paul.
Crawford scored a season-high 30 points, including 12 in a row to start the fourth quarter, and the Clippers looked just fine without Paul in a 117-109 win over the Houston Rockets on Tuesday.
The Clippers won their second consecutive game despite missing their star point guard, who is day to day with a bruised right kneecap.
The Clippers used a big third quarter to take the lead, and Crawford extended the advantage to 20 points by outscoring Houston 12-7 in the opening minutes of the fourth quarter.
The Clippers improved to 11-1 this season when Crawford, a 12-year veteran, leads the team in scoring. He appeared surprised when he learned of that statistic.
"It's everybody honestly," he said. "I've got the easy job just scoring but Grant (Hill), Blake (Griffin), all those guys put me in a position to score. ... I just have to make the shots, they're doing all the hard work."
James Harden had 23 points for the Rockets, whose four-game losing streak is a season worst.
The Clippers opened the second half with a 10-0 run to take a 68-59 lead with nine minutes left in the third quarter. Eric Bledsoe, starting in place of Paul, scored the last five points in that span and ended it with a 3-pointer. Houston missed four shots and had a turnover as the Clippers built their lead.
"Willie did a great job for us in the third, and then Jamal obviously got going in the fourth to take over the game," Clippers coach Vinny Del Negro said.
The Rockets finally found some offense when Chandler Parsons scored their first points of the second half on a layup with 8 1/2 minutes left in the third quarter. But the Clippers didn't let up and Willie Green soon got hot. He scored eight points in less than a minute, thanks in part to two turnovers by Omer Asik, and extended the lead to 81-65.
His last three points in that flurry came when he was fouled on a two-handed dunk, bringing the entire Clippers bench to its feet, and then made the free throw.
Grant Hill was called for a foul on Toney Douglas late in the third quarter and Blake Griffin received a technical foul after arguing with officials following the call. Griffin was immediately pulled from the game and received an earful from Del Negro when he got to the bench.
"I think we just have to control ourselves a little bit more," Del Negro said. "We can't be wasting points. We got a few technicals tonight. I got one on a difficult call against us.
"We just have to do a better job."
The Clippers entered the fourth quarter leading 90-77 after shooting 60 percent in the third quarter.
"We couldn't establish much defensively," Houston coach Kevin McHale said. "We played one side of the court, on the offensive end, in the third quarter. We just gave in in the third quarter. We didn't have what we needed to have."
Bledsoe and Griffin added 19 points apiece for the Clippers and Matt Barnes had 18. Bledsoe's points were a season high and Green also had a season-high 15 points.
Crawford said the win was a perfect example of the way they want to play.
"That's what it's about. We do it collectively," he said. "We all pull for each other and we're all in it together and that's how we win."
Crawford had a spectacular run to start the fourth quarter in which he made five consecutive shots, including a pair of 3-pointers, to push the lead to 102-82. Houston called a timeout after his last basket in that run and DeAndre Jordan dashed off the bench and met him for a celebratory chest bump near center court.
The Rockets went on a 10-2 run later in the fourth quarter to pull within 108-96. But the Clippers responded with two 3-pointers sandwiched around a basket by Jeremy Lin to thwart the comeback attempt.
Harden was disappointed the Rockets didn't get back on track in their one home game before four in a row on the road.
"You can't do that, especially coming off a three-game road trip, a three-game losing streak," he said. "We've got to be better, especially on the defensive end.
"We've got to guard in order to win games. It's simple."
The Clippers were up by one point in the second quarter when Lamar Odom received his third foul. Del Negro received a technical for arguing the call and seconds later Odom also was getting a technical foul for arguing. Harden made just one of the two free throws, but Morris connected on a 3-pointer a few seconds later to give Houston a 39-36 lead.
Houston trailed by two about a minute later before using a 13-4 run to go on top 52-45 about 3 1/2 minutes before halftime. The Clippers outscored the Rockets 13-7 for the rest of the quarter to cut the lead to 59-58 at halftime.
Parsons finished with 17 points and Lin added 12 points with 10 assists.
Also ...
Tuesday was Hill's 1,000 th career game, making him the 20 th active player to reach the mark. ... Houston Texans stars Arian Foster and Andre Johnson watched the game from courtside seats. Foster received a nice ovation from the crowd as he walked alongside the court to his seat in the third quarter. The Texans lost to New England in the divisional round of the NFL playoffs on Sunday.

subset: commoncrawl


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The Quest has always distinguished itself in the bland minivan market by offering distinctive styling and unusual ergonomics. The 2016 Quest is no different. With a boxy rear end, a smirking front grille and Nissan's fun-to-drive attitude, the Quest is a tough package to beat.
Compare the 2016 Nissan Quest against similar models
The Nissan Quest is unchanged for 2016.
A vehicle's warranty can significant impact your maintenance costs after you drive off the dealer's lot, and it's important to understand the different parts. Typically, a new car warranty includes a Basic warranty, which covers everything except the wear items such as brakes and tires; and a Drivetrain warranty, that covers all the parts that make the car move, such as the engine and transmission
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The Nissan Quest fights minivan dullness with satisfying road manners and rewarding driving traits. Passengers will like the Quest's smooth ride, while drivers will appreciate its performance and steering response, and owners will appreciate its fuel economy.
Performance benefits from Nissan's 3.5-liter V6, matched well with a responsive continuously variable transmission. Responsive CVT is considered an oxymoron, but Nissan has some of the best CVTs on the market. The transmission incorporates some pre-programmed virtual shift points, to reduce any rubbery response, which has been the bane of some CVTs. All models are front-wheel drive.
On the whole, the powertrain doesn't struggle or complain. In fact, the entire setup feels quite peppy while propelling such a big vehicle.
Steering delivers good feedback to the driver, while body roll is better curtailed than in other large minivans. Simply put, Quest may offer the best handling among minivans.
Space utilization is disappointing, however. Front-seat passengers get sufficient leg and head room, as well as storage for small items. But sliding side doors don't open wide enough to easily accept large people or objects. A Quest seats only seven passengers, while most rival minivans seat up to eight, though that won't matter to buyers who want a seven-seater. The second-row seats fold forward, but doesn't disappear into the floor and is not removable. The third-row seat does fold flat, but remains in place.
Cargo space totals 35 cubic feet behind the third-row seats, 108 cubic feet with all rear seats folded down, and 64 with the back row folded. Most rival models top 140 cubic feet.
Many consider Quest design to be more adventurous than that of other minivans, helped by an abundance of flared lines up front. At Quest's no-pillar greenhouse and near-vertical tail, there's a similarity to the Ford Flex crossover SUV.
This fourth-generation Quest was introduced as a 2010 model. There are no significant changes for 2016.
Despite family-friendly intentions, safety ratings fall below average. The Insurance Institute for Highway Safety gave the Quest Good crash-test ratings for front and side impacts, but Acceptable for roof crush. In the small-overlap crash, Quest was among the worst they'd observed.
The 2016 Nissan Quest is available in four trim levels. Quest S comes with power air conditioning but lacks satellite radio, rearview camera, or Bluetooth.
Quest SV includes Bluetooth, USB port, rearview camera, power sliding doors, a 4.3-inch LCD audio display, and automatic climate control.
Quest SL upgrades with leather seating, power front passenger seat, power liftgate, heated front seats, heated mirrors, automatic headlights, and 18-inch wheels. Quest Platinum adds satellite radio, a navigation system, power third-row seat, DVD entertainment with 11-inch screen, and xenon headlights.
Safety features include a full complement of airbags, stability control. Extra-cost safety features include a rearview camera (standard on the top three trim levels), a 360-degree AroundView camera and blind-spot monitoring.
More upright and boxy-profiled than in the past, with a straight-edged passenger compartment, the Quest comes across as more trendy than most minivans. Quest's roots stem from Japanese-market models, while other minivans are typically more curvaceous.
Thanks to large air intakes, the front end looks lower and smaller, whereas the tail ends rather abruptly, or even harshly. Large taillights make it easier to find the Quest in a parking lot, or in the dark.
On the inside, Quest appears more typical of minivans: passenger-friendly and pragmatic. Yet even here, it feels somewhat formal, with a dashboard of plain-looking LCD displays and stacked rectangles. Atop the controls is an LCD screen: five-inch on midrange models, or eight inches on upper versions. Piano-key type buttons sit below the screen.
Audio controls can be confusing, and some controls are in non-intuitive places. The transmission lever may block the view of certain knobs and buttons.
Though purposeful, Quest fails to offer the cargo and seating benefits of the best minivans, lacking some of the practicality expected in a family vehicle. Front riders get ample leg and head space, and the plushy-upholstered bucket seats allows for large adults to fit comfortably.
Second- and third-row seats are supportive and neatly angled, but they don't move; seatbacks merely fold over. Seats do fold easily enough, using levers and pull straps. The third-row seat is tight and cramped for adults, but acceptable for youngsters. Squeezing a car seat through the narrow sliding-door opening can be tough.
In addition to having a relatively high load floor, the Quest feels small inside. There's no telescoping steering wheel, though a high seating position helps.
Compared to most minivans, the Quest is fun to drive, providing the best acceleration and steering feel in that vehicle class. Steering beats all competitors, and performance excels, though some may not appreciate the relatively sluggish CVT.
With a smaller footprint than rival minivans, Quest doesn't feel as big as it looks. Due largely to electro-hydraulic steering, it's the most nimble of the group, delivering the most natural steering feel. Ride comfort is helped by an effectively-damped, fully independent suspension. It doesn't bound over long bumps like Chrysler minivans. Despite such impressive handling talents, a Quest seems to corner and accelerate with safety uppermost.
Smoother and quieter than most Nissans that use the same V6, the Quest almost never feels strained or lacking sufficient power. Even the CVT behaves well, thanks in part to Nissan's D-Step shift logic. Those virtual gears help keep the CVT fairly responsive. While CVTs often feel sluggish to respond and amplify noise and vibration, stepped "gears" help it feel fairly responsive, and few will be bothered by occasionally slow reactions to throttle inputs.
The CVT helps make Quest one of the most fuel-efficient minivans, EPA-rated at 20/27 mpg City/Highway, or 22 mpg Combined.
Taking its pluses and minuses into account, the Quest isn't an easy vehicle to recommend in the minivan segment. In safety, space, and features, the Quest doesn't quite compete. To get Bluetooth capability and a rearview camera, you have to step up to a Quest SV, which is the version we recommend. With a full load of amenities, you could spend more than $44,000.
Driving impressions by Kirk Bell, The Car Connection. James M. Flammang contributed to this report.
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text:
Celebrities weigh in on Lance Armstrong's confession
(Yahoo! omg!) - In case you missed it, Lance Armstrong finally admitted he was doping during his storied cycling career. But, you live in the modern age of tweet or it didn't happen and, since the story practically broke the internet, we know you know.
And you weren't the only ones tweeting about it. Since Armstrong was such a huge star with so many celebrity fans and friends, the Twitterverse was exploding during his big interview with Oprah Winfrey on Thursday night.
We thought we'd save you the grunt work and share some of the (mostly hilarious) highlights. Be sure to let us know your favorite in the comments.
Thank you, Lance Armstrong, for sitting down with Oprah last night. I missed the interview, but I heard it was dope. #ThankYouNoteFriday— jimmy fallon (@jimmyfallon) January 19, 2013
The Lance Armstrong confession should've ended with him pedaling away on a tiny bike with training wheels. You know.. symbolism.— Dane Cook (@DaneCook) January 19, 2013
Bad day: Spent it on a 787 Dreamliner with Lance Armstrong and Manti Te'o's ex girlfriend.— Steve Martin (@SteveMartinToGo) January 18, 2013
Despite the latest news my father will not stop using Lance Armstrong as an adjective for strength and determination.— Lena Dunham (@lenadunham) January 18, 2013
I'm just bummed I wasn't asked to sing on this episode. #Oprah— josh groban (@joshgroban) January 18, 2013
Great day for liars! They are dominating the news today. #CongratsUSA— Rashida Jones (@iamrashidajones) January 18, 2013
I always want to make sure Oprah is on MY side.— matthew perry (@MatthewPerry) January 18, 2013
Wow. Watching @oprah interview. Just WOW— Serena Williams (@serenawilliams) January 18, 2013
CHEAT ( noun) A person who behaves dishonestly in order to gain an advantage. Lance left out the "behaves dishonestly" part, right?— Rita Wilson (@RitaWilson) January 18, 2013
Honestly I don't care that Lance doped. He gave people hope and that's more important then anything. So what if he lied. #livestrong— Jack Osbourne (@MrJackO) January 18, 2013
Would love to see Lance Armstrong and Barry Bonds do The Odd Couple on Broadway.— Albert Brooks (@AlbertBrooks) January 18, 2013
Wow..... Oprah comes out very strong!— andyroddick (@andyroddick) January 18, 2013
"It didn't feel wrong"He didn't feel bad.He didn't feel he was cheating.— Anderson Cooper (@andersoncooper) January 18, 2013
If Oprah's smart, she'll have James Frey come out and give Lance a hug.— Michael Ian Black (@michaelianblack) January 18, 2013
The fact @lancearmstrong admits he had to look up what the word 'cheat' means, says all you need to know about the man. #LiveWrong— Piers Morgan (@piersmorgan) January 18, 2013
A lot of sports journalists were questioning if Oprah had what it takes to thoroughly interview Lance Armstrong. The woman is shredding him.— Tom Arnold (@TomArnold) January 18, 2013


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I am having an issue with the illuminated keyboard while running on Backtrack 5. While the computer is first booting the keyboards backlight will turn on, but as soon as it starts to boot into backtrack the lights shut off an I have yet to find a way to get them to come back on. I made sure that the backlight was turned on in the bios.
Any possible solutions?
Computer model: Toshiba Satellite A665D-S6084
Keyboard type: Premium Raised Tile LED Backlit Keyboard with 10-Keypad
OS: Backtrack 5 Gnome 64-bit


text:
Take your first steps into the world of Vana'diel with theTest your mettle against the advancing hoards of beastmen that threaten the peace of the land.
FINAL FANTASY XI 14-day free trial!
FINAL FANTASY XI 14-day free trial!
Dive into the extensive job system that allows you the freedom to change your job as often as you like! Mix and match support jobs to fit your style of play and adventure how you want to!
Now is your chance to experience the rich story-telling that is a staple of the FINAL FANTASY series as you tackle quests and epic missions.
Join the hundreds of thousands of adventurers already a part of an unprecedented global online community!
For more details and conditional restrictions, please click here.


text:
Dolphin Artists :: Mike Vax
Related ArtistsBobby Shew
Mike Vax is a jazz trumpeter. He has played with many great musicians, including Art Pepper, Freddie Hubbard, and the Glen Miller and Jimmy Dorsey Orchestras. He claimed the role of lead trumpet in the Stan Kenton Orchestra and the Stan Kenton Alumni Band. He tours Europe and the United States to provide clinics for young trumpeters trying to learn jazz and classical music. He was an International Artist for Yamaha, but now plays on trumpets, flugelhorns, cornets, and mouthpieces of the Getzen Corporation. Read more on Last.fm more
Related News
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Getzen 3001 Artist Model Custom Bb Trumpet
Typical 0% APR Take it away is an Arts Council initiative designed to help more people get involved in learning and playing music. The scheme allows individuals to apply for a loan of up to £2,000 for the purchase of any kind of musical instrument, and pay it back in nine monthly instalments, completely interest…
Web Price:1833.19
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Getzen Custom Genesis 3003 Bb Trumpet
Press Release: Mike Vax Mike Vax is an International Artist for the Getzen Company. Mr. Vax performs exclusively on Getzen trumpets, cornets and flugelhorns. He has played lead and solo trumpet with the Stan Kenton Orchestra, the Clark Terry Big Bad Band, and the U.S. Navy Show Band. Mike has also performed and/or recorded with such greats as Art…
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text: Michael W. Perry is one of the most recognized and respected names in Hawaii broadcast history.With a degree from Michigan State University, he served as a Lieutenant in the Pacific Submarine Force, then spent 11 years as Hawaii's number one afternoon radio personality before teaming up with Larry Price for 33 years of the Perry and Price Show. And now Perry and The Posse is currently number one in market share for morning radio nationwide!For 28 years, he was Executive Producer and Host of the award-winning Hawaiian Moving Company, one of America's highest rated local TV shows, and acted in national television shows (Hawaii 5-0, Jake and the Fatman, Island Son, Blood and Orchids) and movies (Molokai: The Father Damien Story, Princess Kaiulani).Mike devotes much of his time to local charities (Castle Medical Center, The Sony Open), and is Chairman of the Board of Directors for both REHAB Hospital Foundation and the Takitani Foundation).He is married, has three children, nine grandchildren, and lives in Kailua. Contact Call 296-9292 / 296-5959 Social


text:
This memory foam wedge elevates your legs to improve blood circulation, helping to relieve lower back pain, leg cramps, and muscle spasms as you lie supine. Unlike a stack of pillows that requires repeated readjustment and does not provide proper support, the unit has an insert that adjusts from 5" to 9" high and a memory foam surface that contours to the shape of your legs, ensuring proper, constant support throughout the night. The hypoallergenic leg support quickly reverts to its original shape when not in use, ensuring it will neither sag nor settle. The washable antimicrobial cover is made of breathable Coolmax that wicks away moisture. 11" H x 20" W x 25" L. (2 lbs.)
Lifetime Guarantee
The Pain Relieving Contoured Leg Support comes with The Hammacher Schlemmer Lifetime Guarantee. If this product ever disappoints you, for any reason, you may return your Hammacher Schlemmer purchase for exchange, credit, or refund.
Should you have any questions, we are available seven days a week (8:00 am – midnight EST). Please call 1-800-321-1484 to speak with a specialist or email us at firstname.lastname@example.com to receive a response within three business hours or less.
Shipping charges noted in parentheses apply in addition to our standard shipping & service.
We're sorry, but gift wrap is not available. Please call 1-800-395-7006 for Premium or Express delivery rates.
Oversized items scheduled for expedited delivery (Premium or Express) may incur additional shipping and services charges because of their unusual size. Please call 1-800-321-1484 for an estimate of S&S charges. International callers, please call 1-513-860-3397.
We're sorry, but gift wrap is not available for oversized items.
Shipped via truck and may require customer assistance upon delivery. You will be contacted to make an appointment for delivery.
We're sorry, but gift wrap and gift cards are not available.
GST still applies and will be charged upon processing. For complete shipping & service charges please call Customer Service at 1-800-321-1484.
May we recommend:
(based on 14 reviews)
Ratings Distribution
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Reviewed by 14 customers
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(2 of 2 customers found this review helpful)
Legs are too short
By Linda
from Calgary
This leg support would b perfect, however, my legs are too short, so, I can't get truly comfortable. I simply don't fit the contours of the pillow. Too bad, because I love the feel of the pillow. Material is soft and comfy. I am 5'3"...need to stretch a bit.
Bottom Line Yes, I would recommend this to a friend
Was this review helpful? Yes / No
- flag this review
Relieves the pain
By Tiffy
from NY
I have foot/leg circulation issues where I need to keep my foot elevated to ease the pain. This has helped me a lot instead of stacking a bunch of pillows or placing my leg on a wall wich is a bit uncomfortable with no positive results. I feel immediate relief using this leg support.
(1 of 1 customers found this review helpful)
Works well, needs a slipcover.
By AD
from Japan
I have used this in my last trimester of pregnancy. It's high quality foam and very nice but it needs a slipcover option. The thin zipper cover included is only meant to protect the fabric and isn't a proper pillowcase (but where can one be purchased to fit this obscure shape?)
works better than advertised
By nasa
from norfolk, VA
Although you will never find a matching pillowcase because it is so big, it really works. You can remove foam pieces to get just the right fit. At first I thought it would be worse than other wedges I have used, but I was proven wrong after the first night.
Worth the price
By Pixille
from Tampa, FL
use every night for my tired, achy/varicose vein leg symptoms--offers very comfortable support
This product will continue to provide co
By Rojac
from New Jersey
Although the pillow is large it is extremely comfortable and helps with leg cramps and swelling feet that needs to e elevated. I recommend it highly.
leg support for sleeping
By better sleeper
from Northern Virginia
My husband was using stacked pillows that moved during the night. This stays put and allows flexibility to change height. It is just right, good quality, great price.
Super Product!
By LindyLou
from Tallahassee,Fl
This is a comfortable alternative to a stack of pillows that slide around. It is great for keeping your legs from looking and feeling like stuffed sausages~and I only weigh 125 pounds, but do to heredity I got mama's fat legs. Drs. have suggested regularly elevating my feet. This pillow does the trick.
Great Product, Super Price
By Cherie
from Montreal
Love the leg rest, but it is not a perfect fit for your calves if you are not tall enough. Still, very comfortable. I like the adjustable part. One of the best leg rests I have ever bought and I will definitely buy it again.
Did not fit
By FRL
from Birmingham, AL
I liked this but my legs were to short.
Bottom Line No, I would not recommend this to a friend
COPYRIGHT © 2017 HAMMACHER SCHLEMMER & COMPANY, INC. ALL RIGHTS RESERVED. W107147 E. 57th ST • NEW YORK, NY • 10022 • 1-800-_321-1484


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In before brap brap brap
Fletcher's hat is quite funny tho
In before brap brap brap
Fletcher's hat is quite funny tho
16-bit for life http://findingdyluck.blogspot.co.uk/
Decent show imo, good punch that caught Petrescu, hope Parke is up next.
Also Fletcher is mental lol.
Before this was shown i knew Col would become star of the show and now i'm confident he deffo will be.
3-2-0 Pro Fighter managed by TFL Sports Agency
Who do you think are the main British talents to look out for? i.e highest chance of winning it in each division?
Personally as with most recent TUFs I don't think many on the show from either side will make a dent in the UFC roster.
"The more you sweat in peace, the less you bleed in war"
I thought overall it was quite an enjoyable episode tbh.
Petrescu looked pretty good I thought. The show didn't focus on him struggling to make the weight or anything I noticed. He just got clipped with a nice shot and finished.
16-bit for life http://findingdyluck.blogspot.co.uk/
Col fletcher will win the show id put my life on it
Liam Bad Intentions James, pro mma uk featherweight!!
I think there's a few in that house who, if results go their way and they're shrewd with presentation, could wind up fighting quite a bit for the UFC.
16-bit for life http://findingdyluck.blogspot.co.uk/
What channel/time was this on? Any links to where I can catch up on it, cheers
Baroni - "I'm the man, the fucking man, the best ever, ever"


text:
This event is in the past.
April 16, 2014 | 9:00 a.m. - 1:00 p.m.
Category: Recruitment
Location: Schoolcraft College Henry's Food Court
18600 Haggerty Rd
Livonia, MI 48152
Livonia, MI 48152
Cost: Free
Audience: Prospective Students
Adanna Smith, WSU Admissions Counselor, will conduct a general visit at Schoolcraft College. The general visit will allow an opportunity for prospective students to speak with an Admissions Counselor to find out about admission requirements and details about the promising paths offered to students interested in attending Wayne State University.
For more information about this event, please contact Adanna Smith at 313-577-3577.


text:
Senior Recital: Brandy Clark, soprano
When Saturday November 23, 2013 @ 7:30 PM (1341 days ago)
Where Martin Chapel
Duration 1 hour
Come out to hear a variety of music by composers such as Handel, Schubert, Britten, Mozart, and Rodgers and Hammerstein. Refreshments will be served after the recital.
Intended Audience General Public
Contact Information
Name Music Dept
Phone # 540.432.4225


text:
The LSU Board of Supervisors has agreed to redo a vote on the merger of the president and Baton Rouge chancellor positions after Louisiana's attorney general launched an investigation citing "serious concerns" over whether LSU violated the state's open meetings law.
The board's unanimous Oct. 26 vote came under fire from Faculty Senate President Kevin Cope, who complained the merger vote was not on the board agenda as required by the Open Meetings Law.
Cope took the matter up with Attorney General Buddy Caldwell, arguing that the LSU board intentionally hid its plans in order to stifle public comment.
The LSU Board tried to orchestrate the vote as if it was a spontaneous decision to vote on the job merger, but an attorney representing the board "read on cue a carefully prepared version of the resolution," Cope wrote Caldwell.
Cope called that proof the board intended to vote on the matter at the meeting without giving the public the required access to the report.
"The board's actions shows contempt for the public in that they illegally tried to stifle input from the public," Cope said Thursday. "If the merger is such a good thing, why was the board afraid of public debate."
Blake Chatelain, the LSU board member who pushed for the vote, has denied Cope's allegations.
LSU General Counsel Shelby McKenzie has also argued that, although the meeting agenda was vague, LSU did nothing wrong. McKenzie has since declined further comment.
The letter from state Assistant Attorney General Emalie Boyce to LSU mentioned some missteps in the way LSU handled the vote.
The official meeting agenda gave notice that board members would discuss a report put together by the Association of Governing Boards consulting group, a Washington, D.C. firm known as AGB, helping LSU plan its future.
The 16-page report addressed a number of issues related to LSU's structure, including the efficiencies that could be created by combining the two positions.
State law requires that each item on a meeting agenda is required to be listed and "described with reasonable specificity."
Boyce wrote in her letter that board members voted to consolidate the two positions during the part of the agenda listed vaguely as "consideration of a report from the Association of Governing Boards on the structure of the LSU system."
Boyce later cites the detail in which several other items on the agenda were listed including requests for property transfers and approval of a construction budget. She juxtaposed those items with the imprecise way the merger vote was listed.
"The agenda item which is the subject of this complaint ... does not appear to convey to the public the same degree of specificity that other agenda items indicated," she wrote.
Boyce added that the murkiness of the agenda item denied the public sufficient notice and opportunity to comment on the issue before the board vote — also a possible violation of open meetings law.
The letter ends with Boyce advising LSU that any action made in violation of open meetings law can be voided should someone file suit within 60 days of the vote.
On Thursday morning, shortly after learning of the attorney general's investigation, LSU board chair Hank Danos announced that the board will re-introduce a resolution to combine the two positions at their Dec. 7 meeting.
"We thought what we did was appropriate, but the attorney general suggested there were some concerns. We will take the appropriate action to correct that at our next meeting," Danos said.
Cope called Danos' decision a "welcome development."
"The attorney general's action sends a clear sign to the Board of Supervisors that the old days where much of the business could be conducted in secret, are over," Cope said.
Marsha Shuler contributed to this report.


text:
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Re: Controlling evaluation
Evaluate will evaluate its arguments if it appears as argument in a
function with one of the Hold.. attributes. Consider:
Condition[expr, samelistQ[arg1 // Evaluate, arg2 // Evaluate]]
Condition has the attribute HoldAll. If samelistQ has the asme
attribute, we therefore need to write Evaluate twice:
Condition[expr, Evaluate[samelist[Evaluate[arg1],Evaluate[arg1]]]
hope this helps, Daniel
magma wrote:
> I am building a package and I need to programmatically construct
> expressions .
> At a certain point I have
> arg1 = {a, b, c}; (* some list *)
> arg2 = {d, e, f}; (* some other list *)
> samelistQ[list1_List, list2_List] :=
> list1 === list2 (* some logic function *)
> Now I want to construct an expression like
> Condition[expr, samelistQ[arg1, arg2]]
> with arg1 and arg2 evaluated, but with samelist[...] not evaluated.
> In other words, I want to obtain exactly this
> Condition[expr, samelistQ[{a, b, c}, {d, e, f}]]
> where the 2 args have been evaluated, but samelistQ[...] appears
> always unevaluated
> What is expr is not important, just leave it unassigned.
> The problem is that Condition blocks the evaluation of arg1 and arg2
> and of samelistQ.
> Now, doing
> Condition[expr, samelistQ[arg1 // Evaluate, arg2 // Evaluate]]
> does not work, because Evaluate does not disappear.
> So what to do? I tried Hold, ReleaseHold, ect, but it didn't work.
> This is how I solved it
> Condition @@ List[expr, pp[arg1, arg2]] /. pp -> samelistQ
> where pp is an unassigned symbol.
> My question: isn't there a better way, using the functions which are
> supposed to control evaluation (Hold, Evaluate, ect) to achieve this
> result?
> Perhaps a related more general question:
> how do we block
> f[x,y]
> while allowing evaluation of x, and y ?
> Thank you in advance for any comment


text:
Puma is the product of a sibling-rivalry moment between brothers Rudolf and Adolf Dassler, who in 1948 resolved an argument by splitting their Bavaria-based shoe factory into two new companies: Puma, founded by Rudolf, and Adidas, established by Adolf. In addition to creating iconic suede basketball shoes, Puma has outfitted elite athletes such as soccer legend Pelé and was the first footwear company to use vulcanized rubber and foam-free midsoles. These days the globally recognized lifestyle megabrand produces sneakers and stylish sweats for men, women, and children as well as underwear, accessories, sports league uniforms, golf clothing, chic outerwear, and watches — all emblazoned with Puma's signature leaping cat logo. Always an innovator, Puma has collaborated with high-profile couture designers such as Jil Sander and, through its luxury lifestyle brand Puma Black Label, Alexander McQueen and Mihara Yasuhiro.
No-sweat style, perfect for your time on and off the elliptical
Work up a sweat with these high-performance bras, leggings, and more
Stay active in easy-going separates, shoes, and more
Killer pieces that are sure to provide an extra dose of daily #fitspo


text:
Have you been looking for a Mac OS X dictionary, that can translate any word from any language, for a long time?
Congratulations! You have just found it!
We are happy to present TranslateIt! for Mac!
TranslateIt! for Mac is the multilingual dictionary that allows you to look up words on the fly!
Just hover the pointer over an unfamiliar word in any Cocoa Application, and you will see its translation in a pop-up window instantly.
TranslateIt! promo-video
TranslateIt! for Mac features:
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