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Marijuana - Mixed Connective Tissue Disease (MCTD) PDF Print E-mail
Written by Ruai Pharmaceuticals   
Thursday, 15 September 2011 16:58

Marijuana

  • Marijuana facts
  • What is marijuana, and how is it abused?
  • What is medical marijuana? How is medical marijuana prescribed?
  • What are other names for marijuana?
  • What is the history and different types of marijuana?
  • Is marijuana addictive?
  • What are the psychological and social effects of abusing marijuana?
  • What are the physical effects of abusing marijuana?
  • What are the treatments for marijuana abuse and addiction?
  • Can marijuana abuse and addiction be prevented?
  • What is the prognosis of marijuana abuse and addiction?
  • Where can people find more information about marijuana abuse and addiction?

Marijuana facts

  • Marijuana's (scientific name is Cannabis sativa) leaves, seeds, stems and/or roots are consumed by marijuana users for the purpose of feeling intoxicated.
  • THC, or tetrahydrocannibinol, is one of the hundreds of compounds within marijuana that has major intoxicating effects.
  • Marijuana that is consumed for medical purposes, like for patients with nausea or poor appetite associated with AIDS or cancer treatment, is legal in a few states of the United States.
  • Possession of marijuana, regardless of its purpose, is illegal in most jurisdictions.
  • Marijuana is the most commonly abused illegal substance worldwide.
  • While the number of people who use marijuana at any one time does not seem to have recently increased, the number of people who have a marijuana-related disorder has risen significantly. This is more or less true depending on age and ethnic group.
  • Medical marijuana, also called marinol (Dronabinol), is a synthetic form of marijuana.
  • There are many ways of referring to marijuana itself, as well as for how it is smoked.
  • The history of marijuana goes back for thousands of years. It was only made illegal in many countries during the 20th century.
  • The use of medical marijuana is currently legal in 15 U.S. states and the District of Columbia. In those jurisdictions, people for whom medical marijuana has been specifically recommended by a physician must carry a (medical) marijuana card that indicates their use of the substance for a clear medical purpose.
  • Attempts to completely legalize the use of marijuana, whether for medicinal purposes or not, remain strongly contested in most jurisdictions.
  • There are a variety of marijuana types, also called strains.
  • Numerous research studies show that marijuana is indeed an addictive substance. The symptoms of addiction to marijuana are similar to those of any other addictive substance.
  • The symptoms of marijuana withdrawal are similar to those of other drugs and include irritability, anger, depression, insomnia, drug craving, and decreased appetite.
  • The negative physical, psychological, and social effects of marijuana are numerous.
  • While most individuals with marijuana abuse or dependence are treated on an outpatient basis, admission to both outpatient and inpatient treatment programs for marijuana addiction has increased over the years.
  • Behavioral and family based treatments have been found to be effective for marijuana abuse and addiction.
  • There is as yet no medication that has yet been shown to be a clearly effective treatment of marijuana-use disorders.

What is marijuana, and how is it abused?

Marijuana is a plant whose scientific name is Cannabis sativa. Its leaves, seeds, stems, and/or roots are consumed by marijuana users for the purpose of feeling intoxicated ("high"). Although the plant contains hundreds of compounds, the one that has major intoxicating effects is called tetrahydrocannibinol (THC). Although medical marijuana is legal in a few states of the United States, it is one of many illegal drugs in most jurisdictions. Specifically, laws in most states deem it illegal to engage in possession of marijuana, either for the purpose of your own use or for the purpose of distributing it to others.

Marijuana is the most commonly abused illegal substance worldwide. While the number of people who use marijuana at any one time does not seem to have increased in the past decade, the number of people who have a marijuana-related disorder has increased significantly. This seems to be particularly true for elderly individuals as well as for young Hispanic and African-American adults. In teens, boys remain more likely than girls to smoke or otherwise use marijuana. Native-American adolescents seem to be the ethnic group most vulnerable to engage in recent marijuana use, and Asian adolescents tend to be the least likely.

What is medical marijuana? How is medical marijuana prescribed?

Medical marijuana, also called marinol (Dronabinol), is a synthetic form of marijuana. It comes in 2.5 mg, 5 mg, and 10 mg capsules and is used for the treatment of poor appetite and food intake (anorexia) with weight loss in people with acquired immune deficiency syndrome (AIDS) and for the nausea and vomiting due to cancer chemotherapy in individuals who have not responded adequately to usual treatments for those symptoms. When used for appetite stimulation, marinol is usually dosed at 2.5 mg once or twice per day before lunch, dinner, and/or bedtime. When it is being prescribed to quell nausea, it is usually prescribed at 5 mg, one to three hours before a chemotherapy treatment and every two to four hours after chemotherapy, up to six doses per day.

The most common physical side effects of marinol include asthenia (lack of energy), stomach upset, nausea, vomiting, racing heart rate, facial flushing, and dizziness. The most common psychological side effects of marinol include anxiety, sleepiness, confusion, hallucinations, and paranoia. This medication should therefore be used with caution in persons who have a mental-health diagnosis, particularly depression, mood swings, schizophrenia, or substance abuse. When prescribed for those people, the individual is usually under the care of a psychiatrist.

What are other names for marijuana?

There are many, many ways of referring to marijuana. The technical term for marijuana is cannabis. Some terms like pot, hemp, herb, reefer, ganja, and weed refer to the substance itself. A higher potency form of marijuana is often called hashish or hash. Other words like joints, blunts, backwoods, buds, or bongs refer to the way that marijuana is smoked. Marijuana is also often smoked in pipes or baked in food, like brownies.

What is the history and different types of marijuana?

The history of marijuana goes back for thousands of years. It was only made illegal in many countries during the 20th century. In the past 20 years in the United States, the legalization pros and cons of medical marijuana have been intensely debated as it has become legal to use it in 15 states and the District of Columbia. In those jurisdictions, people for whom medical marijuana has been specifically recommended by a physician must carry a (medical) marijuana card that indicates their use of the substance for a clear medical purpose. Individuals who do not carry such a card risk prosecution for marijuana possession. Different states that allow for legal use of marijuana have different guidelines for the legality of possessing and using medical marijuana. For example, at least one bans home cultivation, and there are regulations concerning the operations of dispensaries in some states.

Federal laws continue to deem marijuana possession, as well as its distribution, as illegal, whether it is used for medicinal purposes or not. While the prosecution rates of individuals who carry small amounts of the substance along with a medical marijuana card tend to be low, dispensaries in states that have legalized medical marijuana remain criminalized and are therefore often raided by law-enforcement agencies.

Attempts to completely legalize the use of marijuana, whether for medicinal purposes or not, remain strongly contested in most jurisdictions. For example, in 2010, Proposition 19, a measure that would have completely legalized possession and growing marijuana then taxed and regulated its use was defeated in the state of California. However, California already reduced legal sanctions for possessing small amounts of marijuana to the level comparable to the penalty for speeding on a freeway.

There are a variety of marijuana types, also called strains. Strains tend to be based on leaf color as indicated in pictures, as well as the strains' potency and medical purpose. Medical strains of marijuana are specifically grown for a particular health benefit, like pain management or reduction of nausea. Some states place restrictions on the strains of marijuana that may be legally used and sold. Marijuana dispensaries often sell hydroponic marijuana seeds through mail order, which can be grown in nutrient solution, with or without soil.

Is marijuana addictive?

Numerous research studies show that marijuana is indeed an addictive substance. More than 4% of Americans develop a dependency on marijuana. The rate of addiction to marijuana has increased for all age groups. Teens are using the drug at younger ages. About one out of every six adolescents who use marijuana develop addiction to it, and half the people who receive treatment for marijuana use are under the age of 25. While the frequency of use seems to have remained the same over the past several years, adults are becoming dependent on marijuana more often. Theories about potential reasons for that increase include increased access to marijuana that is of higher potency, as well as a lower age at which many individuals first use this drug.

The symptoms of addiction to marijuana are similar to those of any other addictive substance. As with any other drug, in order to qualify for the diagnosis of marijuana addiction, the individual must suffer from a negative pattern of use of this drug that results in significant problems or suffering, with at least three of the following symptoms occurring at the same time in the same one year period:

  • Tolerance (decreased effects of marijuana over time or needing to increase the amount used to achieve the desired effect)
  • Withdrawal (characteristic symptoms that occur when the individual abstains from using marijuana for some days)
  • Often taking marijuana in larger amounts or over a longer period of time than planned
  • Persistent desire to use marijuana or trouble decreasing or controlling its use
  • Spending significant time either obtaining marijuana (for example, buying, growing), using it, or recovering from its effects
  • Significant social, educational, occupational, or leisure activities are either abandoned or significantly decreased as a result of marijuana's use
  • Marijuana use continues despite being aware of or experiencing persistent or repeated physical or psychological problems as a result of its use

The symptoms of marijuana withdrawal are similar to those of other drugs, especially tobacco. Those symptoms usually start one to two days after last using marijuana and include irritability, anger, depression, insomnia, drug craving, and decreased appetite. These symptoms tend to interfere with the individual's attempts to stop using marijuana and can motivate the use of both marijuana and other drugs for relief. The symptoms of withdrawal tend to peak within four to six days and last from one to three weeks.

What are the psychological and social effects of abusing marijuana?

The bad effects of marijuana are numerous. For example, it can impair thinking, as in learning, and memory for several days after each time it is used. That risk seems to be even higher for people who score lower on IQ tests compared to those who score higher.

The social effects of smoking marijuana can be quite detrimental as well. Adolescents who use the substance are at higher risk of pregnancy, dropping out of school, delinquency, legal problems, and achieving less educationally and occupationally. Individuals who become dependent on marijuana tend to be less motivated, less happy, or satisfied with their life. They are also at risk for depression and for using larger amounts of alcohol and other drugs.

What are the physical effects of abusing marijuana?

In terms of how long marijuana tends to stay in your system, it can be detected on drug tests for about two weeks. Like many other chemicals that are ingested, marijuana can affect your body in many ways. It seems to be associated with an increased occurrence of certain cancers. It may also increase the risk of sexual dysfunction; statistics indicate that men who smoke or otherwise consume marijuana regularly are at higher risk of either having premature ejaculation or trouble reaching orgasm. Men and women who use this substance on a regular basis seem to have more sexual partners and to be more at risk for contracting sexually transmitted diseases compared to those who do not use marijuana.

Marijuana's effects on the body and brain of a developing fetus seem to be clearly negative. Exposure to this substance before birth (prenatally) is associated with negative effects on fetal growth and body weight, as well as on the impulse control, focusing ability, learning, memory, and decision making in the child who was exposed to marijuana before birth. These negative effects by no means only affect babies who are exposed to marijuana before birth (in utero). Marijuana tends to negatively affect learning, judgment, and muscle skills in people who use marijuana by their own volition.

What are the treatments for marijuana abuse and addiction?

Most individuals with marijuana abuse or dependence are treated on an outpatient basis. Admission to outpatient and inpatient treatment programs for marijuana addiction has increased over the years to the point that the addiction to this substance is nearly as high as dependence on other illegal drugs, like cocaine or heroin.

Behavioral treatments, like motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and contingency management (CM), as well as family based treatments have been found to be effective treatments for marijuana abuse and addiction. MET is designed to lessen the resistance a person who abuses marijuana may have to abstaining from using it. This intervention is also designed to motivate the individual to change. CBT teaches people who abuse marijuana skills to help them stop using the drug and to ways to avoid or manage other problems that might prevent them from marijuana use recovery. CM usually provides marijuana users with vouchers of increasing value as a reward for repeatedly testing negative for (the absence of) drugs over time. Those vouchers are then exchanged for positive items or services that promote the person's participation in more positive (pro-social) activities, like securing employment or advancing their education or health.

In addition to the individual therapies just described, adolescents who abuse or are addicted to marijuana are often treated using one or more family therapies. These include multidimensional therapy, multisystemic therapy, family support network intervention, and brief strategic family therapy. Each of these interventions uses techniques that are designed to enhance the skills of the addicted individual and his or her family members as a way of discouraging marijuana use.

Although there is no medication that has yet been shown to be a clearly effective treatment of marijuana-use disorders, research shows that antidepressant medications like nefazodone (Serzone) and fluoxetine (Prozac) may help some individuals manage marijuana withdrawal and to avoid relapse, respectively. Oral THC (Dronabinol) may also help alleviate symptoms of marijuana withdrawal. Successful psychotherapeutic approaches to treatment of marijuana abuse or addiction include motivational approaches with coping skills development.

Can marijuana abuse and addiction be prevented?

In order to prevent marijuana use, abuse, and addiction, an understanding of the risk factors for those issues is essential. In teens, availability of marijuana in their environment, as well as a tendency to engage in negative behaviors (deviancy) increase the likelihood of marijuana use. For some adolescents, using legal substances like alcohol and tobacco can be gateway drugs for marijuana use, in that the use of those substances increases the likelihood that the teen will use marijuana.

What is the prognosis of marijuana abuse and addiction?

While many people with a marijuana-use disorder successfully stop using it with outpatient psychotherapy that provides motivation and teaches coping skills, the relapse rate is quite high, about 67% after the first year. However, when treatment is provided frequently, that statistic improves. Individuals who begin smoking marijuana before 17 years of age seem to be more than three times more likely to attempt suicide than those who either never use the substance or do so after the age of 17. That risk goes the other way as well, in that people who develop depression or have thoughts of suicide before the age of 17 seem to be at a much higher risk of developing an addiction to marijuana. People who are vulnerable to developing psychosis (for example, having hallucinations like seeing things or hearing voices that aren't there; or delusions, like unfounded beliefs that others are trying to harm him or her) may be more likely to do so if marijuana is used, even on a medicinal basis. Marijuana abuse or addiction is also associated with a much higher risk of developing a dependence on other drugs.

Where can people find more information about marijuana abuse and addiction?

  • Codependents Anonymous: http://www.coda.org
  • Kids Against Drugs: http://www.kidsagainstdrugs.com
  • Marijuana Anonymous World Services: 800-766-6779; This e-mail address is being protected from spambots. You need JavaScript enabled to view it
  • Narcanon: http://www.narcanon.org
  • Narcotics Anonymous: http://www.na.org
  • National Council on Alcoholism and Drug Dependence: 800-NCA-CALL
  • National Institute on Drug Abuse: http://www.nida.nih.gov
  • National Clearinghouse for Alcoholism and Drug Information: 800-729-6686
  • National Resource Center: 866-870-4979
  • Substance Abuse & Mental Health Services Administration (SAMHSA): 1-877-SAMHSA-7
  • http://www.treatmentcenter.com


Masturbation

Your Guide to Masturbation

  • Introduction to masturbation
  • Who masturbates?
  • Why do people masturbate?
  • Is masturbation normal?
  • Is masturbation harmful?

Introduction to Masturbation

Masturbation is the self-stimulation of the genitals to achieve sexual arousal and pleasure, usually to the point of orgasm (sexual climax). It is commonly done by touching, stroking, or massaging the penis or clitoris until an orgasm is achieved. Some women also use stimulation of the vagina to masturbate or use "sex toys," such as a vibrator.

Who Masturbates?

Just about everybody. Masturbation is a very common behavior, even among people who have sexual relations with a partner. In one national study, 95% of males and 89% of females reported that they have masturbated. Masturbation is the first sexual act experienced by most males and females. In young children, masturbation is a normal part of the growing child's exploration of his or her body. Most people continue to masturbate in adulthood, and many do so throughout their lives.

Why Do People Masturbate?

In addition to feeling good, masturbation is a good way of relieving the sexual tension that can build up over time, especially for people without partners or whose partners are not willing or available for sex. Masturbation also is a safe sexual alternative for people who wish to avoid pregnancy and the dangers of sexually transmitted diseases. It also is necessary when a man must give a semen sample for infertility testing or for sperm donation. When sexual dysfunction is present in an adult, masturbation may be prescribed by a sex therapist to allow a person to experience an orgasm (often in women) or to delay its arrival (often in men).

Is Masturbation Normal?

While it once was regarded as a perversion and a sign of a mental problem, masturbation now is regarded as a normal, healthy sexual activity that is pleasant, fulfilling, acceptable and safe. It is a good way to experience sexual pleasure and can be done throughout life.

Masturbation is only considered a problem when it inhibits sexual activity with a partner, is done in public, or causes significant distress to the person. It may cause distress if it is done compulsively and/or interferes with daily life and activities.

Is Masturbation Harmful?

In general, the medical community considers masturbation to be a natural and harmless expression of sexuality for both men and women. It does not cause any physical injury or harm to the body, and can be performed in moderation throughout a person's lifetime as a part of normal sexual behavior. Some cultures and religions oppose the use of masturbation or even label it as sinful. This can lead to guilt or shame about the behavior.

Some experts suggest that masturbation can actually improve sexual health and relationships. By exploring your own body through masturbation, you can determine what is erotically pleasing to you and can share this with your partner. Some partners use mutual masturbation to discover techniques for a more satisfying sexual relationship and to add to their mutual intimacy.


Mixed Connective Tissue Disease
(MCTD)


  • What are connective tissues?
  • What diseases characteristically affect connective tissue?
  • What is mixed connective tissue disease?
  • How is mixed connective tissue disease diagnosed?
  • How is mixed connective tissue disease treated?
  • Mixed Connective Tissue Disease At A Glance
  • Find a local Rheumatologist in your town

What are connective tissues?

The connective tissues are the structural portions of our body that essentially hold the cells of the body together. These tissues form a framework or matrix for the body. The connective tissues are composed of two major structural molecules, collagen and elastin. There are many different collagen proteins that vary in amount in each tissue of the body. Elastin is another protein that has the capability of stretching and returning to original length like a spring. Elastin is the major component of ligaments (tissues which attach bone to bone).

Connective tissue diseases are disorders featuring abnormalities involving the collagen and elastin. Connective tissue diseases are often characterized by a variety of immune abnormalities that are common for each particular type of illness.

What diseases characteristically affect connective tissue?

Diseases of connective tissue that are strictly inheritable (due to genetic inheritance) include Marfan syndrome (can have tissue abnormalities in the heart, aorta, lungs, eyes, and skeleton) and Ehlers-Danlos syndrome (may have loose, fragile skin or loose [hyperextensible] joints). Pseudoxanthoma elasticum is an inherited disorder of elastin.

Other diseases of connective tissue do not have specific gene abnormalities as their sole cause. These connective tissue diseases occur for unknown reasons. They are characterized as a group by the presence of spontaneous over activity of the immune system, which results in the production of unusual antibodies into the blood.

The classic immune-related connective tissue diseases include systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, and dermatomyositis. Each of these diseases has a characteristic presentation with typical clinical findings that doctors can recognize during an examination. Each also has characteristic blood test abnormalities and abnormal antibody patterns. However, each of these diseases can evolve slowly or rapidly from very subtle abnormalities before demonstrating the classic features that help in the diagnosis. When these conditions have not developed the classic features of a particular disease, doctors will often refer to the condition as "undifferentiated connective tissue disease." This implies that the characteristic features that are used to define the classic connective tissue disease are not present, but some symptoms or signs of connective disease exist. Individuals with undifferentiated connective tissue disease may never develop a fully definable condition or they may eventually develop a classic connective tissue disease.

What is mixed connective tissue disease?

Mixed connective tissue disease, as first described in 1972, is "classically" considered as an "overlap" of three diseases, systemic lupus erythematosus, scleroderma, and polymyositis. Patients with this pattern illness have features of each of these three diseases. They also typically have very high quantities of antinuclear antibodies (ANAs) and antibodies to ribonucleoprotein (anti-RNP) detectable in their blood. The symptoms of many of these patients eventually evolve to become dominated by features of one of three component illnesses, most commonly scleroderma.

It is now known that overlap syndromes can occur that involve any combination of the connective tissue diseases. Therefore, for example, patients can have a combination of rheumatoid arthritis and systemic lupus erythematosus (hence, the coined name "rhupus").

How is mixed connective tissue disease diagnosed?

Today, true mixed connective tissue disease is diagnosed when patients demonstrate the clinical features (exam findings) of overlap illnesses (as described above) and have high amounts of the antibodies ANA and anti-RNP in their blood. Mixed connective tissue disease patients do not typically have antibodies such as dsDNA, Scl70, which are particularly common in systemic lupus erythematosus and scleroderma respectively.

How is mixed connective tissue disease treated?

The treatment of mixed connective tissue disease is based on which features are causing symptoms. The prognosis (outlook) varies accordingly. Therapies must be targeted for each of the organ systems affected. In general, treatment is often directed at suppressing the inflammation present in the tissues by using anti-inflammatory and immunosuppressive medications. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs), cortisone drugs/steroids (such as prednisone), antimalarial drugs (hydroxychloroquine), and cytotoxic drugs (such as methotrexate, azathioprine, and cyclophosphamide). Organ damage, such as in the kidneys, can require additional treatments directed at high blood pressure, etc.

For the joint and muscle pains of mixed connective tissue disease, treatment options include NSAIDs, low-dose prednisone, hydroxychloroquine, and methotrexate can be helpful. Sometimes TNF blockers infliximab (Remicade), etanercept (Enbrel), or adalimumab (Humira) are considered for inflammatory arthritis. Physical therapy for certain joints is sometimes helpful. For pulmonary hypertension, medications that tend to open the arteries to the lungs are used along with blood thinning drugs and even supplemental oxygen. For interstitial lung disease, prednisone and cyclophosphamide are considered. To prevent damage to the kidneys, angiotensin converting enzyme inhibitors, such as captopril (Capoten), enalapril (Vasotec) are used, especially if blood pressure is elevated. Esophagus irritation and heartburn can be prevented by elevating the head of the bed and relieved with omeprazole (Prilosec) or lansoprazole (Prevacid). Antacids can also be helpful. Constipation, cramping and diarrhea is sometimes caused by bacteria that can be treated with tetracycline or erythromycin.

 

For Raynaud's phenomenon, patients are recommended to use hand- and body-warming techniques while protecting the fingers from injury. Nifedipine (Procardia), losartan (Cozaar, Hyzaar), and nitroglycerin cream are used to dilate the constricted blood vessels. Severe RP can lead to gangrene and the loss of digits. In rare cases of severe disease, nerve surgery called "sympathectomy" is sometimes considered. In order to prevent blood vessel spasming, the nerves that stimulate the constriction of the vessels (sympathetic nerves) are surgically interrupted. Usually, this is performed during an operation that is localized to the sides of the base of the fingers at the hand. Through small incisions the tiny nerves around the blood vessels are stripped away. This procedure is referred to as a digital sympathectomy.

Mixed Connective Tissue Disease At A Glance
  • Connective tissues are the framework of the cells of the body.
  • Mixed connective tissue disease is an "overlap" combination of connective tissue diseases.
  • Diagnosis of mixed connective tissue disease is supported by detecting abnormal antibodies in the blood.
  • Treatment of mixed connective tissue disease is directed at suppressing immune-related inflammation of tissues.
 

For more specific information related to the individual connective tissue diseases, please read the following articles:

  • Systemic Lupus Erythematosus
  • Rheumatoid Arthritis
  • Scleroderma
  • Polymyositis


Measles (Rubeola)



  • What is measles?
  • What is rubeola?
  • What is rubella?
  • What are other names for measles?
  • What is the history of measles?
  • What causes measles?
  • How is measles spread?
  • How does one become immune to measles?
  • Who is at risk for getting measles?
  • Are measles deadly?
  • What is the danger of getting measles while pregnant?
  • If I am exposed, how long does it take to develop symptoms?
  • What are measles symptoms and signs?
  • What are the complications seen with measles?
  • What is atypical measles?
  • What is modified measles?
  • How is the diagnosis of measles made?
  • If it is not measles, what else could it be?
  • What should I do if I have been exposed to measles?
  • Is there any treatment for measles after symptoms and signs develop?
  • If measles only rarely occurs in the United States, why should I get vaccinated?
  • What is the prognosis for measles?
  • How can I prevent contracting measles?
  • Is there any truth to the fear of getting autism from vaccines?
  • Who should not receive measles vaccinations?
  • If a child has an egg allergy, can they still receive the measles vaccine?
  • What adverse reactions can occur to the measles vaccination?
  • Who should be revaccinated?
  • Where can I find more information about measles?
  • Measles At A Glance

What is measles?

Measles is a highly contagious viral disease that can kill you. Although an uncommon disease in the United States of America, in 2008, measles killed 164,000 children worldwide. In most people, the disease produces fever (temperature > 101 F [38.3 C]), a generalized rash that last greater than three days, cough, runny nose (coryza), and red eyes (conjunctivitis). The complications of measles that result in most deaths include pneumonia and inflammation of the brain (encephalitis).

What is rubeola?

Rubeola is the scientific name used for measles. It should not be confused with rubella (German measles).

What is rubella?

Rubella is the scientific name used of German measles, a different viral illness. While German measles is rarely fatal, it is dangerous in that it causes birth defects and can cause miscarriage and fetal death.

What are other names for measles?

Other terms have been used to describe measles. These include (erroneously) rubella, hard measles, red measles, seven-day measles, eight-day measles, nine-day measles, 10-day measles, and morbilli.

What is the history of measles?

Cases of measles were described as early as the seventh century. However, it was not until 1963 that researchers first developed a vaccine to prevent measles. Before the vaccine was made available, almost every child became infected with the virus because it is so easily spread. Before routine vaccination, there were approximately 3-4 million cases of measles and 500 deaths due to measles each year in the United States.

There were initially two types of vaccines developed against measles. One was developed from a virus that had been killed, and the other was developed using a live measles virus that was weakened (attenuated) and could no longer cause the disease. Unfortunately, the killed measles virus (KMV) vaccine was not effective in preventing people from getting the disease, and its use was discontinued in 1967. The live virus vaccine has been modified a number of times to make it safer (further attenuated) and today is extremely effective in preventing the disease. The currently used vaccine is a live attenuated vaccine.

What causes measles?

Measles is caused by the measles virus (a paramyxovirus).

How is measles spread?

Measles is spread through droplet transmission from the nose, throat, and mouth of someone who is infected with the virus. These droplets are sprayed out when the infected person coughs or sneezes. Among unimmunized people exposed to the virus, over 90% will contract the disease. The infected person is highly contagious for four days before the rash appears until four days after the rash appears. The measles virus can remain in the air (and still be able to cause disease) for up to two hours after an infected person has left a room.

How does one become immune to measles?

Anyone who has had measles is believed to be immune for life. People who have received two doses of vaccine after their first birthday have a 98% likelihood of being immune. Infants receive some immunity from their mother. Unfortunately, this immunity is not complete, and infants are at increased risk for infection until they receive the vaccination at 12 to 15 months of age.

Who is at risk for getting measles?

Those people at high risk for measles include:

  • children less than 1 year of age (although they have some immunity passed from their mother, it is not 100% effective);
  • people who have not received the proper vaccination series;
  • people who received immunoglobulin at the time of measles vaccination;
  • people immunized from 1963 until 1967 with an older ineffective killed measles vaccine.

Are measles deadly?

Measles can kill you. In 2008, approximately 164,000 people died of measles in the world. However, measles is rarely fatal in the United States. This is due to the fact that most people are immunized, which results in very infrequent outbreaks. Also, people most likely to have complications (including death) are those who are malnourished or who have weakened immune systems

What is the danger of getting measles while pregnant?

If you contract measles while you are pregnant, you may have a miscarriage, a stillbirth, or a preterm delivery. There appears to be no risk of having birth defects (unlike an infection with the rubella virus, known as German measles).

If I am exposed, how long does it take to develop symptoms?

The typical time from exposure to a person infected with measles to development of the initial symptoms is 10-12 days (the range is seven to 21 days). The rash occurs a few days after the initial symptoms (ranges from seven to 18 days from exposure).

Picture of a child with measles skin rash
Picture of a baby with measles. Source: CDC

 

What are measles symptoms and signs?

The typical case of measles actually starts with a fever, runny nose, hacking cough, and red eyes. After two to four days of these symptoms, the patient may develop spots within the mouth called Koplik's spots. These spots look like little grains of white sand surrounded by a red ring and are usually found inside the cheek toward the back of the mouth (opposite the first and second upper molars).

The skin rash (also known as an exanthem or exanthema) appears three to five days after the onset of the initial symptoms (fever, cough, runny nose, and red eyes). The rash is a flat to slightly raised (maculopapular) red rash that usually last five to six days. It begins at the hairline and then progresses to the face and upper neck. Over the next two to three days, the rash progresses downward to cover the entire body, including the hands and feet. The rash has mostly distinct lesions, but some may overlap (become confluent). Initially, these lesions will turn white when you press on them (blanch). After three to four days, they no longer will blanch. As the rash begins to fade, there will often be a fine flaking of the skin (desquamation). The rash fades in the same order that it appears.

The fever that occurs with measles is called a stepwise fever. The patient starts with a mild fever that progressively gets higher. Fevers often reach temperatures greater than 103 F (39.4 C).

Although not as common as other symptoms, some patients may have a sore throat.

What complications are seen with measles?

Approximately 30% of cases of measles have an associated complication. These complications can include diarrhea (8%), ear infections (7%), pneumonia (6%), blindness (1%), acute brain inflammation (encephalitis) (0.1%), and persistent brain inflammation (subacute sclerosing panencephalitis) (0.0001%).

Blindness associated with measles is due to a combination of poor nutrition (specifically vitamin A deficiency) and the measles infection. Prevention is the most effective treatment. In third-world countries, post-measles blindness is the leading cause of blindness, with up to 60,000 cases occurring annually.

Acute encephalitis, although rare, is extremely dangerous and results in death in approximately 15% of patients who develop it. When it occurs, acute encephalitis generally starts six days after onset of the rash. Symptoms can include fever, headache, vomiting, stiff neck, drowsiness, seizures, and coma.

Subacute sclerosing panencephalitis (SSP) is an extremely rare degenerative condition of the brain and spinal cord (central nervous system). It is believed to be caused by a chronic infection of the central nervous system with the measles virus. Typically, symptoms start years after the patient had measles (average seven years, range one month to 27 years). The patient has a slow and progressive loss of brain function, seizures, and eventually death results. There is no known treatment for SSP.

Most deaths from measles are due to pneumonia in children and encephalitis in adults. There are approximately 2.2 deaths per 1,000 people who get the measles. The people most likely to have complications (including death) are those who are malnourished or who have weakened immune systems (for example, people with AIDS or other conditions that weaken the immune system).

 

What is atypical measles?

Atypical measles occurs in people who received the killed measles vaccine (KMV; only used from 1963 until 1967) and who are exposed to wild-type measles virus. The KMV unfortunately sensitizes the patient to the measles virus but does not offer any protection. The disease is characterized by fever, pleural effusions, pneumonia, and swelling of the extremities. The rash of atypical measles is different from measles in that it may have an urticarial component (hives) and usually appears first on the ankles and wrists.

It is recommended by the U.S. Centers for Disease Control and Prevention (CDC) that people who may have received the KMV should receive revaccination with the live measles vaccine.

The virus can be isolated in tissue culture in the lab. Blood (serologic) tests are also available.

Picture of Koplik's spots
Picture of Koplik spots. Source: CDC

 

What is modified measles?

Modified measles is seen in patients who, because they were unimmunized, received immune globulin after being exposed to a patient with measles. It is also seen occasionally in young infants who have limited immunity from their mothers. The immune globulin prolongs the time from exposure to onset of symptoms (incubation period). When the symptoms do occur, they are much milder than those seen with normal measles and tend to last a shorter period of time.

How is the diagnosis of measles made?

The diagnosis of suspected measles is mostly clinical, meaning that the appearance and history of the patient suggest the diagnosis. In a person with known exposure to someone with measles or travel to a foreign country, measles should always be considered when faced with a patient who has high fever and characteristic rash. Until the rash appears, the presence of Koplik's spots should help to suggest the diagnosis. Most cases of suspected measles in the United States turn out not to be measles (see below). It is recommended that the diagnosis be confirmed using a blood test for IgM, a type of antibody against the virus. If the IgM test is positive, viral cultures should be obtained. The state and local health department should be contacted immediately for any suspected case in order to follow the correct procedures for viral culture and isolation of the patient. Further information on laboratory testing of suspected cases is available from the CDC (http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.htm).

If it is not measles, what else could it be?

There are a large number of infectious diseases and other conditions that can cause some of the symptoms of measles. These include, but are not limited to, dengue fever, drug rashes, enteroviral infections, fifth disease, German measles (rubella), Kawasaki disease, Rocky Mountain spotted fever, roseola, and toxic shock syndrome. It is important that suspected cases be seen by a medical expert and appropriate laboratory tests be ordered.

 

What should I do if I have been exposed to measles?

People who have been appropriately vaccinated (or who have had the disease) and who are exposed to a patient with measles do not need to do anything. If an unimmunized person is exposed to a patient with measles, they should receive the vaccine as soon as possible. This may prevent the disease if given within 72 hours of exposure. Immune globulin may have some benefit if given within six days of exposure. The CDC recommends that immune globulin be utilized for household contacts of infected people, immunocompromised people, and pregnant women. It is not recommended that immune globulin be utilized to control a measles outbreak.

Is there any treatment for measles after symptoms and signs develop?

The treatment of patients with measles is mostly focused upon symptom relief. Specific complications like pneumonia may require antibiotics. Patients should be on bed rest until the fever has resolved and should remain well hydrated. In malnourished patients, vitamin A supplementation is recommended. Patients should be isolated to prevent spread of the disease.

If measles only rarely occurs in the United States, why should I get vaccinated?

Although measles only rarely occurs in the United States, it still does occur and can be fatal. In the year 2000, almost 1 million children died of the disease. Through a very intensive effort by the World Health Organization, this was decreased to only 164,000 in 2008. When the number of vaccinated individuals starts to decrease, we see the disease start to occur more frequently. This occurred from 1989 until 1991 in the U.S. During that period, there were 55,000 cases and 123 deaths from measles in the U.S. Due to a massive public-health effort, almost all children in the U.S. now receive measles vaccine before they are allowed to enter school. The number of cases of measles in the U.S. dropped to only 37 in 2004. Most cases are now from outside the U.S. (commonly from adopted children from China), although some cases occur as people in this country are exposed to the infected international traveler.

What is the prognosis for measles?

Most people who contract measles will recover completely. Only 2.2 out of 1,000 people who get measles will die. People who are malnourished or immunocompromised are more likely to have complications or die. However, it is possible for any person to die from the measles, which highlights the importance of becoming vaccinated. Almost no one who has been vaccinated has died from the disease.

How can I prevent contracting measles?

The only way to prevent measles is by receiving measles immunization: This is commonly given as a shot containing measles, mumps, and rubella vaccine (MMR) or a shot containing measles, mumps, rubella, and varicella vaccine (MMRV). The MMRV is not recommended for anyone older than 12 years of age. The current recommendation is that everyone receives two doses of the vaccine after 1 year of age. If the vaccine is received before 1 year of age, the person should receive two additional doses.

The measles vaccine is also available as a single vaccine; however, in most cases, there is no reason to utilize the measles vaccine alone without mumps and rubella vaccine. The complete schedule of recommended vaccinations is available from the CDC (http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm).

Is there any truth to the fear of getting autism from vaccines?

There is no valid scientific evidence that the measles vaccine, or any other vaccine, is the cause of autism. The possibility of an association between the measles vaccine and autism was proposed by Andrew Wakefield and colleagues in 1998. The research published by Wakefield was found to be flawed and actually forged, and the results have not been able to be repeated by other researchers. Since 1998, there have been numerous studies that have examined for such an association. None of these studies have shown any risk of autism associated with the use of the vaccine. A recent study performed in Japan after the MMR vaccine was removed from the market showed that autism continued to increase after the vaccine was no longer being utilized. Although autism is a very serious disease that warrants good research to find out its many causes, not obtaining vaccinations is potentially dangerous and not supported by the best scientific data available today.

Who should not receive measles vaccinations?

The following groups of people should not receive measles vaccinations:

  • People who have suffered a severe allergic reaction to either the measles vaccine or its components (gelatin or neomycin) should not receive the vaccine.
  • Women known to be pregnant should not receive the vaccine. Pregnancy should be avoided for four weeks after vaccination.
  • Severely immunocompromised patients (cancer patients or patients who are receiving large doses of corticosteroids) should not receive the vaccine. However, those leukemia patients who have been in remission for three months may receive the MMR.
  • Patients with severe human immunodeficiency virus (HIV) infections should not receive the vaccine. However, asymptomatic patients with HIV are considered to be safe for vaccination. The CDC has issued guidelines for vaccination based on the CD4+ T-lymphocyte counts.
  • People with a moderate to severe acute illness should wait until their illness resolves before receiving the vaccine.

Patients with history of thrombocytopenic purpura or thrombocytopenia (low platelets) may be at increased risk, and immunization should be decided on a case-by-case basis.

If a child has an egg allergy, can they still receive the measles vaccine?

Although the measles vaccine is made using chick embryos, there is no evidence of increased reactions in people with an egg allergy. Therefore the CDC recommends giving MMR vaccine to egg-allergic children without any prior skin testing or the use of special protocols.

What adverse reactions can occur with the measles vaccination?

Adverse reactions to measles vaccination (as part of the MMR) include fever (5%-15%), rash (5%), joint aches (5%), and low platelet count (thrombocytopenia; one instance per 30,000 doses). In adult women, up to 25% will suffer joint pain that is due to the rubella component of the vaccine. The fever usually occurs seven to 12 days after the vaccination, and the rash occurs seven to 10 days after vaccination.

Who should be revaccinated?

The following group of people should be considered unvaccinated and should receive at least one dose of vaccine:

  • People vaccinated before their first birthday should be revaccinated.
  • Anyone known to have been vaccinated with the killed measles vaccine (KMV) should be revaccinated.
  • Anyone vaccinated with KMV who received their dose of live measles vaccine with four months of their last dose of vaccine should be revaccinated.
  • Anyone vaccinated before 1968 in whom it is not known if the vaccine was KMV or not should be revaccinated.

Where can I find more information about measles?

1. http://wwwn.cdc.gov/travel/yellowBookCh4-Measles.aspx

2. http://www.cdc.gov/vaccines/pubs/
pinkbook/downloads/meas.pdf

3. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.htm

4. http://www.who.int/mediacentre/factsheets/fs286/en/

5. http://www.who.int/vaccines-documents/GlobalSummary/GlobalSummary.pdf

6. http://www.immunize.org/catg.d/p2065.pdf (autism)


Melanosis Coli
(Pseudomelanosis Coli)


  • What is melanosis coli?
  • What are the symptoms of melanosis coli?
  • What causes melanosis coli?
  • How is melanosis coli diagnosed?
  • What is the prognosis (outcome) of melanosis coli?
  • Find a local Gastroenterologist in your town

What is melanosis coli?

Melanosis coli is a condition usually associated with chronic laxative use in which dark pigment is deposited in the lamina propria (one of the lining layers) of the large intestine (colon). The pigment deposition results in a characteristic dark brown to black discoloration of the lining of the large intestine. This condition is sometimes called pseudomelanosis coli because the pigment deposits consist of a pigment known as lipofuscin and do not contain melanin as implied by the term "melanosis." Lipofuscin is a cellular pigment that forms when cells are destroyed, often called "wear and tear" pigment that can be found throughout the body.

The dark color of the intestinal lining may be uniform or patterned, and the discoloration may be slight or very pronounced. The intensity and pattern of the discoloration may even vary among different sites in the colon of a patient. The condition may also be reversed upon discontinuation of laxative use. In some cases, the wall of the colon appears normal to the eye, but microscopic evaluation of biopsies by a pathologist reveals areas of pigment in the colon's lining. The pigment in melanosis coli does not accumulate in polyps or tumors of the large intestine.

What are the symptoms of melanosis coli?

Melanosis coli does not cause symptoms.

What causes melanosis coli?

Melanosis coli usually results from chronic use of laxatives of the anthranoid group. Some examples of anthranoid laxatives are senna and rhubarb derivatives. Many of these laxatives have been in use for hundreds of years. In 1997, the U.S. Food and Drug Administration (FDA) banned the use of the popular anthranoid laxative phenolphthalein due to fears that it might be carcinogenic (cancer-causing). Animal studies had shown that extremely high doses of phenolphthalein led to tumors in animals, but it has never been shown to cause cancers in humans.

The anthranoid laxatives pass through the gastrointestinal tract unabsorbed until they reach the large intestine, where they are changed into their active forms. The resulting active compounds cause damage to the cells in the lining of the intestine and leads to apoptosis (a form of cell death). The damaged (apoptotic) cells appear as darkly pigmented bodies that may be taken up by scavenger cells known as macrophages. When enough cells have been damaged, the characteristic pigmentation of the bowel wall develops.

How is melanosis coli diagnosed?

Melanosis coli can be observed during endoscopic procedures that examine the large intestine, such as colonoscopy and sigmoidoscopy . Sometimes the diagnosis is made upon microscopic examination of biopsies taken during endoscopic procedures.

What is the prognosis (outcome) of melanosis coli?

If a person stops using anthranoid laxatives, the changes associated with melanosis coli lessen over time and may disappear.

Early studies suggested that anthranoid laxatives might have carcinogenic or tumor-promoting activities in humans and that the presence of melanosis coli might signal an increased risk for the development of colorectal cancer. However, more recent follow-up studies have failed to show an association between colon cancer and anthranoid laxative use or between colon cancer and the finding of melanosis coli.


MELAS Syndrome


  • What is MELAS?
  • What causes MELAS?
  • What are the symptoms of MELAS?
  • How is MELAS diagnosed?
  • When do people with MELAS develop symptoms?
  • How is MELAS treated?
  • Are there other mitochondrial diseases?

What is MELAS?

MELAS is a rare form of dementia. MELAS is an abbreviation that stands for Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes.

What causes MELAS?

MELAS syndrome is caused by mutations in the genetic material (DNA) in the mitochondria. While most of our DNA is in the chromosomes in the cell nucleus, some of our DNA is in another important structure called the mitochondrion (plural: mitochondria).

The mitochondria are located outside the nucleus in the cell's cytoplasm. Each mitochondrion has a chromosome made of DNA that is quite different from the better known chromosomes in the nucleus. The mitochondrial chromosome is much smaller; it is round (whereas the chromosomes in the nucleus are normally shaped like rods); there are many copies of the mitochondrial chromosome in every cell; and no matter whether we are male or female, we inherit all of our mitochondrial chromosome from our mother.

Much of the DNA in our mitochondria is used to manufacture proteins involved in the key function of mitochondria -- to produce energy and power the cells in our body.

What are the symptoms of MELAS?

As a result of the disturbed function of their cells' mitochondria, patients with MELAS develop brain dysfunction (encephalopathy) with seizures and headaches, as well as muscle disease with a build-up of lactic acid in the blood (a condition called lactic acidosis), temporary local paralysis (stroke-like episodes), and abnormal thinking (dementia).

How is MELAS diagnosed?

The diagnosis of MELAS is usually suspected on clinical grounds. However, confirmation of the diagnosis usually requires a muscle or brain biopsy. The muscle biopsy shows characteristic ragged red fibers; a brain biopsy shows stroke-like changes.

When do people with MELAS develop symptoms?

MELAS can affect people at very different times in life, ranging from age 4 to age 40 or more. However, most patients with MELAS syndrome show symptoms before they are 20 years old.

How is MELAS treated?

There is no known treatment for the underlying disease, which is progressive and fatal. Patients are managed according to what areas of the body are affected at a particular time. Antioxidants and vitamins have been used, but there have been no consistent successes reported.

Are there other mitochondrial diseases?

Yes, mutations (genetic changes) in the mitochondrial chromosome are responsible for a number of other disorders aside from MELAS such as:

  • An important eye disease called Leber hereditary optic atrophy ;
  • A type of epilepsy called MERRF which stands for Myoclonus Epilepsy with Ragged Red Fibers; and
  • A neuromuscular disease called the Kearns-Sayre syndrome .

MELAS and all other mitochondrial diseases were entirely enigmatic before it was discovered that they were due to mutations not in regular chromosomes but in the chromosome of the mitochondria.


Melasma


  • What is melasma? What are signs of melasma?
  • What causes melasma?
  • Where is melasma seen on the body?
  • What are the types of melasma?
  • How is melasma diagnosed?
  • What is the treatment for melasma?
  • What melasma treatments can I have at my doctor's office?
  • Do lasers work for melasma?
  • How does hydroquinone work in melasma?
  • Are there non-hydroquinone alternative treatments for melasma?
  • What is Tri-Luma?
  • What SPF is recommended for melasma?
  • Can melasma be prevented?
  • What is the prognosis for melasma?
  • Melasma At A Glance
  • Find a local Dermatologist in your town

What is melasma? What are signs of melasma?

Melasma is a very common patchy brown, tan, or blue-gray facial skin discoloration, almost entirely seen in women in the reproductive years. It typically appears on the upper cheeks, upper lip, forehead, and chin of women 20-50 years of age. Although possible, it is uncommon in males. It is thought to be primarily related to external sun exposure, external hormones like birth control pills, and internal hormonal changes as seen in pregnancy. Most people with melasma have a history of daily or intermittent sun exposure. Melasma is most common among pregnant women, especially those of Latin and Asian descents. People with olive or darker skin, like Hispanic, Asian, and Middle Eastern individuals, have higher incidences of melasma.

An estimated 6 million women are living in the U.S. with melasma and 45-50 million women worldwide live with melasma; over 90% of all cases are women. Prevention is primarily aimed at facial sun protection and sun avoidance. Treatment requires regular sunscreen application and fading creams.

What causes melasma?

The exact cause of melasma remains unknown. Experts believe that the dark patches in melasma could be triggered by several factors, including pregnancy, birth control pills, hormone replacement therapy (HRT and progesterone), family history of melasma, race, antiseizure medications, and other medications that make the skin more prone to pigmentation after exposure to ultraviolet (UV) light. Uncontrolled sunlight exposure is considered the leading cause of melasma, especially in individuals with a genetic predisposition to this condition. Clinical studies have shown that individuals typically develop melasma in the summer months, when the sun is most intense. In the winter, the hyperpigmentation in melasma tends to be less visible or lighter.

When melasma occurs during pregnancy, it is also called chloasma, or "the mask of pregnancy." Pregnant women experience increased estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels during the second and third trimesters of pregnancy. However, it is thought that pregnancy-related melasma is caused by the presence of increased levels of progesterone and not due to estrogen and MSH. Studies have shown that postmenopausal women who receive progesterone hormone replacement therapy are more likely to develop melasma. Postmenopausal women receiving estrogen alone seem less likely to develop melasma.

In addition, products or treatments that irritate the skin may cause an increase in melanin production and accelerate melasma symptoms.

People with a genetic predisposition or known family history of melasma are at an increased risk of developing melasma. Important prevention methods for these individuals include sun avoidance and application of extra sunblock to avoid stimulating pigment production. These individuals may also consider discussing their concerns with their doctor and avoiding birth control pills and hormone replacement therapy (HRT) if possible.

Where is melasma seen on the body?

Melasma is characterized by discoloration or hyperpigmentation primarily on the face. Three types of common facial patterns have been identified in melasma, including centrofacial (center of the face), malar (cheekbones), and mandibular (jawbone).

The centrofacial pattern is the most prevalent form of melasma and includes the forehead, cheeks, upper lip, nose, and chin. The malar pattern includes the upper cheeks. The mandibular pattern is specific to the jaw.

The upper sides of the neck may less commonly be involved in melasma. Rarely, melasma may occur on other body parts like the forearms. One study confirmed the occurrence of melasma on the forearms of people being given progesterone. This was a unique pattern seen in a Native American study.

What are the types of melasma?

Four types of pigmentation patterns are diagnosed in melasma: epidermal, dermal, mixed, and an unnamed type found in dark-complexioned individuals. The epidermal type is identified by the presence of excess melanin in the superficial layers of skin. Dermal melasma is distinguished by the presence of melanophages (cells that ingest melanin) through out the dermis. The mixed type includes both the epidermal and dermal type. In the fourth type, excess melanocytes are present in the skin of dark-skinned individuals.

 

How is melasma diagnosed?

Melasma is usually readily diagnosed by the typical appearance of brown skin patches on the face. Dermatologists are physicians who specialize in skin disorders and often diagnose melasma by visually examining the skin. A black light or Wood's light (340-400 nm) can assist in diagnosing melasma. In most cases, mixed melasma is diagnosed, which means the discoloration is due to pigment in the dermis and epidermis. Rarely, a skin biopsy may be necessary to help exclude other causes of this local skin hyperpigmentation.

What is the treatment for melasma?

The most common melasma therapies include 2% hydroquinone (HQ) creams like the over-the-counter products Esoterica and Porcelana and prescription 4% creams like Obagi Clear, Glyquin, Tri-Luma, and Solaquin. Products with HQ concentrations above 2% generally require a prescription. Clinical studies show that creams containing 2% HQ can be very effective in lightening the skin and less irritating than higher concentrations of HQ for melasma. These creams are usually applied to the brown patches twice a day. Sunscreen should be applied over the hydroquinone cream every morning. There are treatments for all types of melasma, but the epidermal type responds better to treatment than the others because the pigment is closer to the skin surface.

Melasma may clear spontaneously without treatment. Other times, it may clear with sunscreen usage and sun avoidance. For some people, the discoloration with melasma may disappear following pregnancy or if birth control pills and hormone therapy are discontinued.

In order to treat melasma, combination or specially formulated creams with hydroquinone, a phenolic hypopigmenting agent, azelaic acid, and retinoic acid (tretinoin), nonphenolic bleaching agents, and/or kojic acid may be prescribed. For severe cases of melasma, creams with a higher concentration of HQ or combining HQ with other ingredients such as tretinoin, corticosteroids, or glycolic acid may be effective in lightening the skin.

  • Azelaic acid 15%-20% (Azelex, Finacea)
  • Retinoic acid 0.025%-0.1% (tretinoin)
  • Tazarotene 0.5%-0.1% (Tazorac cream or gel)
  • Adapalene 0.1%-0.3% (Differin gel)
  • Kojic acid
  • Lactic acid lotions 12% (Lac-Hydrin or Am-Lactin)
  • Glycolic acid 10%-20% creams (Citrix cream, NeoStrata)
  • Glycolic acid peels 10%-70%
 

Possible side effects of melasma treatments include temporary skin irritation. People who use HQ treatment in very high concentrations for prolonged periods (usually several months to years) are at risk of developing a side effect called ochronosis. Hydroquinone-induced ochronosis is a permanent skin discoloration that is thought to result from use of hydroquinone concentrations above 4%. Although ochronosis is fairly uncommon in the U.S., it is more common in areas like Africa where hydroquinone concentrations upward of 10%-20% may be used to treat skin discoloration like melasma. Regardless of the potential side effects, HQ remains the most widely used and successful fading cream for treating melasma worldwide. Regular medical follow-up appointments with a doctor are important for people using HQ treatment for melasma. HQ should be discontinued at the first signs of ochronosis.

What melasma treatments can I have at my doctor's office?

In conjunction with home cream applications, in-office treatments include chemical peels (chemical exfoliation), microdermabrasion (mechanical exfoliation), and laser therapy. These additional treatments may be useful for some cases of melasma.

Many types and strengths of chemical peels are available for different skin types. The type of peel should be tailored for each individual and selected by the physician. In treating melasma, 30%-70% glycolic acid peels are very common. Various combinations, including a mix of 10% glycolic acid and 2% HQ, can be used to treat melasma.

Microdermabrasion utilizes vacuum suction and an abrasive material like fine diamond chips or aluminum oxide crystals to exfoliate the top layers of the skin. The vacuum pressure is adjusted depending on the sensitivity and tolerance of the skin. Typical microdermabrasion sessions can last anywhere from a few minutes to one hour. Minimal to no recovery time is needed after microdermabrasion. Microdermabrasion techniques can improve melasma, but dramatic results are not generally seen or expected after one or two treatments. Multiple treatments in combination with sunscreen and other creams yield best results.

There is no guarantee that melasma will be improved with these procedures. In some cases, if treatments are too harsh or abrasive, melasma can be induced or worsen. Additionally, these procedures are almost always considered cosmetic and may not be covered by medical insurance providers.

Do lasers work for melasma?

Lasers may be used in melasma. Laser therapy is not the primary choice to treat melasma as studies reveal little to no improvement in the hyperpigmentation for most patients. Lasers may actually temporarily worsen some types of melasma and should be used with caution. Multiple laser treatments may be necessary to see results, as treatments are most effective when they are repeated.

To ensure that treatment doesn't fail, people must minimize sun exposure. People who treat their melasma report a better quality of life because they feel better about themselves. As with any treatment, people should consult their physician. Pregnant women or mothers breastfeeding may need to wait to treat melasma. Many melasma creams need to be discontinued in pregnancy and breastfeeding because of possible risks to the developing fetus and newborn. These people may consider cosmetics to temporarily conceal the skin discoloration.

How does hydroquinone work in melasma?

Researchers believe that the hydroxyphenolic chemical (HQ) blocks a step in a specific enzymatic pathway that involves tyrosinase. Tyrosinase is the enzyme that converts dopamine to melanin. Melanin gives skin its color.

 

Are there non-hydroquinone alternative treatments for melasma?

Azelaic acid is a non-hydroquinone cream that can be used to treat melasma. Studies have reported that 15%-20% azelaic acid was very effective and safe in melasma. There are no major complications reported with azelaic acid. Possible minor side effects include itching (pruritus), redness (erythema), scaling (dry patches), and a temporary burning sensation that tends to improve after 14-30 days of use.

Tretinoin cream (Retin A, Renova, Retin A Micro) is a non-hydroquinone cream used to treat melasma. Most often, tretinoin is used in combination with other creams like azelaic acid or hydroquinone. Mild localized side effects are fairly common and include peeling, dry skin, and irritation. Overall, melasma may respond slower to treatment with tretinoin alone than with hydroquinone.

Other retinoid creams include tazaratone and adapelene. These are prescription creams used much like tretinoin (Retin A).

What is Tri-Luma?

Tri-Luma is a combination prescription cream containing fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05%. It is used to treat melasma and other skin discoloration. Results may be seen in usually about six to eight weeks from starting treatment. Tri-Luma should not be used for prolonged periods exceeding eight weeks without your doctor's recommendation. It should not be used by pregnant or breastfeeding women unless specifically instructed by your physician.

 

Other combination creams include the Kligman formula which is a triple cream including a retinoid, a hydroquinone, and a topical steroid (for example, fluocinolone acetonide 0.01%, hydroquinone 8%, and tretinoin 0.1%). These triple combination creams may be compounded in different strengths by specialty pharmacists according to a physician's prescription. Triple creams are highly effective for melasma.

What SPF is recommended for melasma?

A daily sun protection factor (SPF) of at least 30 that contains physical blockers, such as zinc oxide and titanium dioxide, is recommended to block UV rays. Chemical blockers may not fully block both types of UV-A and UV-B as effectively as zinc or titanium. The regular use of sun protection enhances the effectiveness of melasma treatments.

Can melasma be prevented?

Sometimes melasma may be preventable by avoiding facial sun exposure. In most cases, prevention is difficult. Individuals who have a family history of melasma must take extra precautions to prevent melasma. The most important way to prevent the onset of melasma and premature aging is to avoid the sun. If exposure to sunlight cannot be avoided, then hats, sunglasses, and sunblock with physical blockers should be worn.

What is the prognosis for melasma?

Although melasma tends to be a chronic disorder with periodic ups and downs, the prognosis for most cases is good. Just as melasma develops slowly, clearance also tends to be slow. The gradual disappearance of dark spots is based on establishing the right treatment combination for each individual skin type. Melasma that does not successfully respond to treatment are because of a lack of avoidance of sun exposure.

Melasma At A Glance
  • Melasma is most common in women 20-50 years of age.
  • Melasma looks like brown, tan, or blue-gray spots on the face (hyperpigmentation).
  • Melasma is characterized by three location patterns (central face, cheekbone, and jawline).
  • Melasma is caused partly by sun, genetic predisposition, and hormonal changes.
  • The most common treatment is topical creams containing hydroquinone.
  • Melasma prevention requires sun avoidance and sun protection with hats and sunscreen.


Melioidosis
(Whitmore's Disease)


  • What is melioidosis? What causes melioidosis?
  • Where does melioidosis occur?
  • What are symptoms of melioidosis?
  • How is melioidosis diagnosed?
  • How is melioidosis treated?
  • Can melioidosis be prevented?
  • What is the prognosis for melioidosis?
  • Melioidosis At A Glance

What is melioidosis? What causes melioidosis?

Melioidosis, also called Whitmore's Disease, is an infectious disease caused by a bacterium called Burkholderia pseudomallei (previously known as Pseudomonas pseudomallei). The bacteria are found in contaminated water and soil and spread to humans and animals through direct contact with the contaminated source. The bacteria are also of some concern as a potential agent for biological warfare and biological terrorism.

Melioidosis is similar to glanders disease, which is passed to humans from infected domestic animals.

Where does melioidosis occur?

Melioidosis is most frequently reported in Southeast Asia and Northern Australia. It also occurs in South Pacific, Africa, India, and the Middle East. The bacterium that causes the disease is found in the soil, rice paddies, and stagnant waters of the area. People acquire the disease by inhaling dust contaminated by the bacteria and when the contaminated soil comes in contact with abraded (scraped) area of the skin. Infection most commonly occurs during the rainy season.

In the United States, confirmed cases range from none to five each year and occur among travelers and immigrants, according to the U.S. Centers for Disease Control and Prevention (CDC).

What are symptoms of melioidosis?

Melioidosis symptoms most commonly stem from lung disease where the infection can form a cavity of pus (abscess). The effects can range from mild bronchitis to severe pneumonia. As a result, patients also may experience fever, headache, loss of appetite, cough, chest pain, and general muscle soreness.

The effects can also be localized to infection on the skin (cellulitis) with associated fever and muscle aches. It can spread from the skin through the blood to become a chronic form of melioidosis affecting the heart, brain, liver, kidneys, joints, and eyes.

Melioidosis can be spread from person to person as well.

How is melioidosis diagnosed?

The diagnosis of melioidosis is made with a microscopic evaluation of a blood, urine, sputum, or skin-lesion sample in the laboratory. A blood test is useful to detect early acute cases of melioidosis, but it can not exclude the illness if it is negative.

How is melioidosis treated?

The treatment of melioidosis involves antibiotics and depends on the location of the disease.

For patients with more mild illness, the CDC recommends antibiotics such as imipenem, penicillin, doxycycline, amoxicillin-clavulanic acid, ceftazidime, ticarcillin-clavulanic acid, ceftriaxone, and aztreonam. Patients who are more severely ill are given a combination of two of the above for up to 12 months.

With pulmonary involvement of melioidosis, if cultures remain positive for six months, surgical removal of the lung abscess with lobectomy is considered.

Can melioidosis be prevented?

In counties where melioidosis occurs, people with compromised immune systems (such as AIDS, cancer, those undergoing chemotherapy, etc.) should avoid contact with soil and contaminated water, especially in farm areas.

What is the prognosis for melioidosis?

Untreated, melioidosis is fatal. When treated with antibiotics, severe forms of the illness have a 50% chance of recovery, but overall the mortality rate is 40%.

Melioidosis At A Glance
  • Melioidosis is an infectious disease caused by a bacterium, Burkholderia pseudomallei.
  • Melioidosis infection commonly involves the lungs.
  • Melioidosis is diagnosed with the help of blood, urine, sputum, or skin-lesion testing.
  • Melioidosis is treated with antibiotics.
  • The overall mortality rate is 40%.


Meniere's Disease

  • What is Meniere's disease?
  • What causes Meniere's disease?
  • What are the symptoms of Meniere's disease?
  • How is Meniere's disease diagnosed?
  • How can Meniere's disease be treated?
  • Meniere's Disease At A Glance
  • Patient Discussions: Meniere's Disease - Treatments
  • Patient Discussions: Meniere Disease - Symptoms Experienced and Effective Treatments
  • Find a local Ear, Nose, & Throat Doctor in your town

What is Meniere's disease?

Meniere's disease is a disorder of the flow of fluids of the inner ear.

What causes Meniere's disease?

Although the cause of Meniere's disease is unknown, it probably results from an abnormality in the way fluid of the inner ear is regulated. In most cases only one ear is involved, but both ears may be affected in about 10% to 20% of patients. Meniere's disease typically starts between the ages of 20 and 50 years of age (although it has been reported in nearly all age groups). Men and women are equally affected. The symptoms may be only a minor nuisance, or can become disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning. Meniere's disease is also called idiopathic endolymphatic hydrops.

What are the symptoms of Meniere's disease?

The symptoms of Meniere's disease typically include at least several of the following:

  • Episodic rotational vertigo: Attacks of a spinning sensation accompanied by disequilibrium (an off-balanced sensation), nausea, and sometimes vomiting. This is usually the most troublesome symptom. The vertigo usually last 20 minutes to two hours or even longer. During attacks, patients are very disabled, and sleepiness may follow. An off-balanced sensation may last for several days.
  • Tinnitus: A roaring, buzzing, machine-like, or ringing sound in the ear. It may be episodic with an attack of vertigo or it may be constant. Usually the tinnitus gets worse or will appear just before the onset of the vertigo.
  • Hearing loss: It may be intermittent early in the onset of the disease, but overtime it may become a fixed hearing loss. It may involve all frequencies, but most commonly occurs in the lower frequencies. Loud sounds may be uncomfortable and appear distorted in the affected ear.
  • Ear fullness: Usually this full feeling occurs just before the onset of an attack of vertigo.

How is Meniere's disease diagnosed?

The diagnosis of Meniere's disease is primarily made from the history and physical examination. Tinnitus or ear fullness (aural fullness) need to be present to make the diagnosis An audiogram is helpful to show a hearing loss, and to rule-out other abnormalities. It is often helpful, if it can be done safely, to have an audiogram during or immediately following an attack of vertigo. This may show the characteristic low frequency hearing loss. As the disease progresses hearing loss usually worsens.

Other tests such as the auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computer tomography (CT scan) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing or balance nerve. These tumors are rare, but they can cause symptoms similar to Meniere's disease. A full neurological evaluation is performed to exclude other causes of vertigo.

How can Meniere's disease be treated?

  • Medications: A diuretic (water pill) such as triamterene (Dyazide, Maxzide) combined with a low salt diet, is the primary treatment of Meniere's disease. Anti-vertigo medications such as meclizine (Antivert, Bonine, Meni-D, Antrizine) or diazepam (Valium) may provide temporary relief during the attacks of vertigo. Anti-nausea medications [for example, promethazine (Phenergan)]  sometimes also are prescribed. Both anti-vertigo and anti-nausea medications may cause drowsiness.
  • Surgery: If vertigo attacks are not controlled medically and are disabling, one of the following surgical procedures may be recommended depending on the individual patient's situation:

     

    • endolymphatic shunt (A surgical procedure in which a shunt (tube) is placed in the endolymphatic sac that drains excess fluid from the ear.)
    • selective vestibular neurectomy
    • labyrinthectomy (surgical removal of the  labyrinth of the ear) and eighth nerve section.

     

Although there is no real cure for Meniere's disease, the attacks of vertigo can be controlled in nearly all cases. If you have vertigo without warning, you should not drive, because failure to control the vehicle may be hazardous to yourself and to others. Safety may require you to forego ladders, scaffolds, and swimming.

Meniere's Disease At A Glance

  • Meniere's disease is a disorder of the flow of fluids of the inner ear.
  • Symptoms of Meniere's disease include ringing, ear fullness, hearing loss, and poor equilibrium.
  • Diagnosis of Meniere's disease is usually based on history and exam, though other tests can be used.
  • Treatments for Meniere's disease include diet and life style changes, medications, and surgery.


Menopause
(Perimenopause)


  • What is menopause?
  • At what age does a woman typically reach menopause?
  • What conditions can affect the timing of menopause?
  • What are the symptoms of menopause?
  • What are the complications and effects of menopause on chronic medical conditions?
  • Are hormone levels or other blood tests helpful in detecting menopause?
  • What are the treatment options for the symptoms of menopause?
  • Hormone therapy
  • Other medical therapies
  • Alternative therapies
  • Non-hormone therapies
  • Lifestyle factors in managing menopause symptoms
  • Menopause At A Glance
  • Menopause and Perimenopause - Slideshow View Menopause and Perimenopause Slideshow
  • Patient Discussions: Menopause - Experience
  • Patient Discussions: Menopause - Symptoms Experienced
  • Find a local Obstetrician-Gynecologist in your town

What is menopause?

Menopause is defined as the state of an absence of menstrual periods for 12 months. The menopausal transition starts with varying menstrual cycle length and ends with the final menstrual period. Perimenopause means "the time around menopause" and is often used to refer to the menopausal transitional period. It is not officially a medical term, but is sometimes used to explain certain aspects of the menopause transition in lay terms. Postmenopause is the entire period of time that comes after the last menstrual period.

Menopause is the time in a woman's life when the function of the ovaries ceases. The ovary (female gonad), is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones such as estrogen. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.

The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle and pregnancy. Estrogens also protect the bone. Therefore, a woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.

Perimenopause is different for each woman. Scientists are still trying to identify all the factors that initiate and influence this transition period.

 

At what age does a woman typically reach menopause?

The average age of menopause is 51 years old. But there is no way to predict when an individual woman will enter menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. Most women reach menopause between the ages of 45 and 55, but menopause may occur as earlier as the 30s or 40s or may not occur until a woman reaches her 60s. As a rough "rule of thumb," women tend to undergo menopause at an age similar to that of their mothers.

Perimenopause, often accompanied by irregularities in the menstrual cycle along with the typical symptoms of early menopause, can begin up to 10 years prior to the last menstrual period.

What conditions can affect the timing of menopause?

Certain medical and surgical conditions can influence the timing of menopause.

Surgical removal of the ovaries

The surgical removal of the ovaries (oophorectomy) in an ovulating woman will result in an immediate menopause, sometimes termed a surgical menopause or induced menopause. In this case, there is no perimenopause, and after surgery, a woman will generally experience the signs and symptoms of menopause. In cases of surgical menopause, women often report that the abrupt onset of menopausal symptoms results in particularly severe symptoms, but this is not always the case.

The ovaries are often removed together with the removal of the uterus (hysterectomy). If a hysterectomy is performed without removal of both ovaries in a woman who has not yet reached menopause, the remaining ovary or ovaries are still capable of normal hormone production. While a woman cannot menstruate after the uterus is removed by a hysterectomy, the ovaries themselves can continue to produce hormones up until the normal time when menopause would naturally occur. At this time a woman could experience the other symptoms of menopause such as hot flashes and mood swings. These symptoms would then not be associated with the cessation of menstruation. Another possibility is that premature ovarian failure will occur earlier than the expected time of menopause, as early as 1-2 years following the hysterectomy. If this happens, a woman may or may not experience symptoms of menopause.

Cancer chemotherapy and radiation therapy

Depending upon the type and location of the cancer and its treatment, these types of cancer therapy (chemotherapy and/or radiation therapy) can result in menopause if given to an ovulating woman. In this case, the symptoms of menopause may begin during the cancer treatment or may develop in the months following the treatment.

Premature ovarian failure

Premature ovarian failure is defined as the occurrence of menopause before the age of 40. This condition occurs in about 1% of all women. The cause of premature ovarian failure is not fully understood, but it may be related to autoimmune diseases or inherited (genetic) factors.

What are the symptoms of menopause?

It is important to remember that each woman's experience is highly individual. Some women may experience few or no symptoms of menopause, while others experience multiple physical and psychological symptoms. The extent and severity of symptoms varies significantly among women. These symptoms of menopause and perimenopause are discussed in detail below.

Irregular vaginal bleeding

Irregular vaginal bleeding may occur during menopause. Some women have minimal problems with abnormal bleeding during perimenopause whereas others have unpredictable, excessive bleeding. Menstrual periods (menses) may occur more frequently (meaning the cycle shortens in duration), or they may get farther and farther apart (meaning the cycle lengthens in duration) before stopping. There is no "normal" pattern of bleeding during the perimenopause, and patterns vary from woman to woman. It is common for women in perimenopause to have a period after going for several months without one. There is also no set length of time it takes for a woman to complete the menopausal transition. It is important to remember that all women who develop irregular menses should be evaluated by her doctor to confirm that the irregular menses are due to perimenopause and not as a sign of another medical condition.

The menstrual abnormalities that begin in the perimenopause are also associated with a decrease in fertility, since ovulation has become irregular. However, women who are perimenopausal may still become pregnant until they have reached true menopause (the absence of periods for one year) and should still use contraception if they do not wish to become pregnant.

Hot flashes & night sweats

Hot flashes are common among women undergoing menopause. A hot flash is a feeling of warmth that spreads over the body and is often most pronounced in the head and chest. A hot flash is sometimes associated with flushing and is sometimes followed by perspiration. Hot flashes usually last from 30 seconds to several minutes. Although the exact cause of hot flashes is not fully understood, hot flashes are likely due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels.

There is currently no method to predict when hot flashes will begin and how long they will last. Hot flashes occur in up to 40% of regularly menstruating women in their forties, so they may begin before the menstrual irregularities characteristic of menopause even begin. About 80% of women will be finished having hot flashes after five years. Sometimes (in about 10% of women), hot flashes can last as long as 10 years. There is no way to predict when hot flashes will cease, though they tend to decrease in frequency over time. The average woman who has hot flashes will have them for about five years.

Sometimes hot flashes are accompanied by night sweats (episodes of drenching sweats at nighttime). This may lead to awakening and difficulty falling asleep again, resulting in unrefreshing sleep and daytime tiredness.

Vaginal symptoms

Vaginal symptoms occur as a result of the lining tissues of the vagina becoming thinner, drier, and less elastic as estrogen levels fall. Symptoms may include vaginal dryness, itching, or irritation and/or pain with sexual intercourse (dyspareunia). The vaginal changes also lead to an increased risk of vaginal infections.

Urinary symptoms

The lining of the urethra (the transport tube leading from the bladder to discharge urine outside the body) also undergoes changes similar to the tissues of the vagina, and becomes drier, thinner, and less elastic with declining estrogen levels. This can lead to an increased risk of urinary tract infection, feeling the need to urinate more frequently, or leakage of urine (urinary incontinence). The incontinence can result from a strong, sudden urge to urinate or may occur during straining when coughing, laughing, or lifting heavy objects.

Emotional and cognitive symptoms

Women in perimenopause often report a variety of thinking (cognitive) and/or emotional symptoms, including fatigue, memory problems, irritability, and rapid changes in mood. It is difficult to precisely determine exactly which behavioral symptoms are due directly to the hormonal changes of menopause. Research in this area has been difficult for many reasons.

Emotional and cognitive symptoms are so common that it is sometimes difficult in a given woman to know if they are due to menopause. The night sweats that may occur during perimenopause can also contribute to feelings of tiredness and fatigue, which can have an effect on mood and cognitive performance. Finally, many women may be experiencing other life changes during the time of perimenopause or after menopause, such as stressful life events, that may also cause emotional symptoms.

Other physical changes

Many women report some degree of weight gain along with menopause. The distribution of body fat may change, with body fat being deposited more in the waist and abdominal area than in the hips and thighs. Changes in skin texture, including wrinkles, may develop along with worsening of adult acne in those affected by this condition. Since the body continues to produce small levels of the male hormone testosterone, some women may experience some hair growth on the chin, upper lip, chest, or abdomen.

What are the complications and effects of menopause on chronic medical conditions?

Osteoporosis

Osteoporosis is the deterioration of the quantity and quality of bone that causes an increased risk of fracture. The density of the bone (bone mineral density) normally begins to decrease in women during the fourth decade of life. However, that normal decline in bone density is accelerated during the menopausal transition. As a consequence, both age and the hormonal changes due to the menopause transition act together to cause osteoporosis.

The process leading to osteoporosis can operate silently for decades. Women may not be aware of their osteoporosis until suffering a painful fracture. The symptoms are then related to the location and severity of the fractures.

Treatment of osteoporosis

The goal of osteoporosis treatment is the prevention of bone fractures by slowing bone loss and increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures for the condition. Therefore, the prevention of osteoporosis is as important as treatment.

Osteoporosis treatment and prevention measures are:

  • Lifestyle changes including cessation of cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.
  • Calcium and vitamin D supplements may be recommended for women who do not consume sufficient quantities of these nutrients.
  • Medications that stop bone loss and increase bone strength include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), zoledronic acid (Reclast), raloxifene (Evista), and calcitonin (Calcimar). Teriparatide (Forteo) is a medication that increases bone formation.
 

Cardiovascular disease

Prior to menopause, women have a decreased risk of heart disease and stroke when compared with men. Around the time of menopause, however, a women's risk of cardiovascular disease increases. Heart disease is the leading cause of death in both men and women in the U.S.

Coronary heart disease rates in postmenopausal women are two to three times higher than in women of the same age who have not reached menopause. This increased risk for cardiovascular disease may be related to declining estrogen levels, but in light of other factors (see Treatment section below), postmenopausal women are not advised to take hormone therapy simply as a preventive measure to decrease their risk of heart attack or stroke.

Are hormone levels or other blood tests helpful in detecting menopause?

Because hormone levels may fluctuate greatly in an individual woman, even from one day to the next, hormone levels are not a reliable method for diagnosing menopause. Even if levels are low one day, they may be high the next day in the same woman. There is no single blood test that reliably predicts when a woman is going through the menopausal transition. Therefore, there is currently no proven role for blood testing regarding menopause except for tests to exclude medical causes of erratic menstrual periods other than menopause. The only way to diagnose menopause is to observe the lack of menstrual periods for 12 months in a woman in the expected age range.

What are the treatment options for menopause?

Menopause itself is a normal part of life and not a disease that requires treatment. However, treatment of associated symptoms is possible if these become substantial or severe.

Hormone therapy

Estrogen and progesterone therapy

Hormone therapy (HT) , also referred to as hormone replacement therapy (HRT) or postmenopausal hormone therapy (PHT), consists of estrogens or a combination of estrogens and progesterone (progestin). Hormone therapy has been used to control the symptoms of menopause related to declining estrogen levels such as hot flashes and vaginal dryness, and HT is still the most effective way to treat these symptoms. But long-term studies (the NIH-sponsored Women's Health Initiative, or WHI) of women receiving combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed.

Hormone therapy is available in oral (pill), transdermal form (patch and spray). Transdermal hormone products are already in their active form without the need for "first pass" metabolism in the liver to be converted to an active form. Since transdermal hormone products do not have effects on the liver, this route of administration has become the preferred form for most women. A number of preparations are available for oral and transdermal forms of HT, varying in the both type and amount of hormones in the products.

There has been increasing interest in recent years in the use of so-called "bioidentical" hormone therapy for perimenopausal women. Bioidentical hormone preparations are medications that contain hormones that have the same chemical formula as those made naturally in the body. The hormones are created in a laboratory by altering compounds derived from naturally-occurring plant products. Some of these so-called bioidentical hormone preparations are U.S. FDA-approved and manufactured by drug companies, while others are made at special pharmacies called compounding pharmacies that make the preparations on a case-by-case basis for each patient. These individual preparations are not regulated by the FDA, because compounded products are not standardized.

Like transdermal HT products, bioidentical hormone therapy products are administered transdermally. They are typically applied as cream or gels. Their advocates believe that their use may avoid potentially dangerous side effects of synthetic hormones used in conventional hormone therapy. However, studies to establish the long-term safety and effectiveness of these products have not been carried out.

The decision about hormone therapy, is a very individual decision in which the patient and doctor must take into account the inherent risks and benefits of the treatment along with each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time. The WHI study findings do not support the use of HT for the prevention of chronic disease.

Oral contraceptive pills

Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding.

Prior to treatment, a doctor must exclude other causes of erratic vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in the menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. The list of contraindications for oral contraceptives in women going through the menopause transition is the same as that for premenopausal women.

Local (vaginal) hormone and non-hormone treatments

There are also local (meaning applied directly to the vagina) hormonal treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring, vaginal estrogen cream, or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined for this purpose.

Vaginal moisturizing agents such as creams or lotions (for example, K-Y Silk-E Vaginal Moisturizer or KY Liquibeads Vaginal Moisturizer) as well as the use of lubricants during intercourse are non-hormonal options for managing the discomfort of vaginal dryness.

Applying Betadine topically on the outer vaginal area, and soaking in a sitz bath or soaking in a bathtub of warm water may be helpful for relieving symptoms of burning and vaginal pain after intercourse.

Other pharmaceutical therapies

Antidepressant medications: The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications have been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Specifically, venlafaxine (Effexor), a drug related to the SSRIs, and the SSRIs fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa) have all been shown to decrease the severity of hot flashes in some women. However, antidepressant medications may be associated with side effects, including decreased libido or sexual dysfunction.

Other medications: Other prescription medications have been shown to provide some relief for hot flashes, although their specific purpose is not the treatment of hot flashes. All of these may have side effects, and their use should be discussed with and monitored by a doctor. Some of these medications that have been shown to help relieve hot flashes include the antiseizure drug gabapentin (Neurontin) and clonidine (Catapres), a drug used to treat high blood pressure.

 

Alternative medical therapies

Plant estrogens (phytoestrogens, isoflavones)

Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. They have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens. Their estrogen potency has been estimated to be only 1/1000 to 1/100,000 of that of estradiol, a natural estrogen.

Two types of isoflavones, genistein and daidzein, are found in soy beans, chick peas, and lentils, and are considered to be the most potent estrogens of the phytoestrogens.

Some studies have shown that these compounds may help relieve hot flashes and other symptoms of menopause. In particular, women who have had breast cancer and do not want to take hormone therapy (HT) with estrogen sometimes use soy products for relief of menopausal symptoms. However, some phytoestrogens can actually have anti-estrogenic properties in certain situations, and the overall risks of these preparations have not yet been determined. For example, researchers have shown that long-term use of phytoestrogens in postmenopausal women led to an overgrowth of the tissues lining the uterus (endometrial hyperplasia) which can be a precursor to cancer.

There is also a perception among many women that plant estrogens are "natural" and therefore safer than HT, but this has never been proven scientifically. Further research is needed to fully characterize the safety and potential risks of phytoestrogens.

Vitamin E

Some women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.

Black Cohosh

Black cohosh is an herbal preparation that has been popular in Europe for the relief of hot flashes. This herb has become more and more popular in the U.S., and the North American Menopause Society does support the short-term use of black cohosh for treating menopausal symptoms, for a period of up to six months, because of its relatively low incidence of side effects when used short term. However, there have still been very few scientific studies done to establish the benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh.

A large study known as the Herbal Alternatives for Menopause Trial (HALT) tested the effectiveness of different herbal or alternative ingredients versus estrogen therapy or placebo for the relief of menopausal symptoms. After one year of therapy, there was no significant reduction in the frequency or severity of hot flashes in women receiving any of the herbal preparations (including a group who received black cohosh) when compared to placebo at any of the follow-up times (3, 6, and 12 months).

Other alternative therapies

There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong quai, chasteberry, and wild yam. Scientific studies have not proven the safety or effectiveness of these products.

Non-pharmaceutical therapies

In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are a variety of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.

Lifestyle factors in controlling the symptoms and complications of menopause

Many of the symptoms of menopause and the medical complications that may develop in postmenopausal women can be lessened or even avoided by taking steps to lead a healthy lifestyle. Regular exercise can help protect against cardiovascular disease as well as osteoporosis, and exercise also has known mental health benefits. Proper nutrition and smoking cessation will also reduce your risk of cardiovascular disease.

Menopause At A Glance
  • Menopause is defined as the absence of menstrual periods for 12 months. It is the time in a woman's life when the function of the ovaries ceases.
  • The process of menopause does not occur overnight, but rather is a gradual process. This so-called perimenopausal transition period is a different experience for each woman.
  • The average age of menopause onset is 51 years old, but menopause may occur as early as the 30s or as late as the 60s There is no reliable lab test to predict when a woman will experience menopause.
  • The age at which a woman starts having menstrual periods is not related to the age of menopause onset.
  • Symptoms of menopause can include abnormal vaginal bleeding, hot flashes, vaginal and urinary symptoms, and mood changes.
  • Complications that women may develop in the postmenopausal period include osteoporosis and heart disease.
  • Treatments for menopause are customized for each patient.
  • Treatments are directed toward alleviating uncomfortable or distressing symptoms.


Menopause and Sex


Sex And Menopause


  • How does menopause affect your sex drive?
  • Does menopause lower sex Drive in all women?
  • What can I do to treat vaginal dryness during menopause?
  • How Can I Improve My Sex Drive During and After Menopause?
  • What can I do to increase intimacy with my partner?
  • Do I still have to worry about sexually transmitted diseases?
  • How can I protect myself from sexually transmitted diseases?
  • Find a local Obstetrician-Gynecologist in your town

How Does Menopause Affect Your Sex Drive?

The loss of estrogen following menopause can lead to changes in a woman's sexual drive and functioning. Menopausal and postmenopausal women may notice that they are not as easily aroused, and may be less sensitive to touching and stroking -- which can result in decreased interest in sex.

In addition, lower levels of estrogen can cause a decrease in blood supply to the vagina. This decreased blood flow can affect vaginal lubrication, causing the vagina to be too dry for comfortable intercourse.

A lower estrogen level is not the only culprit behind a decreased libido; there are numerous other factors that may influence a woman's interest in sexual activity during menopause and after. These include:

  • Bladder control problems
  • Sleep disturbances
  • Depression or anxiety
  • Stress
  • Medications
  • Health concerns

Does Menopause Lower Sex Drive in all Women?

No. In fact, some post-menopausal women report an increase in sex drive. This may be due to decreased anxiety associated with a fear of pregnancy. In addition, many post-menopausal women often have fewer child-rearing responsibilities, allowing them to relax and enjoy intimacy with their partners.

What Can I Do to Treat Vaginal Dryness During Menopause?

During and after menopause, vaginal dryness can be treated with water-soluble lubricants such as Astroglide or K-Y Jelly. Do not use non-water soluble lubricants such as Vaseline because they can weaken latex (the material used to make condoms, which should continue to be used to avoid pregnancy until your doctor verifies you are not producing anymore eggs and to prevent contracting sexually transmitted diseases). Non-water soluble lubricants can also provide a medium for bacterial growth, particularly in a person whose immune system has been weakened by chemotherapy..

How Can I Improve My Sex Drive During and After Menopause?

Currently, there are not any good drugs to treat sexual problems in women dealing with menopause. Estrogen replacement may work, but research has yielded conflicting results regarding its effectiveness. Estrogen can, however, make intercourse less painful by treating vaginal dryness.

Doctors are also studying whether a combination of estrogen and the male hormones, called androgens, may be helpful in increasing sex drive in women.

Although sexual problems can be difficult to discuss, talk to your doctor; there are options to consider, such as counseling. Your doctor may refer you and your partner to a health professional who specializes in sexual dysfunction. The therapist may advise sexual counseling on an individual basis, with your partner or in a support group. This type of counseling can be very successful, even when it is done on a short-term basis.

 

How Can I Increase Intimacy With My Partner During Menopause?

During menopause, if your sex drive isn't what it once was but you don't think you need counseling, you should still take time for intimacy with your partner. Being intimate does not require having intercourse -- love and affection can be expressed in many ways. Enjoy your time together -- you can take long romantic walks, have candlelit dinners, or give each other back rubs.

To improve your physical intimacy, you may want to try the following approaches:

  • Educate yourself about your anatomy, sexual function, and the normal changes associated with aging, as well as sexual behaviors and responses. This may help you overcome your anxieties about sexual function and performance.
  • Enhance stimulation through the use of erotic materials (videos or books), masturbation, and changes to sexual routines.
  • Use distraction techniques to increase relaxation and eliminate anxiety. These can include erotic or non-erotic fantasies; exercises with intercourse; and music, videos, or television.
  • Practice non-coital behaviors (physically stimulating activity that does not include intercourse), such as sensual massage. These activities can be used to promote comfort and increase communication between you and your partner.
  • Minimize any pain you may be experiencing by using sexual positions that allow you to control the depth of penetration. You may also want to take a warm bath before intercourse to help you relax, and use vaginal lubricants to help reduce pain caused by friction.

Do I Still Have to Worry About Sexually Transmitted Diseases?

Yes. Just as you must use protection if you do not want to become pregnant during perimenopause, you must also take measures to protect yourself against sexually transmitted diseases (STDs) during menopause and postmenopause. It's important to remember that your risk of contracting STDs is a possibility at any point in your life during which you are sexually active, and this risk does not go down with age or with changes in your reproductive system.

Left untreated, some STDs can lead to serious illnesses, while others, like AIDS, cannot be cured and are deadly.

How Can I Protect Myself From STDs?

Here are some basic steps that you can take to help protect yourself from STDs:

  • Consider that not having sex is the only sure way to prevent STDs.
  • Use a latex condom every time you have sex. (If you use a lubricant, make sure it is water-based (not Vaseline.)
  • Limit your number of sexual partners. The more partners you have, the more likely you are to catch an STD.
  • Practice monogamy. This means having sex with only one person. That person must also have sex with only you to reduce your risk.
  • Choose your sex partners with care. Don't have sex with someone whom you suspect may have an STD.
  • Get checked for STDs. Don't risk giving the infection to someone else.
  • If you have more than one sex partner, always use a condom.
  • Don't use alcohol or drugs before you have sex. You may be less likely to practice safe sex if you are drunk or high.
  • Know the signs and symptoms of STDs. Look for them in yourself and your sex partners.
  • Learn about STDs. The more you know about STDs, the better you can protect yourself.
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Last Updated on Sunday, 18 December 2011 16:40
 
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