Friday, August 26, 2016

Uterine Fibroids, Part 1-A surprisingly common problem

Uterine fibroids, also known as leiomyomas or simply "myomas", are non-cancerous tumors that grow in, on, or outside of the wall of the uterus.   In a study involving U.S. women between the age of 35 and 49 years of age, it was found that 60% of African-American women and 40% of Caucasian women had evidence of this benign tumor. The prevalence of fibroids increased to over 80% in African-American women and 70% in Caucasian women by the time they were 50.

Fibroids can range in size from smaller than a pea to larger than a grapefruit.   Often, there will be more than one present.  Fibroids are most common during a woman's reproductive years as their growth is affected by the presence of hormones, both estrogen and progesterone. After menopause, when estrogen levels decline, fibroids usually shrink in size.

Many women are unaware they have fibroids because they often cause no symptoms.  These are usually discovered during a routine pelvic exam or after performing an ultrasound of the uterus for some other reason. Approximately 20-25% of women who have fibroids will have symptoms which are based primarily on the size or location of the tumors.  The most common symptoms caused by fibroids are:
  • Heavy, painful, and often prolonged menstrual periods
  • Spotting between periods
  • Chronic pelvic pain
  • Abdominal fullness
  • Constipation or frequent urination due to pressure on the bowel or bladder
  • Painful intercourse
  • Lower back pain
In severe cases, uterine fibroids can produce problems with fertility, premature labor, or repeated miscarriages.

Should an asymptomatic uterine mass be detected on routine examination, or if a woman presents with symptoms or physical findings consistent with fibroids, an ultrasound of the pelvic region is typically performed. In most cases, the sound wave test is adequate to establish the size, number, and location(s) of the tumor(s) and to establish a treatment plan. In  some cases, more in-depth imaging studies such as magnetic resonance imaging (MRI) or x-rays of the pelvis following injection of dye into the uterine cavity and fallopian tubes (hysterosalpingogram) may be required.

In the past, many women with large or highly symptomatic fibroids opted to undergo surgical removal of the uterus (hysterectomy).  Once the uterus is removed, however, a woman can no longer have children.  Additionally, hysterectomies were often accompanied by removal of the ovaries ("total hysterectomy"), producing a "surgical menopause".  While removal of the uterus does provide definitive treatment for symptomatic fibroids there are now a number of other treatment options for treating fibroids.  In next week's Health Tips we'll look at a number of medical as well as surgical options for removing fibroids or addressing the symptoms that they produce.

Sources for article:
Uterine fibroids from Mayo Clinic
Uterine fibroids from MedLine Plus

Friday, August 12, 2016

Help for excessive sweating

Sweating is a physiologic process whose primary purpose is to help with regulation of body temperature. People normally sweat more profusely when it's hot outside or when exercising. People also sweat more in response to situations that make them nervous, angry, embarrassed, or afraid. In an estimated 2 to 3% of Americans, however, sweating can be so excessive that it disrupts normal activities. Sweating of this severity is known as hyperhidrosis. Hyperhidrosis may be present if you have any of the following:
  • Excessive sweating of the soles and palms that causes clammy hands and unpleasant foot odor.
     
  • Profuse sweating that soaks through clothing
     
  • Sweating that results in a skin problem such as a fungal rash or prickly heat
     
  • Sweating that occurs at night or when the ambient temperature is normal
What causes excessive sweating? Hyperhidrosis can be primary or secondary. Primary hyperhidrosis is the most common type. It most often affects people who are otherwise healthy with excessive sweating involving the feet, hands, head, and underarms. Secondary hyperhidrosis has an underlying cause, such as hormonal changes (e.g. menopause), anxiety, an overactive thyroid gland, excessive caffeine consumption, certain medications, and with some types of infection and cancer.

What can be done for hyperhidrosis?  When hyperhidrosis is secondary to some other problem, the most effective treatment is to address the underlying cause. For example, if an overactive thyroid is responsible, addressing this condition should take care of the problem. In instances where there is no known cause, treatment usually follows a stepwise progression:
  1. Over-the-counter (OTC) antiperspirants.  These are usually tried first since they are readily available and fairly inexpensive. Most antiperspirants have an aluminum-based compound as their main ingredient, which works at the level of the sweat glands to decrease sweat production. This distinguishes antiperspirants from deodorants that merely block odor.
     
  2. Prescription antiperspirants. When an OTC antiperspirant is insufficient, use of a prescription antiperspirant may be considered. These also contain aluminum compounds, but at a higher concentration than the OTC products. Xerac and Drysol (aluminum chloride hexahydrate) are two of the most common prescription antiperspirants. These products are most appropriately used to prevent underarm sweating. Since they can be irritating and staining to clothing, they are typically applied before bedtime. After several nights of use, the prescription antiperspirant is then applied only once or twice weekly to maintain the effect.
     
  3. Iontophoresis. This treatment is best applied to hyperhidrosis affecting the hands and/or feet.  It involves the use of a device that passes electricity through the skin while the affected appendages are immersed in water.  While its mechanism of action is unclear, it has been used successfully for years. The procedure is painless, and typically takes anywhere from 10 to 20 minutes.
     
  4. Botox (botulinum toxin). Botox has been approved by the FDA for use in excessive underarm sweating. It works by blocking the nerves that trigger the sweat glands.  Treatment involves the delivery of multiple injections, usually performed by a Dermatologist, into the armpit which can provide up to 6 months of benefit.  As expected, the treatment can be uncomfortable, but side effects are uncommon.
     
  5. Oral medications. The most commonly used medications for managing hyperhidrosis are anticholinergics. Robinul (glycopyrrolate) is one of the most commonly prescribed of these.  In addition to dry mouth, these medications can cause a number of side effects including constipation, blurry vision, urinary retention, loss of taste, dizziness and confusion. Other classes of medications occasionally used include beta blockers (e.g. propranolol) and benzodiazepines (e.g. Valium). These medications work primarily by "blocking" the physical manifestations of anxiety.
     
  6. Surgery. Surgery is the treatment of last resort and is only considered in cases of severe hyperhidrosis when other treatments haven't worked. The two primary surgical options are 1) removal of the sweat glands themselves or 2) sympathectomy, a procedure in which the nerves that activate sweat glands are destroyed.  
Are self-care measures helpful for excessive sweating?  There are a number of things that you can do to reduce sweating and associated body odor. The first is to bathe daily with an antibacterial soap. Be sure to dry yourself completely after bathing, since odor-causing bacteria thrive in a moist environment. Antiperspirants are most effective when applied near bedtime when sweating is minimal. Whenever possible, wear natural fabrics, such as cotton, wool or silk. These help to allow the skin to breathe. When exercising, one of the newer wicking fabrics will help to move moisture away from the skin.  Wear shoes that are made of breathable material, such as leather, and socks made from cotton or wool that will absorb moisture. For many people, it is best to avoid certain foods or drinks, such as alcohol, spicy foods and caffeine, since these can contribute to sweating. If your sweating is precipitated by anxiety or stress, engaging in relaxation exercises may be helpful.

Sources for article:
Hyperhidrosis from the American Academy of Dermatology
What's in Your Antiperspirant? from WebMD
Medications from the International Hyperhidrosis Society

Friday, August 5, 2016

Macular Degeneration

The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain. The macula is a portion of the retina which provides the detailed, central vision needed for activities such as reading and driving.  Macular degeneration is the breakdown of this small, but highly important, area of the retina.  The most common cause for this is aging, thus the name, age-related macular degeneration (AMD).  AMD is estimated to affect approximately 2 million Americans with most cases occurring over the age of 70.
   
Two types of AMD are recognized, dry and wet. Dry AMD (also known as non-neovascular) constitutes around 85% of the cases. It is characterized by yellow deposits in the retina called drusen. Dry AMD usually progresses slowly as the light-sensitive cells in the macula break down. Wet, or vascular AMD, is a more severe form of the disease that starts off as dry AMD. The name "wet" comes from the fluid that leaks from abnormal blood vessels growing beneath the macula. The leakage of blood and fluid beneath the macula can cause rapid and permanent loss of vision.

 What are the symptoms of AMD? The predominant symptoms of AMD are somewhat different depending on whether it is wet or dry.  Initially, with dry AMD, words on a page may appear blurry.  As it progresses, dry AMD causes loss of central vision in the affected eye.  Dry AMD generally affects both eyes, but the rate of progression may vary between eyes.  In wet AMD, an early symptom is that straight lines appear wavy.  This can progress fairly quickly to the development of dark gray spots or blank spots in the visual field.

Who is at risk for developing AMD?  Most AMD develops in those over the age of 60 with up to 30% of people over the age of 75 having some degree of AMD.  Due to their longer life expectancy, women are more likely to develop this disease. Other risk factors include smoking, obesity, high blood pressure, elevated cholesterol, and a family history of AMD.

How is AMD diagnosed? An evaluation by an Ophthalmologist is warranted should visual symptoms (blurry words, central blind spot, etc.) suggestive of AMD occur. A dilated eye exam may demonstrate drusen or abnormalities of the macula. If wet AMD is suspected, a fluorescein angiogram is usually performed.  In this test, a special dye is injected into the arm and pictures are taken of the retina as the dye passes through its blood vessels.  A second scanning procedure known as optical coherence tomography may also be used to make high-resolution images of the retina to look for abnormal blood vessels.

Is there a treatment for AMD?  AMD cannot be cured, but there are measures that can help preserve vision.  For wet AMD, laser surgery, photodynamic therapy, and injections into the eye (anti-VEGF therapy) may be used to destroy the leaky blood vessels growing beneath the macula.  No specific treatment is recommended for early stage, dry AMD, although regular examinations are necessary to monitor for progression to intermediate dry AMD or to wet AMD.  It is recommended that someone with early AMD use a tool known as the Amsler grid to monitor for progression of AMD.  When looking at the center dot on the Amsler grid, the normally straight lines may appear wavy with worsening of the disease. For those with intermediate or advanced AMD, the National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants (vitamin C, vitamin E, beta-carotene) and zinc significantly slowed further progression of AMD and its associated vision loss.

Can AMD be prevented?  AMD cannot be prevented but certain life-style measures that may help to lower the risk of developing the disease. These include eating a healthy diet, not smoking, maintaining normal blood pressure and keeping one's weight at an ideal level. There is also some evidence that avoidance of excessive exposure to sunlight by wearing a hat or sunglasses may help to reduce the risk of developing AMD.

Sources for article: 

Facts About Age-Related Macular Degeneration from the National Eye Institute
Age Related Macular Degeneration from the American Academy of Ophthalmology