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Written by Ruai Pharmaceuticals   
Monday, 19 September 2011 12:49

Pancreatic Cancer


  • Pancreatic cancer facts
  • What is the pancreas, and what is the function of the pancreas?
  • What is cancer?
  • What is pancreatic cancer?
  • What are pancreatic cancer causes and risk factors?
  • What are the symptoms and signs of pancreatic cancer?
  • How is the diagnosis of pancreatic cancer made?
  • How is pancreatic cancer staged?
  • What is the treatment for resectable pancreatic cancer?
  • What is the treatment for locally advanced unresectable pancreatic cancer?
  • What is the treatment for metastatic pancreatic cancer?
  • What are side effects of pancreatic cancer treatment?
  • What is the prognosis of pancreatic cancer?
  • What research is being done on pancreatic cancer?
  • Is complimentary or alternative therapy effective in pancreatic cancer treatment?
  • Can pancreatic cancer be prevented?
  • Where can people get support when coping with pancreatic cancer?
  • Where can people find additional information about pancreatic cancer?
  • Pancreatic Cancer - Slideshow View Pancreatic Cancer Slideshow
  • Pictures of Pancreas - Image Collection
  • Pictures of Pancreas - Image Collection
  • Cancer-Fighting Foods - Slideshow View Cancer-Fighting Foods Slideshow
  • Patient Discussions: Pancreatic Cancer - Effective Treatments
  • Find a local Oncologist in your town

Pancreatic cancer facts

  • Most pancreatic cancers are adenocarcinomas.
  • Few patients diagnosed with pancreatic cancer have identifiable risk factors.
  • Pancreatic cancer is highly lethal.
  • Pancreatic cancer is difficult to diagnose, and the diagnosis is often made late in the disease course. Symptoms include weight loss, back pain, and jaundice.
  • The only curable treatment is surgical removal of all cancer.
  • Chemotherapy after surgery can lower the chances of the cancer returning.
  • Chemotherapy for metastatic pancreatic cancer can extend life and improve the quality of life for people with the disease.
  • Patients diagnosed with pancreatic cancer are encouraged to seek out clinical trials to improve pancreatic cancer treatment.
  • Many organizations exist to help provide information and support for patients and families fighting pancreatic cancer.

What is the pancreas, and what is the function of the pancreas?

The pancreas is an organ in the abdomen that sits in front of the spine above the level of the belly button. It performs two main functions: first, it makes insulin, a hormone that regulates blood sugar levels, and second: it makes enzymes, which help break down proteins. Enzymes help digestion by chopping proteins into smaller parts so that they can be more easily absorbed by the body and used for energy. Enzymes leave the pancreas via a system of tubes called "ducts" that connect the pancreas to the intestines. The pancreas sits deep in the belly and is in close proximity to many important structures such as the small intestine (the duodenum) and the bile ducts, as well as important blood vessels and nerves.


Pancreas (Pancreatic Cancer)
Picture of pancreas in an article on pancreatic cancer
Cancer that starts in the pancreas is called pancreatic cancer. This picture of the pancreas shows its location in the back of the abdomen, behind the stomach.

What is cancer?

Every second of every day within our body, a massive process of destruction and repair occurs. The human body is comprised of trillions of cells, and every day billions of cells wear out or are destroyed. Each time the body makes a new cell to replace one that is wearing out, the body tries to make a perfect copy of the cell that dies off, because that dying cell had a job to do and the newly made cell must be capable of performing that same function. Despite remarkably elegant systems in place to edit out errors in this process, the body makes tens of thousands of mistakes daily in normal cell division either due to random errors or from environmental pressure within the body. Most of these mistakes are corrected, or the mistake leads to the death of the newly made cell and another new cell is then made. Sometimes a mistake is made that, rather than inhibiting the cell's ability to grow and survive, allows the newly made cell to grow in an unregulated manner. When this occurs, that cell can begin to divide independent of the checks and balances that control normal cell growth. When this happens a tumor can develop.

Tumors fall into two categories; there are "benign" tumors and "malignant" or cancerous tumors. So what is the difference? The answer is that a benign tumor grows only in the tissue from which it arises. Benign tumors can sometimes grow quite large or grow rapidly and cause severe symptoms. For example, a fibroid in a woman's uterus can cause bleeding or pain, but it will never travel outside the uterus and grow as a new tumor elsewhere. Fibroids, like all benign tumors, lack the capacity to shed cells into the blood and lymph systems and cannot travel to other places in the body and grow. A cancer, on the other hand, can shed cells from the primary tumor that can float like dandelion seeds in the wind through the bloodstream or lymphatics, landing in tissues distant from the primary tumor, growing new tumors in various other sites. This process, called metastasis, is the defining characteristic of a cancerous tumor. Pancreas cancer, unfortunately, is a particularly good model for this process.

Cancers are named by the tissues from which the primary tumor arises. Hence, a lung cancer that travels to the liver is not a "liver cancer" but is described as metastatic lung cancer and a patient with a breast cancer which spreads to the brain is not described as having a "brain tumor" but rather as having metastatic breast cancer.

What is pancreatic cancer?

Cancers that develop within the pancreas fall into two major categories: (1) cancers of the endocrine pancreas (the part that makes insulin) are called "islet cell" or "pancreatic neuroendocrine" cancers and (2) cancers of the exocrine pancreas (the part that makes enzymes). Islet cell cancers are rare and typically grow slowly compared to exocrine pancreatic cancers. Islet cell tumors often release hormones into the bloodstream and are further characterized by the hormones they produce (insulin, glucagon, gastrin, and other hormones). Cancers of the exocrine pancreas develop from the cells that line the system of ducts that deliver enzymes to the small intestine and are called commonly referred to as pancreatic adenocarcinomas. Adenocarcinoma of the pancreas comprises 95% of all pancreatic ductal cancers and is the subject of this review.

Cells that line the ducts in the exocrine pancreas divide more rapidly than the tissues that surround them. For reasons that we do not understand, these cells can make a mistake when they divide and an abnormal cell can be made. When an abnormal ductal cell begins to divide in an unregulated way, a growth can form. These changes are called "dysplasia." Often, dysplastic cells can undergo additional genetic mistakes over time and become even more abnormal. If these dysplastic cells then begin to invade through the walls of the duct from which they arise into the surrounding tissue, a frank cancer develops.

What are pancreatic cancer causes and risk factors?

About 40,000 cases of pancreatic cancer occur yearly in the United States. Most people who develop pancreatic cancer do so without any predisposing risk factors. Perhaps the biggest risk factor is increasing age; being over the age of 60 puts an individual at greater risk. Rarely, there can be genetic syndromes that run in families that put individuals at higher risk such as BRCA-2 and, to a lesser extent, BRCA-1 gene mutations. Familial syndromes are unusual but it is important to let your doctor know if anyone else in your family has been diagnosed with cancer. Additionally, certain behaviors or conditions are thought to slightly increase an individual's risk for developing pancreatic cancer. For example, African-Americans may be at greater risk as may individuals with close family members who have been previously diagnosed with the disease. Other behaviors or conditions that may put people at risk include tobacco use, obesity, a sedentary lifestyle, a history of diabetes, chronic pancreatic inflammation (pancreatitis), and a fatty (or Western) diet. Prior stomach surgery may moderately increase one's risk as can certain chronic infections such as hepatitis B and H. pylori (an infection of the stomach lining). Certain types of pancreatic cysts may put individuals at risk of developing pancreatic cancer. Despite these associated risks, no identifiable cause is found in most people who develop pancreatic cancer.

What are the symptoms and signs of pancreatic cancer?

Because the pancreas lies deep in the belly in front of the spine, pancreatic cancer often grows silently for months before it is discovered. Early symptoms can be absent or quite subtle. More easily identifiable symptoms develop once the tumor grows large enough to press on other nearby structures such as nerves (which causes pain), the intestines (which affects appetite and causes nausea along with weight loss), or the bile ducts (which causes jaundice or a yellowing of the skin and can cause loss of appetite and itching). Symptoms in women rarely differ from those in men. Once the tumor sheds cancer cells into the blood and lymph systems and metastasizes, more symptoms usually arise depending on the location of the metastasis. Frequent sites of metastasis for pancreatic cancer include the liver, the lymph nodes, and the lining of the abdomen (called the peritoneum). Unfortunately, most pancreatic cancers are found after the cancer has grown beyond the pancreas or has metastasized to other places.

How is the diagnosis of pancreatic cancer made?

Most people with pancreatic cancer first present to their primary-care doctor complaining of nonspecific symptoms. These complaints trigger an evaluation often including a physical examination (usually normal), blood tests, X-rays, and an ultrasound. If pancreatic cancer is present, the likelihood of an ultrasound revealing an abnormality in the pancreas is about 75%. If a problem is identified, frequently a computed tomography (CT) scan is performed as the next step in the evaluation. A pancreatic mass and the suspicion of pancreatic cancer is then raised, and a biopsy is performed to yield a diagnosis.

Different strategies can be used to perform a biopsy of the suspected cancer. Often, a needle biopsy of the liver through the belly wall (percutaneous liver biopsy) will be used if it appears that there has been spread of the cancer to the liver. If the tumor remains localized to the pancreas, biopsy of the pancreas directly usually is performed with the aid of a CT. A direct biopsy also can be made via an endoscope put down the throat and into the intestines. A camera on the tip of the endoscope allows the endoscopist to advance the endoscope within the intestine. An ultrasound device at the tip of the endoscope locates the area of the pancreas to be biopsied, and a biopsy needle is passed through a working channel in the endoscope to obtain tissue from the suspected cancer. Ultimately, a tissue diagnosis is the only way to make the diagnosis with certainty, and the team of doctors work to obtain a tissue diagnosis in the easiest way possible.

In addition to radiologic tests, suspicion of a pancreatic cancer can arise from the elevation of a "tumor marker," a blood test which can be abnormally high in people with pancreatic cancer. The tumor marker most commonly associated with pancreatic cancer is called the "CA 19-9." It is often released into the bloodstream by pancreatic cancer cells and may be elevated in patients newly found to have the disease. Unfortunately, the CA 19-9 test is not specific for pancreatic cancer. Other cancers as well as some benign conditions can cause the CA 19-9 to be elevated. Sometimes (about 10% of the time) the CA 19-9 will be at normal levels in the blood despite a confirmed diagnosis of pancreatic cancer, so the tumor marker is not perfect. It can be helpful, however, to follow during the course of illness since its rise and fall may help guide appropriate therapy.

How is pancreatic cancer staged?

Once pancreatic cancer is diagnosed, it is "staged." Pancreatic cancer is broken into four stages with stage I being the earliest stage and stage IV being the most advanced (metastatic disease). Unlike many cancers, however, patients with pancreatic cancer are typically grouped into three categories: those with local disease, those with locally advanced unresectable disease, and those with metastatic disease. Initial therapy often differs for patients in these three groups.

Patients with stage I and stage II cancers are thought to have local or "resectable" cancer (cancer that can be completely removed with an operation). Patients with stage III cancers have "locally advanced unresectable" disease. In this situation, the opportunity for cure has been lost but local treatments such as radiation remain options. In patients with stage IV pancreatic cancer, chemotherapy is most commonly recommended as a means of controlling the symptoms related to the cancer and extending life. Below, we will review common treatments for resectable, locally advanced unresectable, and metastatic pancreatic cancer.

What is the treatment for resectable pancreatic cancer?

If a pancreatic cancer is found at an early stage (stage I and stage II) and is contained locally within or around the pancreas, surgery may be recommended. Surgery is the only curative treatment for pancreatic cancer. The surgical procedure most commonly performed to remove a pancreatic cancer is a "Whipple" procedure (pancreatoduodenectomy). It often comprises removal of a portion of the stomach, the duodenum (the first part of the small intestine), pancreas, bile ducts, lymph nodes, and gallbladder. It is important to be evaluated at a hospital with lots of experience performing pancreatic cancer surgery because the operation is a big one and evidence shows that experienced surgeons better select people who can get through the surgery safely and also better judge who will most likely benefit from the operation. In experienced hands, mortality from the surgery itself is less than 4%.

After the Whipple surgery, patients typically spend about one week in the hospital recovering from the operation. Complications from the surgery can include blood loss (anemia), leakage from the reconnected intestines or ducts, or slow return of bowel function. Recovery to presurgical health can often take several months.

After patients recover from a Whipple procedure for pancreatic cancer, treatment to reduce the risk of the cancer returning is a standard recommendation. This treatment, referred to as "adjuvant therapy," has proven to lower the risk of recurrent cancer. Typically six months of chemotherapy is recommended, sometimes with radiation incorporated into the plan.

Unfortunately, only about 20 people out of 100 diagnosed with pancreatic cancer are found to have a tumor amenable to surgical resection. The rest have tumors that are too locally advanced to completely remove or have metastatic spread at the time of diagnosis. Even among patients who are amenable to surgery, only 20% live five years.

What is the treatment for locally advanced unresectable pancreatic cancer?

If a pancreatic cancer is found when it has grown into important local structures but not yet spread to distant sites, this is described as locally advanced unresectable pancreatic cancer (stage III). The standard of care in the United States for the treatment of locally advanced cancer is a combination of low-dose chemotherapy given simultaneously with radiation treatments to the pancreas and surrounding tissues. Radiation treatments are designed to lower the risk of local growth of the cancer, thereby minimizing the symptoms that local progression causes (back or belly pain, nausea, loss of appetite, intestinal blockage, jaundice). Radiation treatments are typically given Monday through Friday for about five weeks. Chemotherapy given concurrently (at the same time) may improve the effectiveness of the radiation and may lower the risk for cancer spread outside the area where the radiation is delivered. When the radiation is completed and the patient has recovered, more chemotherapy is often recommended. Recently, newer forms of radiation delivery (stereotactic radiosurgery, gamma knife radiation, cyberknife radiation) have been utilized in locally advanced pancreatic cancer with varying degrees of success, but these treatments can be more toxic and are, for now, largely experimental.

What is the treatment for metastatic pancreatic cancer?

Once a pancreatic cancer has spread beyond the vicinity of the pancreas and involves other organs, it has become a problem through the system. As a result, a systemic treatment is most appropriate and chemotherapy is recommended. Chemotherapy travels through the bloodstream and goes anywhere the blood flows and, as such, treats most of the body. It can attack a cancer that has spread through the body wherever it is found. In metastatic pancreatic cancer, chemotherapy is recommended for individuals well enough to receive it. It has been proven to both extend the lives of patients with pancreatic cancer and to improve their quality of life. These benefits are documented, but unfortunately the overall benefit from chemotherapy in pancreatic cancer treatment is modest and chemotherapy prolongs life for the average patient by only a few months. Chemotherapy options for patients with pancreatic cancer vary from treatment with a single chemotherapy agent to treatment with as many as three chemotherapies given together. The aggressiveness of the treatment is determined by the cancer doctor (medical oncologist) and by the overall health and strength of the individual patient.

What are the side effects of pancreatic cancer treatment?

Side effects of treatment for pancreatic cancer vary depending on the type of treatment. For example, radiation treatment (which is a local treatment) side effects tend to accumulate throughout the course of radiation therapy and include fatigue, nausea, and diarrhea. Chemotherapy side effects depend on the type of chemotherapy given (less aggressive chemotherapy treatments typically cause fewer side effects whereas more aggressive combination regimens are more toxic) and can include fatigue, loss of appetite, change in taste, hair loss (although not usually), and lowering of the immune system with risk for infections (immunosuppression). While these lists of side effects may seem worrisome, recognize that radiation doctors (radiation oncologists) and medical oncologists have much better supportive medications than they did in years past to control any nausea, pain, diarrhea, or immunosuppression related to treatment. The risks associated with pancreatic cancer treatment must be weighed against the inevitable and devastating risks associated with uncontrolled pancreatic cancer and, if the treatments control progression of the cancer, most patients feel better on treatment that they otherwise would.

What is the prognosis of pancreatic cancer?

Pancreatic cancer is a difficult disease. Even for surgically resectable (and therefore curable) tumors, the risk of cancer recurrence and subsequent death remains high. Only about 20% of patients undergoing a Whipple procedure for curable pancreatic cancer live five years, with the rest surviving on average less than two years. For patients with incurable (locally advanced unresectable or metastatic) pancreatic cancer, survival is even shorter; typically it is measured in months. With metastatic disease (stage IV), the average survival is just over six months. Doctors around the world continue to study this terrible disease and strive to improve treatments, but progress has been difficult to come by.

What research is being done on pancreatic cancer?

Doctors and researchers all over the world are hard at work developing better treatments for pancreatic cancer. Cooperative research led by centers of excellence in this country and many others continue daily to test new surgical techniques, radiation strategies, chemotherapy agents, and alternative therapies in an effort to improve care. Given the slow progress experienced over the last quarter century, many doctors feel that every eligible patient with pancreatic cancer should be offered enrollment in a research trial. For a complete list of clinical trials in pancreatic cancer treatment, please check online at http://www.cancer.gov.

Is complimentary or alternative medicine effective in pancreatic cancer treatment?

Complimentary or alternative medicine is of unclear benefit in pancreatic cancer treatment. No specific complimentary or alternative therapy has been proven beneficial, but many adjunctive treatments have been tried. Compounds such as circumin, the principle ingredient in turmeric, have shown efficacy in nonhuman research and are being tested in clinical trials in pancreatic cancer. Given the modest benefit derived from chemotherapy and radiation in this disease, alternative approaches in the treatment of pancreatic cancer in conjunction with (rather than instead of) standard treatment is warranted.

Can pancreatic cancer be prevented?

At this time there is no known surveillance strategy to reduce the risk of pancreatic cancer for the general population. With only 40,000 new diagnoses a year occurring in a country with over 300 million people, screening blood tests or X-rays have never been proven to be cost effective or beneficial. Additionally, doctors do not routinely screen individuals with family members diagnosed with the disease aside from the rare instance where a known genetic risk factor is present.

Where can people get support when coping with pancreatic cancer?

There are many fine organizations helping provide support for individuals and families battling pancreatic cancer. Many hospitals provide support networks utilizing the expertise of trained social workers with experience in caring for people with cancer. Additionally, the Pancreatic Cancer Action Network (PANCAN) and the American Cancer Society both provide information and support for people living with pancreatic cancer. Visit their web sites at http://www.pancan.org and http://www.cancer.org.

Where can people find additional information about pancreatic cancer?

Again, both PANCAN and the American Cancer Society are excellent resources for additional information regarding pancreatic cancer. The American Society of Clinical Oncology web site http://www.cancer.net also boasts a wealth of information for patients, family members, and professionals interesting in learning more about this disease.


Pancreas Divisum

  • What is pancreas divisum?
  • What causes pancreas divisum?
  • What are pancreas divisum symptoms?
  • How is pancreas divisum diagnosed?
  • How is pancreas divisum treated?
  • Find a local Gastroenterologist in your town

What is pancreas divisum?

Pancreas divisum is a common congenital anomaly (an anomaly that is present at birth) of the pancreatic duct(s). The Pancreas is a deep-seated organ located behind the stomach. One of its functions is to produce enzymes that are important for the digestion of food in the intestine. The digestive enzymes, in the form of digestive juice, drain from the pancreas via the pancreatic duct into the duodenum (the upper portion of the small intestine) where they aid in digesting food.

What causes pancreas divisum?

The human embryo starts life with two ducts in the pancreas; the ventral duct and the dorsal duct. In more than 90% of the embryos, the dorsal and the ventral ducts will fuse to form one main pancreatic duct. The main pancreatic duct will join the common bile duct (the duct that drains bile from the gallbladder and the liver) to form a common bile and pancreatic duct which drains into the duodenum through the major papilla. In approximately 10% of embryos, the dorsal and the ventral ducts fail to fuse. Failure of the ventral and the dorsal pancreatic ducts to fuse is called pancreas divisum (because the pancreas is drained by two ducts). In pancreas divisum, the ventral duct drains into the major papilla, while the dorsal duct drains into a separate minor papilla.

What are pancreas divisum symptoms?

The majority of individuals born with pancreas divisum experience no symptoms throughout life, will remain undiagnosed and will not require treatment. A small number of patients with pancreas divisum will experience repeated episodes of pancreatitis. Pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain and more severe complications. Some patients with pancreas divisum may develop chronic abdominal pain without pancreatitis.

Doctors are not certain how pancreas divisum causes abdominal pain and pancreatitis. One theory is that the minor papilla is too narrow to adequately drain the digestive juices in the dorsal duct. The backup of the digestive juices elevates the pressure in the minor duct that causes abdominal pain and pancreatitis.

For more, please read the Pancreatitis and Abdominal Pain articles.

How is pancreas divisum diagnosed?

The most accurate test to diagnose pancreas divisum is ERCP, which can demonstrate the presence of two separately draining pancreatic ducts. However, ERCP itself sometimes can cause attacks of pancreatitis. Other tests that can help diagnose pancreas divisum without the risk of causing pancreatitis include endoscopic ultrasound (EUS), and MRI (magnetic resonance imaging).

How is pancreas divisum treated?

Pancreas divisum without symptoms needs no treatment. Treatment of patients with abdominal pain and recurrent pancreatitis attributable to pancreas divisum has not been well established. Some doctors will attempt sphincterotomy (cutting of the minor papilla during ERCP to enlarge its opening). Others will insert a stent during ERCP into the duct to prevent duct blockage. These procedures are not risk free. Therefore, patients with symptomatic pancreas divisum are best evaluated and treated by doctors in centers experienced in treating pancreatic diseases.


Pancreatitis

  • Pancreatitis facts*
  • What is pancreatitis?
  • What are the causes of acute pancreatitis?
  • What are the symptoms of acute pancreatitis?
  • How is acute pancreatitis diagnosed?
  • How is acute pancreatitis treated?
  • What about gallstones and pancreatitis?
  • What is chronic pancreatitis?
  • What are the symptoms of chronic pancreatitis?
  • How is chronic pancreatitis diagnosed?
  • How is chronic pancreatitis treated?
  • How common is pancreatitis in children?
  • Hope through research
  • Pancreatitis At A Glance
  • For more information about pancreatitis
  • Patient Discussions: Pancreatitis - Treatments
  • Patient Discussions: Pancreatitis - Describe Your Experience
  • Find a local Gastroenterologist in your town

Pancreatitis facts*

*Pancreatitis facts Medically Edited by: Charles P. Davis, MD, PhD

  • Pancreatitis is inflammation of the pancreas, the organ that secretes digestive enzymes into the gastrointestinal tract; it also synthesizes and secretes insulin and glucagon.
  • Pancreatitis may be caused by gallstones (by blocking the pancreatic duct outlet), chronic alcohol use, trauma, medications, infections, tumors, and genetic abnormalities.
  • Acute pancreatitis with upper abdominal pain that is often severe and constant over several days, and may be accompanied by fever, nausea, vomiting, tachycardia, and abdominal swelling; severe cases can develop dehydration, low blood pressure, shock, organ failure, and death.
  • Acute pancreatitis is diagnosed preliminarily by the patient's history, physical exam and the levels of amylase and lipase in the blood (elevated in pancreatitis patients); other tests such as abdominal ultrasound, CT scan, endoscopic ultrasound, or MCRP (Magnetic resonance cholangiopancreatography) may be done to detect gallstones or to identify the damaged pancreas and other blood tests may need to be done (glucose and electrolyte levels)
  • Acute pancreatitis is usually treated by hospitalization for IV fluid administration (and often antibiotics) as the patient is not to eat or drink for a few days; many patients will require an ERCP, a procedure that allows a flexible tube with attachments, including a camera, to be inserted into the ducts that empty into the GI tract and can be used to do several procedures such as gallstone removal, sphincterotomy, and others to help treat the patient.
  • Chronic pancreatitis is pancreatic inflammation that does not heal, gets worse over time and results in permanent pancreatic damage; the most common cause is heavy alcohol use over years, but conditions such as hereditary disorders, cystic fibrosis, autoimmune problems and other causes result in chronic pancreatitis.
  • Chronic pancreatitis has many of the same symptoms of acute, but may include diarrhea, oily stools and weight loss.
  • Chronic pancreatitis is diagnosed essentially the same way acute is diagnosed and is often confused with acute pancreatitis; a good history of chronic problems that includes an accurate alcohol intake history, weight loss history or family history can help make the differential diagnosis.
  • Chronic pancreatitis is treated similar to acute, but the hospital stay may be prolonged because of the need for pain, fluid and nutritional support; synthetic enzymes may be prescribed when a more normal diet can be consumed by the patient.
  • Pancreatitis in children is rare, but can occur secondary to hereditary disease or trauma to the pancreas; often in these rare instances, the cause is unknown.
  • Research is ongoing at the NIH (National Institutes of Health) to further understand causes and develop treatments for all types of pancreatitis.

What is pancreatitis?

Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum - the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile - a liquid produced in the liver and stored in the gallbladder - to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them.

Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.

Both forms of pancreatitis occur more often in men than women.

Illustration of the Pancreas

What are the causes of acute pancreatitis?

Acute pancreatitis is inflammation of the pancreas that occurs suddenly and usually resolves in a few days with treatment. Acute pancreatitis can be a life-threatening illness with severe complications. Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis.1 The most common cause of acute pancreatitis is the presence of gallstones - small, pebble-like substances made of hardened bile - that cause inflammation in the pancreas as they pass through the common bile duct. Chronic, heavy alcohol use is also a common cause. Acute pancreatitis can occur within hours or as long as 2 days after consuming alcohol. Other causes of acute pancreatitis include abdominal trauma, medications, infections, tumors, and genetic abnormalities of the pancreas.

What are the symptoms of acute pancreatitis?

Acute pancreatitis usually begins with gradual or sudden pain in the upper abdomen that sometimes extends through the back. The pain may be mild at first and feel worse after eating. But the pain is often severe and may become constant and last for several days. A person with acute pancreatitis usually looks and feels very ill and needs immediate medical attention. Other symptoms may include:

  • swollen and tender abdomen
  • nausea
  • vomiting
  • fever
  • rapid pulse

Severe acute pancreatitis may cause dehydration and low blood pressure. The heart, lungs, or kidneys can fail. If bleeding occurs in the pancreas, shock and even death may follow.

How is acute pancreatitis diagnosed?

While asking about a person's medical history and conducting a thorough physical examination, the doctor will order a blood test to assist in the diagnosis. During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas. Changes may also occur in other body chemicals such as glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the person's condition improves, the levels usually return to normal.

Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas. The doctor will likely order one or more of the following tests:

  • Abdominal ultrasound. Sound waves are sent toward the pancreas through a handheld device that a technician glides over the abdomen. The sound waves bounce off the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture - called a sonogram - on a video monitor. If gallstones are causing inflammation, the sound waves will also bounce off them, showing their location.
  • Computerized tomography (CT) scan. The CT scan is a noninvasive X-ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The test may show gallstones and the extent of damage to the pancreas.
  • Endoscopic ultrasound (EUS). After spraying a solution to numb the patient's throat, the doctor inserts an endoscope - a thin, flexible, lighted tube - down the throat, through the stomach, and into the small intestine. The doctor turns on an ultrasound attachment to the scope that produces sound waves to create visual images of the pancreas and bile ducts.
  • Magnetic resonance cholangiopancreatography (MRCP). MRCP uses magnetic resonance imaging, a noninvasive test that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like tube for the test. The technician injects dye into the patient's veins that helps show the pancreas, gallbladder, and pancreatic and bile ducts.

How is acute pancreatitis treated?

Treatment for acute pancreatitis requires a few days' stay in the hospital for intravenous (IV) fluids, antibiotics, and medication to relieve pain. The person cannot eat or drink so the pancreas can rest. If vomiting occurs, a tube may be placed through the nose and into the stomach to remove fluid and air.

Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require nasogastric feeding - a special liquid given in a long, thin tube inserted through the nose and throat and into the stomach - for several weeks while the pancreas heals.

Before leaving the hospital, the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals. In some cases, the cause of the pancreatitis is clear, but in others, more tests are needed after the person is discharged and the pancreas is healed.

Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) for Acute and Chronic Pancreatitis

ERCP is a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis - gallstones, narrowing or blockage of the pancreatic duct or bile ducts, leaks in the bile ducts, and pseudocysts - accumulations of fluid and tissue debris.

Soon after a person is admitted to the hospital with suspected narrowing of the pancreatic duct or bile ducts, a physician with specialized training performs ERCP.

After lightly sedating the patient and giving medication to numb the throat, the doctor inserts an endoscope - a long, flexible, lighted tube with a camera - through the mouth, throat, and stomach into the small intestine. The endoscope is connected to a computer and screen. The doctor guides the endoscope and injects a special dye into the pancreatic or bile ducts that helps the pancreas, gallbladder, and bile ducts appear on the screen while X-rays are taken.

The following procedures can be performed using ERCP:

  • Sphincterotomy. Using a small wire on the endoscope, the doctor finds the muscle that surrounds the pancreatic duct or bile ducts and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.
  • Gallstone removal. The endoscope is used to remove pancreatic or bile duct stones with a tiny basket. Gallstone removal is sometimes performed along with a sphincterotomy.
  • Stent placement. Using the endoscope, the doctor places a tiny piece of plastic or metal that looks like a straw in a narrowed pancreatic or bile duct to keep it open.
  • Balloon dilatation. Some endoscopes have a small balloon that the doctor uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent may be placed for a few months to keep the duct open.

People who undergo therapeutic ERCP are at slight risk for complications, including severe pancreatitis, infection, bowel perforation, or bleeding. Complications of ERCP are more common in people with acute or recurrent pancreatitis. A patient who experiences fever, trouble swallowing, or increased throat, chest, or abdominal pain after the procedure should notify a doctor immediately.

Complications

Gallstones that cause acute pancreatitis require surgical removal of the stones and the gallbladder. If the pancreatitis is mild, gallbladder removal - called cholecystectomy - may proceed while the person is in the hospital. If the pancreatitis is severe, gallstones may be removed using therapeutic endoscopic retrograde cholangiopancreatography (ERCP) - a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis. Cholecystectomy is delayed for a month or more to allow for full recovery.

If an infection develops, ERCP or surgery may be needed to drain the infected area, also called an abscess. Exploratory surgery may also be necessary to find the source of any bleeding, to rule out conditions that resemble pancreatitis, or to remove severely damaged pancreatic tissue.

Pseudocysts - accumulations of fluid and tissue debris - that may develop in the pancreas can be drained using ERCP or EUS. If pseudocysts are left untreated, enzymes and toxins can enter the bloodstream and affect the heart, lungs, kidneys, or other organs.

Acute pancreatitis sometimes causes kidney failure. People with kidney failure need blood-cleansing treatments called dialysis or a kidney transplant.

In rare cases, acute pancreatitis can cause breathing problems. Hypoxia, a condition that occurs when body cells and tissues do not get enough oxygen, can develop. Doctors treat hypoxia by giving oxygen to the patient. Some people still experience lung failure - even with oxygen - and require a respirator for a while to help them breathe.

What is chronic pancreatitis?

Chronic pancreatitis is inflammation of the pancreas that does not heal or improve - it gets worse over time and leads to permanent damage. Chronic pancreatitis, like acute pancreatitis, occurs when digestive enzymes attack the pancreas and nearby tissues, causing episodes of pain. Chronic pancreatitis often develops in people who are between the ages of 30 and 40.

The most common cause of chronic pancreatitis is many years of heavy alcohol use. The chronic form of pancreatitis can be triggered by one acute attack that damages the pancreatic duct. The damaged duct causes the pancreas to become inflamed. Scar tissue develops and the pancreas is slowly destroyed.

Other causes of chronic pancreatitis are

  • hereditary disorders of the pancreas
  • cystic fibrosis - the most common inherited disorder leading to chronic pancreatitis
  • hypercalcemia - high levels of calcium in the blood
  • hyperlipidemia or hypertriglyceridemia - high levels of blood fats
  • some medicines
  • certain autoimmune conditions
  • unknown causes

Hereditary pancreatitis can present in a person younger than age 30, but it might not be diagnosed for several years. Episodes of abdominal pain and diarrhea lasting several days come and go over time and can progress to chronic pancreatitis. A diagnosis of hereditary pancreatitis is likely if the person has two or more family members with pancreatitis in more than one generation.

What are the symptoms of chronic pancreatitis?

Most people with chronic pancreatitis experience upper abdominal pain, although some people have no pain at all. The pain may spread to the back, feel worse when eating or drinking, and become constant and disabling. In some cases, abdominal pain goes away as the condition worsens, most likely because the pancreas is no longer making digestive enzymes. Other symptoms include:

  • nausea
  • vomiting
  • weight loss
  • diarrhea
  • oily stools

People with chronic pancreatitis often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to digest food, so nutrients are not absorbed normally. Poor digestion leads to malnutrition due to excretion of fat in the stool.

How is chronic pancreatitis diagnosed?

Chronic pancreatitis is often confused with acute pancreatitis because the symptoms are similar. As with acute pancreatitis, the doctor will conduct a thorough medical history and physical examination. Blood tests may help the doctor know if the pancreas is still making enough digestive enzymes, but sometimes these enzymes appear normal even though the person has chronic pancreatitis.

In more advanced stages of pancreatitis, when malabsorption and diabetes can occur, the doctor may order blood, urine, and stool tests to help diagnose chronic pancreatitis and monitor its progression.

After ordering X-rays of the abdomen, the doctor will conduct one or more of the tests used to diagnose acute pancreatitis - abdominal ultrasound, CT scan, EUS, and MRCP.

How is chronic pancreatitis treated?

Treatment for chronic pancreatitis may require hospitalization for pain management, IV hydration, and nutritional support. Nasogastric feedings may be necessary for several weeks if the person continues to lose weight.

When a normal diet is resumed, the doctor may prescribe synthetic pancreatic enzymes if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the person digest food and regain some weight. The next step is to plan a nutritious diet that is low in fat and includes small, frequent meals. A dietitian can assist in developing a meal plan. Drinking plenty of fluids and limiting caffeinated beverages is also important.

People with chronic pancreatitis are strongly advised not to smoke or consume alcoholic beverages, even if the pancreatitis is mild or in the early stages.

Complications

People with chronic pancreatitis who continue to consume large amounts of alcohol may develop sudden bouts of severe abdominal pain.

As with acute pancreatitis, ERCP is used to identify and treat complications associated with chronic pancreatitis such as gallstones, pseudocysts, and narrowing or obstruction of the ducts. Chronic pancreatitis also can lead to calcification of the pancreas, which means the pancreatic tissue hardens from deposits of insoluble calcium salts. Surgery may be necessary to remove part of the pancreas.

In cases involving persistent pain, surgery or other procedures are sometimes recommended to block the nerves in the abdominal area that cause pain.

When pancreatic tissue is destroyed in chronic pancreatitis and the insulin-producing cells of the pancreas, called beta cells, have been damaged, diabetes may develop. People with a family history of diabetes are more likely to develop the disease. If diabetes occurs, insulin or other medicines are needed to keep blood glucose at normal levels. A health care provider works with the patient to develop a regimen of medication, diet, and frequent blood glucose monitoring.

How common is pancreatitis in children?

Chronic pancreatitis in children is rare. Trauma to the pancreas and hereditary pancreatitis are two known causes of childhood pancreatitis. Children with cystic fibrosis - a progressive and incurable lung disease - may be at risk of developing pancreatitis. But more often the cause of pancreatitis in children is unknown.

Hope through research

The National Institute of Diabetes and Digestive and Kidney Diseases' Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal diseases, including the causes of pancreatitis and cell injury in the gastrointestinal tract. In addition, researchers are studying the genetics of hereditary pancreatitis and risk factors such as cystic fibrosis.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

Pancreatitis At A Glance

 

  • Pancreatitis is inflammation of the pancreas, causing digestive enzymes to become active inside the pancreas and damage pancreatic tissue.
  • Pancreatitis has two forms: acute and chronic.
  • Common causes of pancreatitis are gallstones and heavy alcohol use.
  • Sometimes the cause of pancreatitis cannot be found.
  • Symptoms of acute pancreatitis include abdominal pain, nausea, vomiting, fever, and a rapid pulse.
  • Treatment for acute pancreatitis includes intravenous (IV) fluids, antibiotics, and pain medications. Surgery is sometimes needed to treat complications.
  • Acute pancreatitis can become chronic if pancreatic tissue is permanently destroyed and scarring develops.
  • Symptoms of chronic pancreatitis include abdominal pain, nausea, vomiting, weight loss, diarrhea, and oily stools.
  • Treatment for chronic pancreatitis may involve IV fluids; pain medication; a low-fat, nutritious diet; and enzyme supplements. Surgery may be necessary to remove part of the pancreas.


Pancreatic Cysts


  • What is the pancreas?
  • What are pancreatic cysts?
  • What are the symptoms of pancreatic cysts?
  • What are the different causes and types of pancreatic cysts?
  • Inflammatory cysts
  • Non-inflammatory cysts
  • How are pancreatic cysts diagnosed?
  • What is the treatment for pancreatic cysts?
  • Patient Discussions: Pancreatic Cysts – Diagnosis
  • Find a local Gastroenterologist in your town

What is the pancreas?

The pancreas is an organ approximately six inches long that is located in the abdomen behind the stomach. The pancreas is divided into three regions; the head, the body, and the tail. The head of the pancreas is located in the right abdomen adjacent to the duodenum, the tail is in the left abdomen, and the body lies between the head and the tail.

Illustration of the Pancreas

The pancreas makes several hormones that are released into the blood--including insulin to regulate blood glucose levels (see the Diabetes Mellitus article)-as well as digestive enzymes that aid in the digestion of food, for example, amylase. The digestive enzymes produced by the pancreas are combined in a bicarbonate-rich fluid also produced by the pancreas. The pancreatic duct within the pancreas collects the bicarbonate-rich fluid and digestive enzymes and drains them into the duodenum, the first part of the small intestine just beyond the stomach.

The common duct (also called the common bile duct) collects bile (a fluid that helps digest fat) produced by the liver. Like the pancreatic duct, the common duct also drains into the duodenum. In fact, the common duct usually joins the pancreatic duct in the head of the pancreas. The union of these two ducts forms the ampulla of Vater which drains both bile and pancreatic fluid into the duodenum.

What are pancreatic cysts?

Pancreatic cysts are collections (pools) of fluid within the head, body, or tail of the pancreas. Some pancreatic cysts are true cysts, that is, they are lined by a special layer of cells that are responsible for secreting fluid into the cysts. Other cysts are pseudocysts and do not contain specialized lining cells. Pancreatic cysts can range from several millimeters to several centimeters in size. Many pancreatic cysts are benign and produce no symptoms, but some cysts are cancerous or precancerous. (Precancerous cysts are benign cysts that have the potential to become cancerous.)

Different types of cysts contain different types of fluids. For example, pseudocysts that form after an attack of acute pancreatitis contain digestive enzymes such as amylase in high concentrations. Mucinous cysts contain mucus (a proteinaceous liquid produced by the mucinous cells that form the inside lining of the cyst).

What are the symptoms of pancreatic cysts?

The symptoms of pancreatic cysts depend on their size and location. Small (less than two cm) cysts usually cause no symptoms. Large pancreatic cysts can cause abdominal pain and back pain presumably by putting pressure on surrounding tissues and nerves. Large cysts in the head of the pancreas also may cause jaundice (yellowing of the skin and eyes with darkening of urine color) due to obstruction of the common duct. Obstruction causes bile to back up and forces bilirubin (the chemical that produces jaundice) back into the bloodstream.

On rare occasions, acute pancreatitis can cause the formation of large pseudocysts that can compress the stomach or the duodenum leading to obstruction to flow within the intestines, abdominal pain and vomiting. These cysts also may become infected and lead to fever, chills, and sepsis.

What are the different causes and types of pancreatic cysts?

There are two major types of pancreatic cysts; inflammatory cysts and noninflammatory cysts. Inflammatory cysts are benign, whereas noninflammatory cysts can be benign, precancerous, or cancerous.

Inflammatory cysts

Most of the inflammatory cysts of the pancreas are pancreatic pseudocysts. Pseudocysts of the pancreas result from pancreatitis (inflammation of the pancreas). The common causes of pancreatitis include alcoholism, gallstones, trauma, or surgery. The fluid inside the pseudocysts represents liquefied dead pancreatic tissue, cells of inflammation, and a high concentration of digestive enzymes (for example, amylase). Most pseudocysts caused by acute pancreatitis resolve spontaneously (without treatment) within several weeks. Pseudocysts that need treatment are those that persist beyond six weeks and are causing symptoms such as pain, obstruction of the stomach or duodenum, or become infected.

Non-inflammatory cysts

  • Serous cyst adenomas: These cysts are mostly benign and commonly occur in middle-aged women. They usually are located in the body or tail of the pancreas. Typically they are small and cause no symptoms. Rarely they cause abdominal pain.
  • Mucinous cyst adenomas: Thirty percent of these cysts contain cancer, and those that do not contain cancer are considered precancerous. They also are more common in middle-aged women and are usually located in the body or tail of the pancreas.
  • Intraductal papillary mucinous neoplasm (IPMN): These cysts have a high likelihood of being or becoming cancerous. At the time of diagnosis, there is a 40%-50% chance of already being cancerous. These cysts are more common among middle-aged men and are more commonly located in the head of the pancreas. The cysts typically produce large amounts of mucous which can be seen draining out of the ampulla of Vater at the time of endoscopic retrograde cholangio-pancreatography (ERCP), a test that visualizes the ampulla of Vater and the pancreatic duct. These cysts can cause abdominal pain, jaundice and pancreatitis.
  • Solid pseudopapillary tumor of the pancreas: These are rare tumors found mainly in young Asian and black females. They may reach a large size, and can become malignant. Prognosis is excellent after complete surgical resection of these tumors.

How are pancreatic cysts diagnosed?

Since the majority of pancreatic cysts are small and produce no symptoms, they often are discovered incidentally when abdominal scans (ultrasound, CT scan, or MRI) are performed to investigate unrelated symptoms. Unfortunately, ultrasound, CT, and MRI scans cannot reliably distinguish benign cysts (cysts that usually need no treatment) from precancerous and cancerous cysts (cysts that usually require surgical removal).

Endoscopic ultrasound (EUS) is becoming increasingly useful in determining whether a pancreatic cyst is benign, precancerous, or cancerous. During EUS, an endoscope with a small ultrasound transducer on its tip is inserted through the mouth, esophagus, and stomach into the duodenum. From this location very close to the pancreas, liver, and gallbladder, accurate and detailed images can be obtained of the liver, pancreas and the gallbladder.

During EUS fluid from cysts and samples of tissue also can be obtained by passing special needles through the endoscope and into the cysts or tumors. The process of obtaining tissue or fluid with a thin needle is called fine needle aspiration (FNA).

The fluid obtained by FNA can be analyzed for cancerous cells (cytology), amylase content, and for tumor markers [tumor markers, such as CEA (carcinoembryonic antigen), are proteins produced in large quantities by tumor cells]. For example, pancreatic pseudocyst fluid will typically have high amylase levels but low CEA levels. A benign serous cyst adenoma will have low amylase and low CEA levels, whereas a precancerous or cancerous mucinous cyst adenoma will have low amylase levels but high CEA levels.

The cells obtained by fine needle aspiration can be examined under a microscope for cancer or precancerous cells.

What is the treatment for pancreatic cysts?

The most important aspect of management of pancreatic cysts is the determination of whether a cyst is benign (and usually needs no treatment) or if it is cancerous and must be removed.

The second most important aspect of management is to determine whether a patient with a precancerous or cancerous pancreatic cyst is a suitable surgical candidate. In medical centers experienced in performing pancreas surgery, surgical removal of precancerous or cancerous cysts has a high rate of cure.

There are not yet standard recommendations for managing pancreatic cysts. Different medical centers have adopted different approaches to diagnosis and treatment. Management decisions must be individualized for each patient after discussions with a doctor familiar with the patient's health status. The following is one example of how a doctor may manage pancreatic cysts.

  1. Pancreatic pseudocysts need treatment if they persist beyond six weeks after acute pancreatitis, especially if they reach a large enough size and cause symptoms such as obstruction of the stomach or common duct, abdominal pain, or become infected.

  2. Small pancreatic cysts (for example, cysts smaller than two cm) will have little chance (3.5%) of being cancerous and can be observed. Nevertheless, even these small cysts can grown in size and turn cancerous in the future. Thus, these patients are monitored with yearly scans (for example, yearly CT scans). These patients will be evaluated further using endoscopic ultrasound with possible fine needle aspiration if the cysts grow in size and/or cause symptoms.

  3. Pancreatic cysts larger than two cm in young, healthy individuals usually are treated with surgical removal, especially if the cysts produce symptoms.

  4. Pancreatic cysts larger than two cm in elderly patients can be studied with endoscopic ultrasound and fine needle aspiration. If fluid cytology and CEA measurements suggest cancerous or precancerous changes, the patients can be evaluated for pancreatic surgery.


Panic Attacks
(Panic Disorder)


  • What are panic attacks?
  • What are panic attack symptoms and signs in adults, teenagers, and children?
  • Are panic attacks serious?
  • What causes panic attacks?
  • What is the treatment for panic attacks? What medications treat panic attacks?
  • What are complications of untreated panic attacks?
  • Panic Attack At A Glance
  • Patient Discussions: Panic Attacks - Symptoms
  • Patient Discussions: Panic Attacks - Symptoms
  • Patient Discussions: Panic Attacks - Effective Treatments
  • Find a local Psychiatrist in your town

"All of a sudden, I felt a tremendous wave of fear for no reason at all. My heart was pounding, my chest hurt, and it was getting harder to breathe. I thought I was going to die."

"I'm so afraid. Every time I start to go out, I get that awful feeling in the pit of my stomach and I'm terrified that another panic attack is coming or that some other, unknown terrible thing was going to happen."

What are panic attacks?

Panic attacks may be symptoms of an anxiety disorder. These attacks are a serious health problem in the U.S. At least 20% of adult Americans, or about 60 million people, will suffer from panic attacks at some point in their lives. About 1.7% of adult Americans, or about 3 million people, will have full-blown panic disorder at some time in their lives, twice as often for women than men. The peak age at which people have their first panic attack (onset) is 15-19 years. Another fact about panic is that this symptom is strikingly different from other types of anxiety; panic attacks are so very sudden and often unexpected, appear to be unprovoked, and are often disabling.

Childhood panic disorder facts include that about 0.7% of children suffer from panic disorder or generalized anxiety disorder and that although panic is found to occur twice as often in women compared to men, boys and girls tend to experience this disorder at an equal frequency.

Once someone has had a panic attack, for example, while driving, shopping in a crowded store, or riding in an elevator, he or she may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point at which the mere idea of engaging in the activities that preceded the first panic attack triggers future panic attacks, resulting in the individual with panic disorder being unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus, there are two types of panic disorder, panic disorder with or without agoraphobia. Like other major illnesses, panic disorder can have a serious impact on a person's daily life unless the individual receives effective treatment.

Panic attacks in children may result in the child's grades declining, avoiding school and other separations from parents, as well as substance abuse, depression, and suicidal thoughts, plans, and/or actions.

What are panic attack symptoms and signs in adults, teenagers, and children?

As described in the first example above, the symptoms of a panic attack appear suddenly, without any apparent cause. They may include

  • racing or pounding heartbeat (palpitations);
  • chest pains;
  • stomach upset;
  • dizziness, lightheadedness, nausea;
  • difficulty breathing, a sense of feeling smothered;
  • tingling or numbness in the hands;
  • hot flashes or chills;
  • trembling and shaking;
  • dreamlike sensations or perceptual distortions;
  • terror, a sense that something unimaginably horrible is about to occur and one is powerless to prevent it;
  • a need to escape;
  • nervousness about the possibility of losing control and doing something embarrassing;

     

  • fear of dying.

Although the duration of a panic attack can vary greatly, it typically lasts for more than 10 minutes, is one of the most distressing conditions that a person can experience, and its symptoms can closely mimic those of a heart attack. Typically, most people who have one attack will have others, and when someone has repeated attacks with no other apparent physical or emotional cause, or feels severe anxiety about having another attack, he or she is said to have panic disorder. A number of other emotional problems can have panic attacks as a symptom. Some of these illnesses include posttraumatic stress disorder (PTSD), schizophrenia, and intoxication or withdrawal from certain drugs of abuse.

Certain medical conditions, like thyroid abnormalities and anemia, as well as certain medications, can produce intense anxiety. Examples of such medications include stimulants like methylphenidate (Ritalin), diabetes medications like metformin and insulin, antimalarial medications like quinine, as well as corticosteroid withdrawal, such as withdrawal from dexamethasone (Decadron). As individuals with panic disorder seem to be at higher risk of having a heart valve abnormality called mitral valve prolapse (MVP), this possibility should be investigated by a doctor since MVP may dictate the need for special precautions to be taken when the individual is being treated for any dental problem. While the development of panic attacks have been attributed to the use of food additives like aspartame, alone or in combination with food dyes, more research is needed to better understand the role such substances may have on this disorder.

Anxiety attacks that take place while sleeping, also called nocturnal panic attacks, occur less often than panic attacks during the daytime but affect about 40%-70% of those who suffer from daytime panic attacks. This symptom is also important because people who suffer from panic symptoms while sleeping tend to have more respiratory distress associated with their panic. They also tend to experience more symptoms of depression and other psychiatric disorders compared to people who do not have panic attacks at night. Nocturnal panic attacks tend to cause sufferers to wake suddenly from sleep in a state of sudden fear or dread for no apparent reason. In contrast to people with sleep apnea and other sleep disorders, sufferers of nocturnal panic can have all the other symptoms of a panic attack. The duration of nocturnal panic attacks tends to be less than 10 minutes, but it can take much longer to fully calm down for those who experience them.

While panic disorder in adolescents tends to have similar symptoms as in adults, symptoms of panic disorder in younger children are less likely to include the thought-based or so-called cognitive aspects. Specifically, teenagers are more likely to feel unreal or as if they are functioning in a dream-like state (derealization) or be frightened of going crazy or of dying.

Symptoms of panic attacks in women tend to include more avoidance of anxiety provoking situations, show more frequent recurrence, and more often result in the use of medical care compared to panic attack symptoms in men. The frequency of panic attacks may increase, decrease, or remain unchanged during pregnancy.

Are panic attacks serious?

Yes, panic attacks are real and potentially quite emotionally disabling. Fortunately, they can be controlled with specific treatments. Because of the disturbing physical signs and symptoms that accompany panic attacks, they may be mistaken for heart attacks or some other life-threatening medical illness. In fact, up to 25% of people who visit emergency rooms because of chest pain are actually experiencing panic. As a result, people with this symptom often undergo extensive medical tests to rule out these other conditions. Sadly, sometimes more than 90% of these individuals are not appropriately diagnosed as suffering from panic.

Loved ones as well as medical personnel generally attempt to reassure the panic attack sufferer that he or she is not in great danger. But these efforts at reassurance can sometimes add to the patient's difficulties. If the doctors use expressions such as "nothing serious," "all in your head," or "nothing to worry about," this may give the incorrect impression that there is no real problem, that they should be able to overcome their symptoms on their own and that treatment is not possible or necessary. The point is that while panic attacks can certainly be serious, they are not organ-threatening. Therefore, for individuals who might wonder what to do to help the panic sufferer at the time of an anxiety attack, a more effective approach tends to be to acknowledge their fear and the intensity of their symptoms while reassuring the person having the panic attack that what is occurring is not life-threatening and can be treated.

What causes panic attacks?

Although there are not specific causes for panic attacks in adults or children, like most other emotional symptoms, panic is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model). According to one theory of panic disorder, the body's normal "alarm system," the set of mental and physical mechanisms that allows a person to respond to a threat, tends to be triggered unnecessarily, when there is no danger. Scientists don't know exactly why this happens or why some people are more susceptible to the problem than others. Panic disorder has been found to run in families, and this may mean that inheritance (genetics) plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Studies differ as to whether nutritional deficiencies like of zinc or magnesium deficiencies may also play a role as a risk factor for developing panic disorder. While some statistics suggest that disadvantaged ethnic minorities tend to suffer from internalizing disorders like panic disorder less often than the majority population in the United States, other research shows that may be the result of differences in how ethnic groups interpret and discuss signs and symptoms of intense fright, like panic attacks.

Psychologically, people who develop panic attacks or an anxiety disorder are more likely to have a history of what is known as anxiety sensitivity. Anxiety sensitivity is the tendency for a person to fear that anxiety-related bodily sensations (like brief chest pain) have dire personal consequences (for example, believing that it automatically means their heart will stop). From a social standpoint, a risk factor for developing panic disorder as an adolescent or adult is a history of being physically or sexually abused as a child. This is even more the case for panic disorder when compared to other anxiety disorders. Often, the first attacks are triggered by physical illnesses, another major life stress, or perhaps medications that increase activity in the part of the brain involved in fear reactions.

What is the treatment for panic attacks? What medications treat panic attacks?

Thanks to research, there are a variety of treatments available for controlling panic attacks, including several effective medical treatments, and specific forms of psychotherapy. In terms of medications, specific members of the selective serotonin reuptake inhibitor (SSRI), the selective serotonin and norepinephrine reuptake inhibitors (SSNRI), and the benzodiazepine families of medications are approved by the U.S. Food and Drug Administration (FDA) for effective treatment of panic disorder. Examples of such medications include sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa) from the SSRI group, duloxetine (Cymbalta) and venlafaxine (Effexor) from the SSNRI group, and clonazepam (Klonopin) and lorazepam (Ativan) from the benzodiazepine group. Although alprazolam (Xanax) is often used to treat panic attacks, its short duration of action can sometimes result in having to take it several times per day. Medications from the beta-blocker family (for example, propranolol [Inderal]) are sometimes used to treat the physical symptoms associated with a panic attack. Some individuals who suffer from severe panic attacks may benefit from treatment with gabapentin (Neurontin), which was initially found to treat seizures, or benefit from a neuroleptic medication like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), or aripiprazole (Abilify).

 

Before SSRIs and SSNRIs became available, medications from the group known as the tricyclic antidepressants (TCAs) were often used to address panic disorder. Although TCAs have been found to be equally effective in treating panic attacks, SSRIs and SSNRIs have been proven to be safer and better tolerated. Therefore TCAs are used much less often.

When used in the appropriate person with close monitoring, medications can be quite effective as part of treatment for panic disorder. However, as anything that is ingested carries risk of side effects, it is important for the panic attack sufferer to work closely with the prescribing doctor to decide whether treatment with medications is an appropriate intervention and if so, which medication should be administered. The person being treated should be closely monitored for the possibility of side effects that can vary from minor to severe, and in some cases even be life-threatening. Due to the possible risks to the fetus of a mother being treated for panic attacks with medication, psychotherapy should be the first treatment tried when possible in pregnant women.

For individuals who may be wondering how to avoid panic attacks using treatment without prescribed medications, natural remedies may be an option. While herbal supplements that contain kava have been found to be helpful for some people with mild to moderate panic disorder, the research data is still considered to be too limited for many physicians to recommend treatment with other natural remedies like valerian or passionflower. Also, care should be taken when taking any dietary supplements, since many supplements are not regulated in terms of quality, content, or effectiveness.

The psychotherapy component of treatment for panic disorders is at least as important as medication treatment. In fact, research shows that psychotherapy alone or the combination of medication and psychotherapy treatment are more effective than medication alone in overcoming panic attacks. To address anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy treatment, for both adults and children. This form of therapy seeks to help those with panic disorder identify and decrease the irrational thoughts and behaviors that reinforce panic symptoms and can be administered either individually, in group therapy, and even in partner-assisted therapy. Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously precipitated anxiety in the individual. Helping the anxiety sufferer to understand how to handle the emotional forces that may have contributed to developing symptoms (panic-focused psychodynamic psychotherapy) has also been found to be effective in teaching an individual with panic disorder how to prevent an anxiety attack or to decrease or stop a panic attack once it starts.

Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed in a fairly short period of time, about two to three months. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to 70%-90% of people with panic disorder.

There are also things that people with panic disorder can do to help make treatment more effective. Since substances like caffeine, alcohol, and illicit drugs can worsen panic attacks, those things should be avoided. Other tips to prevent or manage panic attacks include engaging in aerobic exercise and stress-management techniques like deep breathing, massage therapy, and yoga, since these self-help activities have also been found to help decrease the frequency and severity of panic attacks. Although many people breathe into a paper bag when afflicted by the hyperventilation that can be associated with panic, the benefit received may be the result of the individual believing it will remedy the symptoms (placebo effect). Also, breathing into a paper bag when one is having trouble breathing can make matters worse when the hyperventilation is the result of conditions of oxygen deprivation, like an asthma attack or a heart attack.

People with panic disorder also may need treatment for other emotional problems. Depression has often been associated with panic disorder, as have alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with panic disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself.

Sadly, many people with panic attacks do not seek or receive treatment.

What are complications of untreated panic attacks?

Without treatment, panic attacks tend to occur repeatedly for months or years. While they typically begin in young adulthood, the symptoms may arise earlier or later in life in some people. Complications, which are symptoms that can develop as a result of continued panic attacks and develop into other mental illnesses, may include specific irrational fears (phobias), especially of leaving home (agoraphobia), avoidance of social situations, depression, work or school problems, suicidal thoughts or actions, financial problems, and alcohol or other substance abuse. Panic disorder also predisposes sufferers to developing heart disease.

If left untreated, anxiety may worsen to the point at which the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with friends and family, failed in school, and/or lost jobs while struggling to cope with panic attacks. There may be periods of spontaneous improvement in the attacks, but panic attacks do not usually go away unless the person receives treatments designed specifically to help people with panic attacks.

Panic Attacks At A Glance
  • Symptoms of panic attack usually begin abruptly and include rapid heartbeat, chest sensations, shortness of breath, dizziness, tingling, and severe anxiousness.
  • While panic disorder can certainly be serious, it is not immediately organ-threatening.
  • A variety of treatments are available, including several effective medications, and specific forms of psychotherapy.
  • People who experience panic attacks can use a number of lifestyle changes like aerobic exercise, avoiding alcohol, caffeine, and illicit drugs, as well as stress-management techniques to help decrease anxiety.


Pap Smear

  • What is a Pap smear?
  • Who should have a Pap smear?
  • Which women are at increased risk for having an abnormal Pap smear?
  • How is a Pap smear done?
  • What are the risks of having a Pap smear?
  • How is a Pap smear read (analyzed)?
  • What information is included on a Pap smear report?
  • Why is a woman's menstrual status important for the Pap smear?
  • Why is a woman's past Pap smear history pertinent?
  • When might a Pap smear not be adequate for interpretation?
  • How is the final Pap smear diagnosis made?
  • What are the possible recommendations for follow-up after a Pap smear?
  • What treatments are available if a Pap smear is abnormal?
  • What is the follow-up after treatment for an abnormal Pap smear?
  • What is the current status of human papilloma virus (HPV) testing?
  • When should women start and stop having Pap smears, and how often should Pap smears be performed?
  • What is the current status of the newer Pap smear technologies?
  • With Pap smears so available, why are women still dying of cervical cancer?
  • Historical note: Dr. Pap
  • Pap Smear At A Glance
  • Patient Discussions: Pap Smear - Results
  • Find a local Obstetrician-Gynecologist in your town

What is a Pap smear?

A Pap smear (also known as the Pap test) is a medical procedure in which a sample of cells from a woman's cervix (the end of the uterus that extends into the vagina) is collected and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for pre-malignant (before-cancer) or malignant (cancer) changes.

A Pap smear is a simple, quick, and relatively painless screening test. Its specificity - which means its ability to avoid classifying a normal smear as abnormal (a "false positive" result) - while very good, is not perfect. The sensitivity of a Pap smear - which means its ability to detect every single abnormality -- while good, is also not perfect, and some "false negative" results (in which abnormalities are present but not detected by the test) will occur. Thus, a few women develop cervical cancer despite having regular Pap screening.

In the vast majority of cases, a Pap test does identify minor cellular abnormalities before they have had a chance to become malignant and at a point when the condition is most easily treatable. The Pap smear is not intended to detect other forms of cancer such as those of the ovary, vagina, or uterus. Cancer of these organs may be discovered during the course of the gynecologic (pelvic) exam, which usually is done at the same time as the Pap smear.

Who should have a Pap smear?

Pregnancy does not prevent a woman from having a Pap smear. Pap smears can be safely done during pregnancy.

Pap smear testing is not indicated for women who have had a hysterectomy (with removal of the cervix) for benign conditions. Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy.

The screening guidelines of several key medical organizations are summarized in the table below.

Organization When to start Pap smear testing Frequency of Pap smear testing At what age to stop having Pap smears
American Cancer Society 2004 3 years after vaginal intercourse, no later than age 21 Yearly with exceptions:
  • every 2 years if liquid-based kit
  • every 2-3 years if three normal tests in a row in women >30 years old
  1. Total hysterectomy for benign disease
  2. > 70 years old with at least three normal Pap smear results and no abnormal Pap results in the last 10 years
United States Preventative Services Task Force 2003 Within 3 years of onset of sexual activity or age 21, whichever comes first At least every 3 years (no evidence that every year is better than every 3 years)
  1. Recommend against doing Pap smears in women older than 65 years of age, if adequate screening with normal results and otherwise not at risk for cervical cancer.
  2. Recommend against doing Pap smears in women who have had a total hysterectomy for benign disease.
American College of Obstetrics and Gynecology 3 years after first sexual intercourse or age 21, whichever comes first. Yearly until age 30 years. Beginning at age 30, if three normal annual Pap results, can do a Pap alone every 2-3 years Difficult to set an upper age limit-postmenopausal women screened within the prior 2-3 years have a very low risk of developing abnormal Pap smears.

Which women are at increased risk for having an abnormal Pap smear?

A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.

  • HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. (See below for details). About 95%-100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women.
  • Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.
  • Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.
  • Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk.
  • Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age.

How is a Pap smear done?

A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician). These agents may wash away or hide any abnormal cervical cells.

A Pap smear can be done in a doctor's office, a clinic, or a hospital by either a physician or other specially trained health care professional, such as a physician assistant, a nurse practitioner, or a nurse midwife.

  • With the woman positioned on her back, the clinician will often first examine the outside of the patient's genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal.
  • A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.)
  • A cotton swab is sometimes used to clear away mucus that might interfere with an optimal sample.
  • A small brush called a cervical brush is then inserted into the opening of the cervix (the cervical os) and twirled around to collect a sample of cells. Because this sample comes from inside the cervix, is called the endocervical sample ("endo" meaning inside).
  • A second sample is also collected as part of the Pap smear and is called the ectocervical sample ("ecto" meaning outside).
  • These cells are collected from a scraping of the area surrounding, but not entering, the cervical os.
  • Both the endocervical and the ectocervical samples are gently smeared on a glass slide and a fixative (a preservative) is used to prepare the cells on the slide for laboratory evaluation.

A bimanual (both hands) pelvic exam usually follows the collection of the two samples for the Pap smear. The bimanual examination involves the physician or health care practitioner inserting two fingers of one hand inside the vaginal canal while feeling the ovaries and uterus with the other hand on top of the abdomen (belly).

The results of the Pap smear are usually available within two to three weeks. At the end of Pap smear testing, each woman should ask how she should expect to be informed about the results of her Pap smear. If a woman has not learned of her results after a month, she should contact her health care practitioner's office.

What are the risks of having a Pap smear?

There are absolutely no known medical risks associated with Pap smear screening. (However, there are medical risks from not having a Pap smear.)

How is a Pap smear read (analyzed)?

Pap smear analysis and reports are all based on a medical terminology system called The Bethesda System. The system was developed (at the National Institutes of Health (NIH) in Bethesda, Maryland) to encourage all medical professionals analyzing Pap smears to use the same reporting system. Standardization reduces the possibility that different laboratories might report different results for the same smear. Standardization and uniform terminology also make Pap smear reports less confusing for the clinicians who request the tests and for their women patients.

The Bethesda System was the outcome of a National Cancer Institute workshop that was held in 1988 in an effort to standardize Pap reports. The guidelines address many aspects of Pap smear testing and its results. In 2001, the guidelines were revised and improved. Acceptance of the Bethesda reporting system in the United States is virtually universal.

The major categories for abnormal Pap smears reported in the Bethesda Systems are as follows:

  • ASC-US: This abbreviation stands for atypical squamous cells of undetermined significance. Under the old system of classification, this category was called atypical squamous cells, just ASC. The new system requires the reader to pick one of two choices to add at the end of ASC: ASC-US, which means undetermined significance or ASC-H, which means cannot exclude HSIL-see below.

     

  • LSIL: This abbreviation stands for low-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade I.

     

  • HSIL: This abbreviation stands for high-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade II, CIN grade III, or CIS.

The word "squamous" describes the thin, flat cells that lie on the surface of the cervix. "Intraepithelial" indicates that the surface layer of cells is affected. A "lesion" means that abnormal tissue is present. These important terms - LSIL and HSIL - are described in greater detail below.

What information is included on a Pap smear report?

The first items on a Pap smear report are for purposes of identification. The report is expected to have the name of the woman, the name of the pathologist and/or the cytotechnologist who read the smear, the source of the specimen (in this case, the cervix), and the date of the last menstrual period of the woman.

The Pap smear report should also include the following:

  • A description of the woman's menstrual status (for example, "menopausal" (no longer menstruating) or "regular menstrual periods")

     

  • The woman's relevant medical history (example, "history of genital warts")

     

  • The number of slides (either one or two, depending on the health care practitioner's routine practice)

     

  • A description of the specimen adequacy (whether the sample is satisfactory for interpretation)

     

  • The final diagnosis (for example, "within normal limits")

     

  • The recommendation for follow-up (for example, "recommend routine follow-up" or "recommend repeat smear")

Why is a woman's menstrual status important for the Pap smear?

A woman who is menstruating sheds cells from the lining of her uterus called endometrial cells. If these cells are seen on the Pap smear of a menstruating woman, the report may note "endometrial cells, cytologically benign, in a menstruating woman. The comment that cells are "cytologically benign" means that they do appear not to be malignant (cancerous) cells. A comment of this nature is absolutely not worrisome since a menstruating woman may be expected to shed such cells.

However, if a woman is menopausal (no longer menstruating) she would not be expected to be shedding cells from the uterine lining. Therefore, endometrial cells on a Pap report might be indicative of an abnormal thickening of the endometrium, the lining of the uterus. The Pap smear is not specifically designed to detect such an abnormality. Nonetheless, if these cells are noted in a non-menstruating woman, her physician should attempt to determine the cause of the shedding of the endometrial cells.

Sometimes, the cause is endometrial hyperplasia, a precancerous condition of the uterine lining, which can be detected by a relatively simple office procedure called an endometrial biopsy. Sometimes, menopausal hormone therapy can cause shedding of endometrial cells that appear on a Pap smear. The pattern of bleeding, the exact type of hormone therapy, and the individual woman's health history are the three components that guide the physician to know whether and what type of further evaluation is necessary.

Why is a woman's past Pap smear history pertinent?

If a woman has had a history of a cellular abnormality on a previous Pap smear, it is important for her to inform the health care practitioner performing the current Pap smear. The patient should provide the details of any previous problems and treatments so that this information can be noted on the lab form. The past history of the woman helps the person who is reading (interpreting) the current Pap smear, because a particular abnormality on previous screening alerts the health care practitioner to look more carefully for specific findings on the current Pap smear.

When might a Pap smear not be adequate for interpretation?

It is a requirement that the report comment on the adequacy of the smear sample for Pap analysis. If the sample is inadequate, the report details the reason. Examples of problems that might be listed under "sample adequacy" include "drying artifact" or "excessive blood." These comments refer to factors that the person analyzing the smear feels may have interfered with his or her ability to interpret the sample.

Sometimes, a Pap smear report will read "unsatisfactory due to excessive inflammation." Inflammation that is present in the woman's cervical area may make it difficult to interpret the Pap smear. Examples of causes of inflammation might include infections or irritation. Inflammation is a common finding on pap smears. If it is severe, your doctor may want to try to determine the cause of the inflammation. In many cases, a repeat pap smear is recommended to determine if the inflammation has resolved and to obtain a sample that is adequate for interpretation.

How is the final Pap smear diagnosis made?

The final Pap smear diagnosis is based on three determining factors:

  1. The patient's history: The reader (the person reading the smear) takes into account the woman's history as noted on the lab request by the clinician performing the smear.
  2. Sample adequacy: The reader then decides whether the sample was adequate for interpretation.
  3. The presence or absence of cellular abnormalities: The reader then notes whether cellular abnormalities were seen on the slides. If the appearance of the Pap smear does not seem to coincide with the woman's clinical history, a comment may also be made to that effect.

The final diagnosis is a short statement that summarizes what the reader has found. Examples of final diagnoses include:

  • Within normal limits;

     

  • Absence of endocervical cells on the Pap smear;

     

  • Unreliable Pap smear due to inflammation;

     

  • Atypical squamous cells of undetermined significance (ASCUS);

     

  • Low-grade squamous intraepithelial lesion (LSIL); or

     

  • High-grade squamous intraepithelial lesion (HSIL).

There may also be additional comments such as "low-grade squamous intraepithelial lesion (LSIL) with human papilloma virus."

What are the possible recommendations for follow-up after a Pap smear?

Once the final diagnosis has been made, the follow-up recommendation informs you what the appropriate next step(s) might be. For example, if the final diagnosis states that the smear was "within normal limits," the appropriate follow-up might be "recommend routine follow-up."

An abnormal Pap smear is one in which the laboratory interprets the cellular changes to be different from those normally seen on a healthy cervix. There are a number of possible follow-up scenarios for an abnormal Pap smear.

Absence of endocervical cells on the Pap smear: There is a particular area wherein the cells lining the vagina change to the endocervical cells that characterize the inside of the cervix. This is called the "transition zone" and is the target of the endocervical sample. However, it may be so far up inside the cervix that the Pap smear sampling instrument simply cannot reach that high. To further complicate the situation, the transition zone in a woman migrates (changes its position) at different times in her life and under different conditions. Sometimes, the transition zone may be less accessible to the Pap brush or the cervical os (opening to the cervix) cannot be seen well enough to obtain an adequate sample. Sometimes, the reason for the absence of endocervical cells on the Pap smear is simply not evident.

Regardless, if the cause of the absent endocervical cells is known or unknown, the situation must be evaluated by the physician. In everyday practice, an appropriate response to the absence of endocervical cells is to redo the Pap smear, but also to take the woman's prior history into account in determining the timing. If the woman has had regular Pap smears, has never had an abnormal one, and does not have an added risk factor for an abnormal Pap smear, then the clinician will often wait a year before repeating the smear. If the woman does have risk factors, the clinician will often elect to repeat the smear sooner.

Unreliable Pap smear due to inflammation: If severe inflammation is present, its cause(s) must be investigated. The physician's goals are to identify the cause of inflammation and to treat and resolve the condition, if possible. Untreated inflammation can have consequences for the woman as well as her sexual partner(s).

Sometimes, the woman's medical history will shed light on the cause of inflammation. For example, a woman may complain of irritation, dryness, or pain in her vaginal area. The inflammation can then be verified by the physician during a pelvic exam. The vaginal irritation may be caused by a lack of estrogen, such as occurs after menopause when the ovaries stop producing this hormone. This lack of estrogen tends to make the vaginal walls irritated and red. If a woman has this condition and it is related to an estrogen deficiency (called "atrophic vaginitis" and usually described on the Pap smear report as "atrophic changes"), her physician may recommend a trial of topical (locally- applied) vaginal estrogen (cream, vaginal estrogen tablets, vaginal estrogen ring) to hopefully heal the inflammation. The Pap smear is then repeated.

In summary, the physician will use clinical judgment in terms of the specific follow-up after a Pap smear that reports inflammation.

Atypical squamous cells of undetermined significance (ASCUS): Sometimes, atypical squamous cells of undetermined significance (also called "ASCUS"), is the determination written on the Pap report. This is the mildest form of cellular abnormality on the spectrum of cells ranging from normal to cancerous. ASCUS means that the cells appear abnormal but are not malignant.

"Of undetermined significance" means that the atypical-appearing cells may be the end result of a number of different types of injuries to the cervix. For example, the human papilloma virus (HPV) could be the cause of ASCUS. Most instances of ASCUS (80%-90%) resolve spontaneously (by themselves without specific medical intervention or treatment). This is the reason why many women with ASCUS readings will be asked to simply have a repeat Pap smear in 4 to 6 months. The expectation is that regardless of the original cause of the ASCUS, it will be resolved by the time the Pap smear is repeated. If not, the cause of the ASCUS can still be identified and treated if ASCUS is again observed on the repeat Pap smear 4 to 6 months later. This standard recommendation of serial Pap smears - repeating the Pap smear in 4 to 6 months - is made unless the physician has a concern that the woman is not willing or able to return for a repeat Pap smear. In these cases, a colposcopy (see below) may be done without waiting to repeat the Pap smear.

The third approach to ASCUS (besides serial Pap testing and immediate colposcopy) is called reflex HPV testing. Reflex HPV testing refers to a process in which the HPV test is only performed if the Pap smear result is abnormal. If the Pap smear result is normal, it is not performed. For reflex testing to be possible, a liquid-based Pap testing kit is required, which allows the lab to store the sample until the Pap smear result tells them whether the HPV test will be necessary or not. Not all facilities have access to liquid-based cytology kits. If repeat smears are to be done for monitoring, the testing needs to be done every 4 to 6 months for 2 years until there have been three consecutive normal smears, at which time routine screening can be resumed. The Pap smears, however, must not only be negative, but also satisfactory for interpretation, according to National Cancer Institute Workshop Guidelines.

The irritation of the genital area that accompanies menopause can trigger ASCUS by causing inflammation. If the physician suspects that this is the cause of ASCUS, he or she may prescribe intravaginal estrogen (local estrogen, such as a vaginal ring, vaginal cream, or vaginal estrogen tablets) and repeat the Pap smear in 4 to 6 months to confirm that the inflammation is resolved. If the inflammation persists, colposcopy will be necessary. Sometimes, the ASCUS reading is accompanied by a comment to the effect that the Pap smear reader thinks there may be a suggestion of dysplasia (abnormally dividing or abnormal appearing cells), often worded as "favor dysplasia." In this case, the ASCUS is generally not monitored over time but rather treated as if it is dysplasia (see discussion below). Similarly, a woman who has a suppressed immune system is not a good candidate for serial Pap smear tests because she is at higher risk of serious abnormalities. Therefore, she should undergo colposcopy instead of serial Pap smears. It is evident from this discussion that many factors go into a physician's decision regarding which of the three treatment options to recommend to an individual woman.

Low-grade squamous intraepithelial lesion (LSIL): A more serious cellular abnormality is low-grade squamous intraepithelial lesion (LSIL). A reading of LSIL is a reason for immediate further investigation because it is more abnormal than ASCUS. Fifteen to 30% of women who have this abnormality on Pap testing will have a more serious abnormality on biopsy of the cervix. Thus, all women with LSIL are recommended to undergo colposcopy. On the brighter side, even LSIL spontaneously returns to normal without therapy in many women within several months. For that reason, if the initial colposcopy and biopsy results are favorable, serial Pap smears every 4 to 6 months may be recommended, after which a return to normal screening is possible if there are three negative, consecutive, satisfactory Pap smears.

High-grade squamous intraepithelial lesion (HSIL): The most severe cellular abnormality that is not actually cancer is high-grade squamous intraepithelial lesion (HSIL). A finding of HSIL unquestionably requires prompt treatment.

Women with HSIL have a 70%-75% chance of having a more serious abnormality (CIN 2,3 see below) on biopsy of the cervix, and a 1%-2% chance of having actual cervical cancer on biopsy of the cervix. Therefore, colposcopy is undoubtedly the routine recommendation for all women with HSIL.

Cervical intraepithelial neoplasia (CIN): This is the most severe form of high-grade squamous intraepithelial lesion (HSIL). A neoplasia is within the realm of cancer. Type 1 CIN is "low grade," or less serious than Type 2, 3 CIN (high-grade). The diagnosis of a cervical intraepithelial neoplasia (CIN) on a woman's Pap smear means that she needs to be evaluated and treated as soon as possible by a qualified physician.

Carcinoma in situ: This diagnosis is also a form of high-grade squamous intraepithelial lesion (HSIL). A reading of "carcinoma in situ" on a Pap smear report means there is cervical cancer present. However, the cancer is "in situ," which means that it appears to be limited to the cervix and not to have invaded other tissues.

What treatments are available if a Pap smear is abnormal?

If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, and large-loop excision of the transformation zone.

All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in a number of other respects and so will be discussed separately.

Colposcopy: Colposcopy is a procedure that allows the physician to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.

During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).

If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist and the biopsy results determine the next step in the treatment.

The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.

In unusual circumstances, colposcopy does not allow an adequate view of the cervix and another procedure called conization is necessary in order to obtain a tissue biopsy.

Conization: This is still the standard method to which all other methods are compared. Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch long and 3/4 inch wide) is taken from around the endocervical canal.

Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual intercourse.

Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.

With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis of cancer) already, or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.

Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments. It may also be appropriate for women with certain specific findings after conization.

Cryocauterization: Cryocauterization is a simple and safe procedure. A probe, called a cryoprobe, is first cooled by carbon dioxide and then touched to the abnormal cervical area. This freezes and kills the cells, resulting in the sloughing of the abnormal tissue.

A woman undergoing cryocauterization can expect a watery vaginal discharge for several weeks after the procedure.

Laser therapy: Laser therapy makes use of the principle that laser light can be produced by electricity running through gas. In the treatment of cervical lesions, the gas is usually carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells.

When a laser beam (using a tiny wand called a micromanipulator) is directed into the cervix at an area of abnormal cervical tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization. However, the laser apparatus is expensive, and its use requires more skill than other treatment options, such as cryocauterization. The procedure is also painful and generally requires general anesthesia.

The benefit of laser therapy is that it may cause less cervical scarring as compared to cryocauterization. This in turn may mean that, should the woman need colposcopy in the future, the chances of adequately viewing her cervix may be better after laser therapy.

Large-loop excision (LEEP) of the transformation zone: Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.

Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. When there is no more evidence of abnormal cervical tissue, it may be possible to resume annual screening Pap smears.

What is the follow-up after treatment for an abnormal Pap smear?

Follow-up is crucial after treatment for an abnormal Pap test. Women who have undergone any one of the above-described treatment procedures require special follow-up schedules. They must be evaluated and checked until the physician is fully convinced that routine Pap smears can be resumed.

What is the current status of human papilloma virus (HPV) typing?

HPV is a sexually transmitted virus that may be spread from one person to another even when the genital sores are not visible. Many sexually active people are carriers of HPV, very often without even knowing they are carriers. It is estimated that up to 60% of sexually active women harbor this virus on their cervix or in their vaginal area. It is not unusual for a woman to be unaware that she has HPV - only to find out that her Pap smear shows evidence of HPV.

HPV is not curable, although the cellular damage it causes is generally treatable and a vaccine against the four most commonly found HPV types is available. A woman with HPV needs careful and regular long-term medical follow-up to watch for any resulting HPV-associated pre-cancerous cellular changes.

There are over 70 different strains of HPV virus. Based on the observation that certain strains of HPV (for example, types 16 and 18) are more likely to be associated with cervical cancer, some people have advocated testing HPV infected women in order to identify their specific strain of HPV. Following an abnormal Pap smear, this information would then be used to help select the specific treatment strategy. In other words, a physician would more aggressively treat a woman with an abnormal Pap smear if she tests positive for an HPV type that is more likely to be associated with the development of cervical cancer.

However, even the so-called "low-risk" HPV strains can still be associated with cervical cancer at some time in the future and not all of the high-risk HPV strain abnormalities will necessarily result in cervical cancer. Furthermore, the HPV typing is expensive. The main use of HPV testing in screening for cervical cancer is for determination of treatment and follow-up recommendations for women with Pap smears interpreted as atypical squamous cells of undetermined significance (ASC-US) . Those with positive tests for high risk HPV types and an ASC-US smear are referred for further evaluation.

HPV testing along with Pap screening (a combined test) was approved for primary screening for cervical cancer by the U.S. Food and Drug Administration (FDA) in 2003. This combined testing has been used as an alternative screening test for low risk women aged 30 and over at intervals of three years or greater.

When should women start and stop having Pap smears, and how often should Pap smears be performed?

The table summarizes the consensus of all the major organizations regarding these important questions. The key points of the table are as follows:

  • All the guidelines agree that Pap smears should be started within 3 years of first sexual activity or age 21, whichever comes first.
  • There are minor differences in the recommendations for the frequency and age at which to stop Pap smears.
  • Older women who have had many normal Pap smears in a row and have been regularly screened are highly unlikely to have an abnormal Pap smear. These findings point to stopping Pap smears in older women, as reflected by several of the guidelines in the Table.
  • Women who have had a total hysterectomy for a benign condition no longer have a cervix, and thus do not derive any benefit from screening for cervical cancer.
  • In contrast, women who have had a subtotal hysterectomy still have a cervix, and thus should be screened according to the recommendations of women who have not had a hysterectomy.
  • Women who have had a hysterectomy for abnormal Pap smears have their own special recommendations.

Special situations may impact the frequency of screening. For example, women who have had cervical cancer, exposure to diethylstilbestrol, or a compromised immune system (as with HIV infection, for example) should continue annual screening as long as they are in reasonably good health. Women who have had a hysterectomy for CIN2 or CIN3 (a type of abnormal Pap smear) should be screened until they have had three normal Pap smears, (and if no abnormal Paps show up in 10 years, they can stop having Pap tests).

What is the current status of the newer Pap smear technologies?

New technologies have been developed to try to circumvent the problem of false-negative Pap smears. False-negative results occur when a disease or condition is present but the test does not detect it. False-negative Pap smears (slides with abnormal cells judged to be "normal") are estimated to be between 5% and 30%.

The new techniques consist of alternative ways to prepare and read Pap smears. In one new preparation method known as liquid-based cytology, cervical cells are obtained as usual but a new technique is used to prepare the slides for analysis. The physician puts the cell sample into a vial of liquid preservative. The cells are then sent to the laboratory where they are filtered and spread on glass slides. This method removes any contamination from blood or mucous.

Prepared slides are usually read by cytotechnologists who examine thousands of slides under a microscope every day. This exhausting process may be subject to human error. Computer systems are now being developed to assist by providing an automated analysis of slides. Slides containing abnormally appearing cervical cells can first be automatically identified and then subjected to a second, manual re-screening.

Recent guidelines are conflicting as to whether to recommend the new technologies because sound scientific research is not available on which to base a thoughtful recommendation. Besides being more expensive, the underlying problem is that the new technologies (such as liquid-based cytology) have never been proven to decrease mortality from cervical cancer as compared to conventional Pap testing. In addition, even if future research shows that more cases of cervical cancer are detected with the new technologies versus the conventional Pap testing, there may be too many "false positive" cases in which women are labeled to have abnormal Pap smears when they are perfectly normal. This last point is critical. The information must be gathered before rational recommendations can be widely instituted.

With Pap smears so available, why are women still dying of cervical cancer?

It is critically important to recognize that the women who are at highest risk for abnormal Pap smear testing are those who are not getting regular Pap testing. Therefore, it follows that in order to improve overall cervical cancer screening, women who are not getting regular Pap smears should be educated about and offered Pap testing. These under-served women should be the most heavily targeted for Pap screening.

Between 60% and 80% of American women who are newly diagnosed with invasive cervical cancer have not had a Pap smear in the past five years and may never have had one. Women who have not had Pap smear screening tend to be concentrated in certain population groups including:

  • Older women;

     

  • The uninsured;

     

  • Ethnic minorities, especially Latino, African American, and Asian American women;

     

  • Poor women; and

     

  • Women in rural areas.

Many physicians feel that the emphasis should be on universal access to proper Pap screening as opposed to the comparatively small benefit that would come from utilizing the newer technologies in women already undergoing screening. Cervical cancer is one of the most common causes of cancer worldwide. It is also one of the most preventable and treatable cancers.

Historical note: Dr. Pap

The Pap smear is named after Dr. George Papanicolaou (1883-1962). Born in Greece, Dr. Papanicolaou received a medical degree from the University of Athens in 1904 and a PhD in zoology from the University of Munich in 1910. He came to the United States in 1913 as an assistant research biologist under Dr. Charles R. Stockard at Cornell Medical College in New York City. He stayed at Cornell for 47 years. There, he studied the role of chromosomes in sex determination. In the process, he noticed recurring changes in the cells in the vaginal discharge of the guinea pig over the menstrual cycle. Extending his studies to humans, "Dr. Pap" began examining vaginal smear changes in 1923. He unexpectedly discovered that women with uterine cancer had "abnormal cells, with enlarged, deformed, or hyperchromatic nuclei." He called the discovery of these abnormal cells on the smear "one of the most thrilling experiences in my scientific career."

Dr. Pap's new test was at first viewed as quite unnecessary for the diagnosis of cervical cancer. Then, in 1943, he and the gynecologist Herbert F. Traut published a report entitled "Diagnosis of uterine cancer by the vaginal smear." They demonstrated clearly how cellular abnormalities could be detected before the tumor became invasive. It was a revolution in the management of cervical cancer. The Pap smear test was soon accepted as a routine screening technique. Within two decades, cervical cancer dropped from first to third place as a cause of cancer death in women.

Dr. Pap was the founder of what is called exfoliative cytology, which is the microscopic examination of cells shed from the surface of the body, or from a tumor, in order to among other things, detect cancer and gauge the effect of hormones. Dr. Pap applied his technique to other types of tumors including those in the respiratory, gastrointestinal, and urinary tracts and the breast. His method has also been used to predict cancer radiosensitivity and to evaluate the effectiveness of radiotherapy. However, it is as the creator of the Pap smear that Dr. Pap is best remembered today.

Pap Smear At A Glance
  • A Pap smear is a simple, quick, and essentially painless screening test.

     

  • Cells collected from a woman's cervix are spread on a microscope slide for examination.

     

  • The cells are evaluated for abnormalities, specifically for pre- cancerous and cancerous changes.

     

  • Pap smears are recommended for all women starting at age 21 years or within 3 years of becoming sexually active, whichever comes first.

     

  • Most women over age 30 who have had reliable Pap screening with persistently normal results can be screened less often than yearly.

     

  • Pap smears should not be performed in women who have had a total hysterectomy for benign conditions and had prior normal Pap smears.

     

  • The Pap smear is read (analyzed) according to a uniform standardized system known as the Bethesda System.

     

  • A recording of the woman's menstruation status and whether and when she had abnormal Pap smears previously, is essential to the reader of the current Pap smear.

     

  • Screening guidelines recommend that most women over 65-70 years old who have had regular Pap screening with negative results can stop having Pap tests, because abnormal Pap smears are very unusual in this setting.

     

  • Up to 80% of women diagnosed with invasive cancer of the cervix have not had a Pap smear in the past 5 years.

     

  • Cancer of the cervix is a preventable disease.


Paraphilias


  • Paraphilias Introduction
  • What behaviors are considered paraphilias?
  • How common are paraphilias?
  • What causes paraphilia?
  • How is paraphilia treated?
  • How successful is treatment for paraphilia?
  • Find a local Psychiatrist in your town

Paraphilias Introduction

Paraphilias are problems with controlling impulses that are characterized by recurrent and intense sexual fantasies, urges, and behaviors involving unusual objects, activities, or situations not considered sexually arousing to others. In addition, these objects, activities or situations often are necessary for the person's sexual functioning. With a paraphilia, the individual's urges and behaviors cause significant distress and/or personal, social or occupational dysfunction. Someone with a paraphilia may be referred to as "kinky" or "perverted," and these behaviors may have serious social and legal consequences.

What Behaviors Are Considered Paraphilias?

Exhibitionism ("Flashing")

Exhibitionism is characterized by intense, sexually arousing fantasies, urges or behaviors involving exposure of the individual's genitals to an unsuspecting stranger. The individual with this problem, sometimes called a "flasher," feels a need to surprise, shock or impress his victims. The condition usually is limited to the exposure, with no other harmful advances made, although "indecent exposure" is illegal. Actual sexual contact with the victim is rare. However, the person may masturbate while exposing himself or while fantasizing about exposing himself.

Fetishism

People with this problem have sexual urges associated with non-living objects. The person becomes sexually aroused by wearing or touching the object. For example, the object of a fetish could be an article of clothing, such as underwear, rubber clothing, women's shoes, or women's underwear or lingerie. The fetish may replace sexual activity with a partner or may be integrated into sexual activity with a willing partner. When the fetish becomes the sole object of sexual desire, sexual relationships often are avoided. A related disorder, called partialism, involves becoming sexually aroused by a body part, such as the feet, breasts or buttocks.

Frotteurism

With this problem, the focus of the person's sexual urges is related to touching or rubbing his genitals against the body of a non-consenting, unfamiliar person. In most cases of frotteurism, a male rubs his genital area against a female, often in a crowded public location. This disorder also is a problem because the contact made with the other person is illegal.

Pedophilia

People with this problem have fantasies, urges or behaviors that involve illegal sexual activity with a prepubescent child or children (generally age 13 years or younger). Pedophilic behavior includes undressing the child, encouraging the child to watch the abuser masturbate, touching or fondling the child's genitals and forcefully performing sexual acts on the child. Some pedophiles are sexually attracted to children only (exclusive pedophiles) and are not attracted to adults at all. Some pedophiles limit their activity to their own children or close relatives (incest), while others victimize other children. Predatory pedophiles may use force or threaten their victims if they disclose the abuse. Health care providers are legally bound to report such abuse of minors.

This activity constitutes rape and is a felony offense punishable by imprisonment.

Sexual Masochism

Individuals with this disorder use sexual fantasies, urges or behaviors involving the act (real, not simulated) of being humiliated, beaten or otherwise made to suffer in order to achieve sexual excitement and climax. These acts may be limited to verbal humiliation, or may involve being beaten, bound or otherwise abused. Masochists may act out their fantasies on themselves -- such as cutting or piercing their skin, or burning themselves -- or may seek out a partner who enjoys inflicting pain or humiliation on others (sadist). Activities with a partner include bondage, spanking, and simulated rape.

Sadomasochistic fantasies and activities are not uncommon among consenting adults. In most of these cases, however, the humiliation and abuse are acted out in fantasy. The participants are aware that the behavior is a "game," and actual pain and injury is avoided.

A potentially dangerous, sometimes fatal, masochistic activity is autoerotic partial asphyxiation, in which a person uses ropes, nooses or plastic bags to induce a state of asphyxia (interruption of breathing) at the point of orgasm. This is done to enhance orgasm, but accidental deaths sometimes occur.

Sexual Sadism

Individuals with this disorder have persistent fantasies in which sexual excitement results from inflicting psychological or physical suffering (including humiliation and terror) on a sexual partner. This disorder is different from minor acts of aggression in normal sexual activity; for example, rough sex. In some cases, sexual sadists are able to find willing partners to participate in the sadistic activities.

At its most extreme, sexual sadism involves illegal activities such as rape, torture, and even murder, in which case the death of the victim produces sexual excitement. It should be noted that while rape may be an expression of sexual sadism, the infliction of suffering is not the motive for most rapists, and the victim's pain generally does not increase the rapist's sexual excitement. Rather, rape involves a combination of sex and gaining power over the victim. These individuals need intensive psychiatric treatment and may be jailed for these activities.

 

Transvestitism

Transvestitism, or transvestic fetishism, refers to the practice by heterosexual males of dressing in female clothes to produce or enhance sexual arousal. The sexual arousal usually does not involve a real partner, but includes the fantasy that the individual is the female partner, as well. Some men wear only one special piece of female clothing, such as underwear, while others fully dress as female, including hair style and make-up. Cross-dressing itself is not a problem, unless it is necessary for the individual to become sexually aroused or experience sexual climax.

Voyeurism ("Peeping Tom")

This disorder involves achieving sexual arousal by observing an unsuspecting and non-consenting person who is undressing or unclothed, and/or engaged in sexual activity. This behavior may conclude with masturbation by the voyeur. The voyeur does not seek sexual contact with the person he is observing. Other names for this behavior are "peeping" or "peeping Tom."

How Common Are Paraphilias?

Most paraphilias are rare, and are more common among males than among females (about 20 to 1 of males to females). However, the reason for this disparity is not clearly understood. While several of these disorders are associated with aggressive behavior, others are not aggressive or harmful. Some paraphilias -- such as pedophilia, exhibitionism, voyeurism, sadism, and frotteurism -- are criminal offenses.

Having paraphilic fantasies or behavior, however, does not always mean the person has the mental illness. The fantasies and behaviors can exist in less severe forms that are not dysfunctional in any way, do not impede the development of healthy relationships, do not harm the individual or others, and do not entail criminal offenses. They may be limited to fantasy during masturbation or intercourse with a partner.

What Causes Paraphilia?

It is not know for certain what causes paraphilia. Some experts believe it is caused by a childhood trauma, such as sexual abuse. Others suggest that objects or situations can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity. In most cases, the individual with a paraphilia has difficulty developing personal and sexual relationships with others.

Many paraphilias begin during adolescence and continue into adulthood. The intensity and occurrence of the fantasies associated with paraphilia vary with the individual, but usually decrease as the person ages.

How Is Paraphilia Treated?

Most cases of paraphilia are treated with counseling and therapy to help these people modify their behavior. Medications may help to decrease the compulsiveness associated with paraphilia, and reduce the number of deviant sexual fantasies and behaviors. In some cases, hormones are prescribed for individuals who experience frequent occurrences of abnormal or dangerous sexual behavior. Many of these medications work by reducing the individual's sex drive.

How Successful Is Treatment for Paraphilia?

To be most effective, treatment must be provided on a long-term basis. Unwillingness to comply with treatment can hinder its success. It is imperative that people with paraphilias of an illegal nature receive professional help before they harm others or create legal problems for themselves.


Male Reproductive Problems: Penis Disorders


  • What disorders affect the penis?
  • What is priapism?
  • What causes priapism?
  • How is priapism treated?
  • What is Peyronie's disease?
  • What causes Peyronie's disease?
  • How is Peyronie's disease treated?
  • What is balanitis?
  • What causes balanitis?
  • How is balanitis treated?
  • What is phimosis?
  • What causes phimosis?
  • How is phimosis treated?
  • What is paraphimosis?
  • What causes paraphimosis?
  • How is paraphimosis treated?
  • What is penile cancer?
  • What causes penile cancer?
  • What are the symptoms of penile cancer?
  • What treatments are given for penile cancer?
  • Find a local Urologist in your town

There are two primary disorders that affect the male reproductive external organs . These include penis disorders and testicular disorders. Disorders of the penis and testes can affect a man's sexual functioning and fertility.

What disorders affect the penis?

Some disorders that affect the penis include priapism, Peyronie's disease , balanitis, phimosis, paraphimosis, and penile cancer .

What is priapism?

Priapism is a persistent, often painful erection lasting more than 4 hours in duration. The priapism erection is not associated with sexual activity and is not relieved by orgasm. It occurs when blood flows into the penis but is not adequately drained.

What causes priapism?

Common causes of priapism include:

  • Alcohol or drug abuse (especially cocaine)
  • Certain medications, including some antidepressants and blood pressure medications
  • Spinal cord problems
  • Injury to the genitals
  • Anesthesia
  • Penile injection therapy (a treatment for erectile dysfunction)
  • Blood diseases, including leukemia and sickle cell anemia

 

How is priapism treated?

Treatment for priapism is a medical emergency, because a prolonged erection can scar the penis and result in a long term complication of erectile dysfunction if if not treated. The goal of treatment is to relieve the erection and preserve normal penile function. In most cases, treatment involves draining the blood using a needle placed in the side of the penis. Medications that help shrink blood vessels, which decreases blood flow to the penis, also may be used. In rare cases, surgery may be required to avoid permanent damage to the penis. If the condition is due to sickle cell disease, a blood transfusion may be necessary. Treating any underlying medical condition or substance abuse problem is important to preventing priapism.

What is Peyronie's disease?

Peyronie's disease is a condition in which a plaque, or hard lump, forms on the penis. The plaque may develop on the upper (more common) or lower side of the penis, in the layers that contain erectile tissue. The plaque often begins as a localized area of irritation and swelling (inflammation), and can develop into a hardened scar. The scarring reduces the elasticity of the penis in the area affected.

Peyronie's disease can occur in a mild form that heals without treatment in 6 -18 months. In these cases, the problem does not progress past the inflammation phase. In severe cases, the disease can be permanent. The hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection.

In addition to the bending of the penis, Peyronie's disease can cause general pain as well as painful erections. It also can cause emotional distress, and affect a man's desire and ability to function during sex.

What causes Peyronie's disease?

The exact cause of Peyronie's disease is unknown. In people whose disease develops quickly, lasts a short time, and goes away without treatment, the likely cause is trauma (hitting or bending) that causes bleeding inside the penis. However, in some people, Peyronie's disease develops slowly and is severe enough to require surgical treatment. Other possible causes of Peyronie's disease include:

  • Vasculitis: This is an inflammation of blood or lymphatic vessels. This inflammation can lead to the formation of scar tissue.
  • Connective tissue disorders: According to the National Institutes of Health, about 30% of men with Peyronie's disease also develop disorders that affect the connective tissue in other parts of their bodies, such as the hands and feet. These conditions generally cause a thickening or hardening of the connective tissue. Connective tissue is specialized tissue -- such as cartilage, bone, and skin -- that acts to support other body tissues.
  • Heredity: Some studies suggest that a man who has a relative with Peyronie's disease is at greater risk for developing the disease himself.

How is Peyronie's disease treated?

There are two ways in which Peyronie's disease can be treated: surgery or non-surgical treatment.

Because the plaque of Peyronie's disease often shrinks or disappears without treatment, most doctors suggest waiting one to two years or longer before attempting to correct it with surgery. In many cases, surgery produces positive results. But because complications can occur, and because many of the problems associated with Peyronie's disease (for example, shortening of the penis) are not corrected by surgery, most doctors prefer to perform surgery only on men with curvatures so severe that sexual intercourse is impossible.

There are two surgical techniques used to treat Peyronie's disease. One method involves the removal of the plaque followed by placement of a patch of skin or artificial material (skin graft). With the second technique, the surgeon removes or pinches the tissue from the side of the penis opposite the plaque, which cancels out the bending effect. The first method can involve partial loss of erectile function, especially rigidity. The second method, known as the Nesbit procedure, causes a shortening of the erect penis.

Penile implants can be used in cases where Peyronie's disease has affected the man's ability to achieve or maintain an erection.

A non-surgical treatment for Peyronie's disease involves injecting medication directly into the plaque in an attempt to soften the affected tissue, decrease the pain, and correct the curvature of the penis. Vitamin E pills haves also been shown to benefit some men with Peyronie's disease.

Another, less invasive option is laser treatment to thin the plaques of Peyronie's disease.

What is balanitis?

Balanitis is an inflammation of the head of the penis. A similar condition, balanoposthitis, refers to inflammation of the head of the penis and the foreskin. Symptoms of balanitis include redness or swelling, itching, rash, pain and a foul-smelling discharge.

What causes balanitis?

Balanitis most often occurs in men and boys who have not been circumcised (had their foreskin surgically removed), and who have poor hygiene. Inflammation can occur if the sensitive skin under the foreskin is not washed regularly, allowing sweat, debris, dead skin and bacteria to collect under the foreskin and cause irritation. The presence of tight foreskin may make it difficult to keep this area clean and can lead to irritation by a foul-smelling substance (smegma) that can accumulate under the foreskin.

Other causes of balanitis may include:

  • Dermatitis/Allergy: Dermatitis is an inflammation of the skin, often caused by an irritating substance or a contact allergy. Sensitivity to chemicals in certain products -- such as soaps, detergents, perfumes and spermicides -- can cause an allergic reaction, including irritation, itching, and a rash.
  • Infection: Infection with the yeast candida albicans (thrush) can result in an itchy, spotty rash. Certain sexually transmitted diseases -- including gonorrhea, herpes and syphilis -- can produce symptoms of balanitis.

In addition, men with diabetes are at greater risk for balanitis. Glucose (sugar) in the urine that is trapped under the foreskin serves as a breeding ground for bacteria.

How Is balanitis treated?

Treatment for balanitis depends on the underlying cause. If there is an infection, treatment will include an appropriate antibiotic or antifungal medication. In cases of severe or persistent inflammation, a circumcision may be recommended.

Taking appropriate hygiene measures can help prevent future bouts of balanitis, such as retracting the foreskin daily and adequately cleaning and drying the head of the penis. In addition, it is important to avoid strong soaps or chemicals, especially those known to cause a skin reaction.

What is phimosis?

Phimosis is a condition in which the foreskin of the penis is so tight that it cannot be pulled back (retracted) to reveal the head of the penis.

What causes phimosis?

Phimosis, which is seen most often in children, may be present at birth. It also can be caused by an infection, or by scar tissue that formed as a result of injury or chronic inflammation. Another cause of phimosis is balanitis, which leads to scarring and tightness of the foreskin. Immediate medical attention is necessary if the condition makes urination difficult or impossible.

How is phimosis treated?

Treatment of phimosis may include gentle, manual stretching of the foreskin over a period of time. Sometimes, the foreskin can be loosened with medication applied to the penis. Circumcision, the surgical removal of the foreskin, often is used to treat phimosis. Another surgical procedure, called preputioplasty, involves separating the foreskin from the glans (head of the penis). This procedure preserves the foreskin and is less traumatic than circumcision.

What is paraphimosis?

Paraphimosis occurs when the foreskin, once retracted, cannot return to its original location. It is a medical emergency that can cause serious complications if not treated.

What causes paraphimosis?

Paraphimosis may occur after an erection or sexual activity, or as the result of injury to the head of the penis. With paraphimosis, the foreskin becomes stuck behind the ridge of the head of the penis. If this condition is prolonged, it can cause pain and swelling, and impair blood flow to the penis. In extreme cases, the lack of blood flow can result in the death of tissue (gangrene), and amputation of the penis may be necessary.

How is paraphimosis treated?

Treatment of paraphimosis focuses on reducing the swelling of the glans and foreskin. Applying ice may help reduce swelling, as may applying pressure to the glans to force out blood and fluid. If these measures fail to reduce swelling and allow the foreskin to return to its normal position, an injection of medication to help drain the penis may be necessary. In severe cases, a surgeon may make small cuts in the foreskin to release it. Circumcision also may be used as a treatment for paraphimosis.

What is penile cancer?

Penile cancer is a rare form of cancer that occurs when abnormal cells in the penis divide and grow uncontrolled. Certain benign (non-cancerous) tumors may progress and become cancer.

What causes penile cancer?

The exact cause of penile cancer is not known, but there are certain risk factors for the disease. A risk factor is anything that increases a person's chance of getting a disease. The risk factors for cancer of the penis may include the following:

  • Uncircumcision: Men who are not circumcised at birth have a higher risk for getting cancer of the penis.
  • Human papilloma virus (HPV) infection: HPV includes more than 100 types of viruses that can cause warts (papillomas). Certain types of HPV can infect the reproductive organs and the anal area. These types of HPV are passed from one person to another during sexual contact.
  • Smoking: Smoking exposes the body to many cancer-causing chemicals that affect more than the lungs.
  • Smegma: Oily secretions from the skin can accumulate under the foreskin of the penis. The result is a thick, bad-smelling substance called smegma. If the penis is not cleaned thoroughly, the presence of smegma can cause irritation and inflammation.
  • Phimosis: This is a condition in which the foreskin becomes constricted and difficult to retract.
  • Treatment for psoriasis: The skin disease psoriasis is sometimes treated with a combination of medication and exposure to ultraviolet light, which may increase a person's risk for penile cancer.
  • Age: Over half of penile cancer occur in men over age 68.

What are the symptoms of penile cancer?

Symptoms of penile cancer include growths or sores on the penis, abnormal discharge from the penis, and bleeding.

What treatments are given for penile cancer?

Surgery to remove the cancer is the most common treatment for penile cancer. A doctor may take out the cancer using one of the following operations:

  • Wide local excision takes out only the cancer and some normal tissue on either side.
  • Electrodessication and curettage removes the cancer by scraping the tumor with a curette (thin, long instrument with a scraping edge) and applying an electric current to the area to kill cancer cells.
  • Cryosurgery uses liquid nitrogen to freeze and kill the cancer cells.
  • Microsurgery (Moh's surgery) is an operation that removes the cancer and as little normal tissue as possible. During this surgery, the doctor uses a microscope to look at the cancerous area to make sure all the cancer cells are removed.
  • Laser surgery uses a narrow beam of light to remove cancer cells.
  • Circumcision is an operation that removes the foreskin.
  • Amputation of the penis (penectomy) is an operation that removes the penis. It is the most common and most effective treatment of cancer of the penis. In a partial penectomy, part of the penis is removed. In a total penectomy, the whole penis is removed. Lymph nodes in the groin may be taken out during surgery.


Parathyroidectomy


  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

What are the parathyroid glands?

The parathyroid glands are four, small, pea-shaped glands that are located in the neck on either side of the trachea (the main airway) and next to the thyroid gland. In most cases there are two glands on each side of the trachea, an inferior and a superior gland. Fewer than four or more than four glands may be present, and sometimes a gland(s) may be in an unusual location. The function of the parathyroid glands is to produce parathyroid hormone (PTH), a hormone that helps regulate calcium within the body.

Illustration of the Parathyroid Glands

What is a parathyroidectomy?

Parathyroidectomy is the removal of one or more of the parathyroid glands, and it is used to treat hyperparathyroidism.

What is hyperparathyroidism?

Hyperparathyroidism is a condition in which the parathyroid glands produce too much PTH. If there is too much PTH, calcium is removed from the bones and goes into the blood, and there is increased absorption of calcium from the intestine into the blood. This results in increased levels of calcium in the blood and an excess of calcium in the urine. (If there is too little PTH, the blood calcium level can fall to dangerously low levels.) In more serious cases, the bone density will diminish and kidney stones can form. Other non-specific symptoms of hyperparathyroidism include depression, muscle weakness, and fatigue. Every effort is made to medically treat or control these conditions prior to surgery. These efforts include avoiding calcium rich foods, proper hydration (intake of fluids), and medications to avoid osteoporosis.

 

In this Article

  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

What causes hyperparathyroidism?

There are two types of hyperparathyroidism, primary and secondary. The most common disorder of the parathyroid glands and one that causes primary hyperparathyroidism, is a small, tumor called a parathyroid adenoma. A parathyroid adenoma is a benign condition in which one parathyroid gland increases in size and produces PTH in excess. (As opposed to parathyroid adenoma, it should be noted that malignant tumors of the parathyroid glands, that is, cancer, is very rare.) In most situations patients are unaware of the adenoma, and they are found when routine blood test results show an elevated blood calcium and PTH level. Less commonly, primary hyperparathyroidism may be caused by overactivity of all of the parathyroid glands, referred to as parathyroid hyperplasia.

With secondary hyperparathyroidism, the secretion of PTH is caused by a nonparathyroid disease, usually kidney failure.

When is a parathyroidectomy necessary and how is it performed?

Parathyroidectomy is necessary when calcium levels are elevated, if there is a complication of hyperparathyroidism, or if a patient is relatively young. During a parathyroidectomy, the surgeon delicately removes one or more of the tiny parathyroid glands. In some situations, both sides of the neck are explored, while in other cases a direct approach is made through a small incision (referred to as a minimally invasive parathyroidectomy). Tests such as a high-resolution ultrasound or a nuclear medicine scan (called a sestamibi scan) help to direct the approach preoperatively or intra-operatively by identifying the location of the overactive, enlarged gland. In rare situations, the offending gland cannot be found. (A portion of a gland also may be transplanted to another site in the neck or the arm to preserve parathyroid function.)

Whereas preoperative tests help to identify hyperparathyroidism and to direct the surgical approach, PTH levels obtained during parathyroidectiomy help to guarantee the successful resection of the abnormal gland by demonstrating a return of the PTH levels to normal after the suspected parathyroid adenoma is removed. Using this method, a PTH determination is obtained immediately prior to the resection and compared to a PTH determination done ten minutes after the resection.


In this Article

  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

What are the risks of parathyroidectomy?

The anatomy of the parathyroid glands is complicated by two important structures: the recurrent laryngeal nerve and the thyroid gland. The recurrent laryngeal nerve is a very important nerve that runs very close to or through the thyroid gland next to the parathyroid glands. This nerve controls movement of the vocal cord on that side of the larynx , and damage to the nerve can weaken or paralyze the vocal cord. Weakness or paralysis of one vocal cord causes a breathy weak voice, and difficulty swallowing thin liquids. Weakness or paralysis of both vocal cords causes difficulty breathing. In most situations, a special breathing tube is used that rests in the larynx (voice box) between the vocal cords and is designed to allow for the continued monitoring of their function. In rare situations, the parathyroid adenoma is found within the thyroid gland, and it is necessary to remove the thyroid gland as well. The main goal of the parathyroidectomy operation is to remove the offending gland(s) while protecting the remaining normal parathyroid glands as well as the recurrent laryngeal nerves and the thyroid gland.

Surgery may be unsuccessful, that is, the hyperparathyroidism may not be cured and there may be complications of the surgery. Because individuals differ in their response to surgery, their reaction to the anesthetic and their healing following surgery, there can be no guarantee made as to the results or the lack of complications. Furthermore, the outcome of surgery may depend on preexisting or concurrent medical conditions.

What are the possible complications of parathyroidectomy?

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. They are listed here for your information only, not to frighten you, but to make you aware and more knowledgeable concerning parathyroidectomy. Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons practicing community standards of care. Anyone who is contemplating surgery must weigh the potential risks and complications against the potential benefits of the surgery or any alternative to surgery.

  1. Damage to the recurrent laryngeal nerve with resultant weakness or paralysis of the vocal cord or cords: This is a rare but serious complication. Unilateral weakness results in a weak, breathy voice, and there will be problems swallowing. A second surgical procedure can alleviate many of the symptoms of unilateral vocal cord paralysis. Bilateral vocal cord paralysis results in a relative normal voice; however, there is difficulty breathing, and the patient may ultimately require a tracheotomy. Every effort is made to protect the recurrent laryngeal nerve. Temporary vocal cord weakness occurs much more frequently than permanent vocal cord weakness, and it usually will resolve after several days or within a few weeks. Rarely, a malignant tumor has already invaded the nerve and has caused vocal cord weakness or paralysis.
  1. Bleeding or hematoma: In rare situations, a blood transfusion may be necessary because blood is lost during surgery. Patients can choose to have autologous blood (their own blood) or blood from a friend or relative collected in advance of the surgery in case a transfusion is necessary. The surgeon can make arrangements for patients interested in these options.
  1. Damage to the remaining parathyroid glands with resultant problems in maintaining calcium levels in the blood: In most situations, you only need one functioning gland to have normal calcium levels. In the rare event that all glands are removed, blood calcium levels may fall, and patients may need to take calcium supplementation for the rest of their lives.
  1. Need for further and more aggressive surgery: In some cases, surgical exploration fails to identify the abnormal parathyroid gland or multiple abnormal glands may be present. Further and more aggressive surgery may be necessary, such as an extensive surgical exploration of the neck or chest.
  1. Need for a limited or total thyroidectomy: In rare situations, the abnormal parathyroid gland is within the thyroid gland itself or an unexpected thyroid carcinoma, a malignant cancer, is identified. In such situations, much or all of the thyroid gland must be removed, and there may be a need for life-long thyroid hormone treatment.
  1. Prolonged pain, impaired healing, need for prolonged hospitalization, permanent numbness of the neck skin, poor cosmetic result, and/or scar formation.
  1. Recurrence of the tumor or failure to cure the tumor despite effective therapy.

In this Article

  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

What else do you need to know before parathyroidectomy?

Parathyroidectomy usually takes up to three hours. In most situations, the surgery is performed at a hospital or at an outpatient surgery center. An anesthesiologist provides anesthesia and monitors patients throughout the surgery. The anesthesiologist calls the night before surgery to review each patient's medical history or talks to the patient on the morning of the surgery. If preoperative laboratory studies are ordered, they are done several days before the surgery to allow enough time for the results to be obtained and sent to the surgeon and anesthesiologist.

Most patients are told not take aspirin or any product containing aspirin for 10 days prior to surgery in order to prevent aspirin from increasing bleeding at the time of surgery. Nonsteroidal antiinflammatory medications, or NSAIDs, (such as Advil, Motrin, Ibuprofen, Naprosyn, Aleve, etc.) also are stopped several days prior to the surgery for the same reason. It is important to note that many over-the-counter products contain aspirin or ibuprofen, so it is important that patients carefully check all medications that they are taking. If there is any question about a medication, patients should call their doctor's office or consult with their pharmacist. Tylenol is an acceptable pain reliever if a pain reliever is needed prior to surgery. Doctors often give patients their prescriptions for postoperative medications at the preoperative visit so that they may have them filled prior to the surgery. Surgeons may advise purchasing calcium-containing antacids such as Tums-Extra Strength tablets in case the blood calcium drops after surgery and calcium supplements are needed. The amount and duration of supplementation is determined by the surgeon.

Patients do not eat or drink anything for approximately six hours prior to the time of surgery. This includes even water, candy, or chewing gum. Anything in the stomach increases the chances of an anesthetic complication.

Smokers should make every effort to stop smoking (or at least reduce the number of daily cigarettes). This may improve the healing process and reduce postoperative coughing and bleeding.


In this Article

  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

What about care after parathyroidectomy?

After surgery, patients go to the recovery room where nurses monitor them for about one hour. In most situations patients spend one night in the hospital, although some patients undergoing a minimally invasive parathyroidectomy may go home the same day. A friend or family member usually is required to pick patients up from the surgical facility if they are going directly home. It is a good idea for someone to be at home with the patient for the first night.

Patients' necks may be swollen and bruised after surgery, and in most instances there will be a bandage wrapped around the neck. Bandages usually are removed one or two days following surgery. There may be a small plastic drain exiting through the skin. If so, the drainage of fluid from the drain will be monitored in the recovery room or hospital. Sometimes patients may even go home with a drain in place after the nursing staff teaches them how to manage the drain. Sutures taped to the neck should not be cut or trimmed.

Starting several hours after surgery and possibly for several days, blood calcium levels usually are monitored. It is not uncommon for there to be a fall in the blood calcium level following surgery. (The remaining parathyroid glands are "sleepy" following surgery.) As a result, patients may need to take supplemental oral calcium for several days or weeks following surgery. Permanent calcium problems are rare. If patients experience numbness and tingling of the lips, arms, or feet, and or twitching of the muscles--symptoms of low blood calcium--they should contact their surgeon or endocrinologist immediately. In most situations in which these symptoms occur, surgeons will ask patients to take supplemental calcium, such as in Tums-Extra Strength, after surgery. This helps to replenish calcium that is moving back into the bones.

Numbness, slight swelling, tingling, discoloration, bumpiness, hardness, crusting, tightness, and a small amount of redness around the incision are a normal findings after surgery and should improve with time. It is usually alright for patients to wash their face, neck, and hair after the bandages have been removed. Excessive scrubbing of the wound should be avoided, and a gentle soap and shampoo should be used.

In the hospital and after going home, patients generally lie in bed and rest with their head elevated on 2-3 pillows. By keeping their head elevated above their heart, swelling of the neck due to edema may be lessened. Patients get out of bed with assistance to use the bathroom, however. It is good to avoid straining when having a bowel movement, and, if constipation is a problem, a stool softener or a gentle laxative is a good idea.

It may be better to eat a light, soft, and cool diet as tolerated after recovery from the anesthetic. Even though patients may be hungry immediately after surgery, it may be best to go slowly to prevent postoperative nausea and vomiting. Occasionally, patients may vomit one or two times immediately after surgery. If vomiting persists, the doctor may prescribe medications to settle the stomach. A good overall diet with ample rest promotes healing.

Antibiotics often are prescribed after surgery. Patients should finish all the pills that have been ordered. Some form of a narcotic pain medication usually will be prescribed and is to be taken as needed. Patients who take narcotics should not drive. If there is nausea or vomiting postoperatively, patients may be prescribed medications such as promethazine (Phenergan). If patients have any questions or feel that they are developing a reaction to any of the medications, it is important that they consult with their doctor. Patients should not take any other medication, prescribed or over-the-counter, unless they have discussed it with their doctor.

Sutures are removed approximately 7 days after surgery. If not already scheduled, patients should call the surgeon's office to arrange for a follow-up visit. Routine follow-up care depends on the nature of any problems that develop. After healing has occurred, patients usually return to their endocrinologist for long-term monitoring of their calcium levels.

Patients may go back to work or school only when their doctors say they may. Patients probably should rest for the first week following surgery and avoid excessive talking, smiling, hard chewing, strenuous activities, lifting heavy objects, and bending over. Alcohol and tobacco should be avoided because they may prolong swelling and healing. Tanning is discouraged for 6 months after surgery; if patients must be in the sun they should use a number 15 or greater sun block and consider wearing a hat. Make-up may be used anytime after surgery.

After 3 weeks, if there are not problems with bleeding or excessive swelling, it is reasonable to resume exercise and swimming. To allow for postoperative care, it is probably a good idea not to travel out of town for three weeks after surgery.


In this Article

  • What are the parathyroid glands?
  • What is a parathyroidectomy?
  • What is hyperparathyroidism?
  • What causes hyperparathyroidism?
  • When is a parathyroidectomy necessary and how is it performed?
  • What are the risks of parathyroidectomy?
  • What are the possible complications of parathyroidectomy?
  • What else do you need to know before parathyroidectomy?
  • What about care after parathyroidectomy?
  • When should I contact the doctor?

When should patients contact their doctor?

Patients should contact their doctor if they notice:

  1. A sudden increase in the amount of bruising and pain associated with excessive swelling of the neck and difficulty breathing.
  1. A fever greater than 101.5 degrees F that persists despite increasing the amount of fluid they drink and acetaminophen (Tylenol). (A person with a fever should try to drink approximately one cup of fluid each waking hour.)
  1. Drainage from the wound.
  1. Spasms or severe cramps in the muscles or twitching of the face. If this occurs, patients should call their surgeon immediately and be ready to have their blood calcium level determined.


Parenting


  • Introduction to healthy parenting
  • 10 principles of good parenting
  • Avoiding the dinnertime battle
  • Fitting in family fitness

Introduction to healthy parenting

Raising a happy, healthy child is one of the most challenging jobs a parent can have -- and one of the most rewarding. Yet many of us don't approach parenting with the same focus we would use for a job. We may act on our gut reactions or just use the same parenting techniques our own parents used, whether or not these were effective parenting skills.

Parenting is one of the most researched areas in the field of social science. No matter what your parenting style or what your parenting questions or concerns may be, from helping your child avoid becoming part of America's child obesity epidemic to dealing with behavior problems, experts can help.

In his book The Ten Basic Principles of Good Parenting, Laurence Steinberg, PhD, provides tips and guidelines based on some 75 years of social science research. Follow them and you can avert all sorts of child behavior problems, he says.

Good parenting helps foster empathy, honesty, self-reliance, self-control, kindness, cooperation, and cheerfulness, says Steinberg, a distinguished professor of psychology at Temple University in Philadelphia. It also promotes intellectual curiosity, motivation, and encourages a desire to achieve. Good parenting also helps protect children from developing anxiety, depression, eating disorders, antisocial behavior, and alcohol and drug abuse.

Here are Dr. Steinberg's 10 principles of good parenting:

1. What you do matters. Whether it's your own health behaviors or the way you treat other people, your children are learning from what you do. "This is one of the most important principles," Steinberg explains. "What you do makes a difference...Don't just react on the spur of the moment. Ask yourself, What do I want to accomplish, and is this likely to produce that result?"

2. You cannot be too loving. "It is simply not possible to spoil a child with love," Steinberg writes. "What we often think of as the product of spoiling a child is never the result of showing a child too much love. It is usually the consequence of giving a child things in place of love -- things like leniency, lowered expectations, or material possessions."

3. Be involved in your child's life. "Being an involved parent takes time and is hard work, and it often means rethinking and rearranging your priorities. It frequently means sacrificing what you want to do for what your child needs to do. Be there mentally as well as physically."

Being involved does not mean doing a child's homework -- or correcting it. "Homework is a tool for teachers to know whether the child is learning or not," Steinberg says. "If you do the homework, you're not letting the teacher know what the child is learning."

4. Adapt your parenting to fit your child. Keep pace with your child's development. Your child is growing up. Consider how age is affecting the child's behavior.

"The same drive for independence that is making your 3-year-old say 'no' all the time is what's motivating him to be toilet trained," writes Steinberg. "The same intellectual growth spurt that is making your 13-year-old curious and inquisitive in the classroom also is making her argumentative at the dinner table."

5. Establish and set rules. "If you don't manage your child's behavior when he is young, he will have a hard time learning how to manage himself when he is older and you aren't around. Any time of the day or night, you should always be able to answer these three questions: Where is my child? Who is with my child? What is my child doing? The rules your child has learned from you are going to shape the rules he applies to himself.

"But you can't micromanage your child," Steinberg notes. "Once they're in middle school, you need to let the child do their own homework, make their own choices and not intervene."

6. Foster your child's independence. "Setting limits helps your child develop a sense of self-control. Encouraging independence helps her develop a sense of self-direction. To be successful in life, she's going to need both."

It's normal for children to push for autonomy, says Steinberg. "Many parents mistakenly equate their child's independence with rebelliousness or disobedience. Children push for independence because it is part of human nature to want to feel in control rather than to feel controlled by someone else."

7. Be consistent. "If your rules vary from day to day in an unpredictable fashion or if you enforce them only intermittently, your child's misbehavior is your fault, not his. Your most important disciplinary tool is consistency. Identify your non-negotiables. The more your authority is based on wisdom and not on power, the less your child will challenge it."

8. Avoid harsh discipline. Parents should never hit a child, under any circumstances, Steinberg says. "Children who are spanked, hit, or slapped are more prone to fighting with other children," he writes. "They are more likely to be bullies and more likely to use aggression to solve disputes with others."

"There are many other ways to discipline a child -- including 'time out' -- which work better and do not involve aggression."

9. Explain your rules and decisions. "Good parents have expectations they want their child to live up to," he writes. "Generally, parents overexplain to young children and underexplain to adolescents. What is obvious to you may not be evident to a 12-year-old. He doesn't have the priorities, judgment, or experience that you have."

10. Treat your child with respect. "The best way to get respectful treatment from your child is to treat him respectfully," Steinberg writes. "You should give your child the same courtesies you would give to anyone else. Speak to him politely. Respect his opinion. Pay attention when he is speaking to you. Treat him kindly. Try to please him when you can. Children treat others the way their parents treat them. Your relationship with your child is the foundation for her relationships with others."

For example, if your child is a picky eater: "I personally don't think parents should make a big deal about eating," Steinberg says. "Children develop food preferences. They often go through them in stages. You don't want to turn mealtimes into unpleasant occasions. Just don't make the mistake of substituting unhealthy foods. If you don't keep junk food in the house, they won't eat it."

 

Avoiding the dinnertime battle

Still, there are some gentle ways parents can nudge their kids toward more healthful eating habits. Here are a few thoughts from nationally known nutrition experts on how to get kids to go from being picky eaters to people with sound, varied diets:

  • Avoid a mealtime power struggle. One of the surest ways to win the battle but lose the war is to engage in a power struggle with your child over food, says Jody Johnston Pawel, LSW, CFLE, author of The Parent's Toolshop. With power struggles, you're saying, "Do it because I'm the parent" and that's a rationale that won't work for long, she says. But if your child understands the why behind the rules, those values can lay the groundwork for a lifetime of sound food choices.
  • Let kids participate. Get a stepstool and ask your kids to lend a hand with easy tasks in the kitchen, says Sal Severe, PhD, author of How to Behave So Your Children Will, Too. "If they participate in helping to make the meal, they are more likely to want to try it," he says.
  • Don't label. Severe reminds parents that, more often than not, kids under 5 are going to be selective eaters. "Being selective is actually normal," says Elizabeth Ward, MS, RD. She prefers the term "limited eater" to the more negative term "picky."
  • Build on the positives. "When I sit down with parents, we'll often find that their child actually does eat two or three things from each food group," says Ward. Just as children can get comfort from reading the same story over and over, they enjoy having a set of "predictable" foods. "Even though they aren't getting a wide variety of foods, they are actually doing OK nutritionally," says Ward. When the child goes through a growth spurt and has a bigger appetite, use that opportunity to introduce new foods, she recommends.
  • Expose, expose, expose. Ward says a child needs to be exposed to a new food 10 to 15 times before he or she will accept it. But many parents give up long before that. So, even if your child only plays with the strawberry on her plate, don't give up. One day, she just may surprise you by taking a bite. But don't go overboard, says Severe. Limit exposure to one or two new foods a week.
  • Don't bribe. Avoid using sweets as a bribe to get kids to eat something else, says Pawel. That can send the message that doing the right thing should involve an external reward. The real reward of sound nutrition is a healthy body, not a chocolate cupcake.
  • Beware of oversnacking. Sometimes the problem isn't that the child doesn't like new foods, but that they are already full, says Ward. "Kids can consume a lot of their calories as milk and juice." The same goes for snacks that provide little more than calories, such as chips, sweets, and sodas. "If you are going to offer snacks, make sure they are supplementing meals, not sabotaging them," she says.
  • Establish limits. Having a set of bottom-line limits can help a parent provide some consistency, says Pawel. For example, parents may require that kids eat nutritious foods before snack food. Or that they must at least try a new food before rejecting it. "Consistency only works if what you are doing in the first place is reasonable," she says. So, avoid overly controlling or overly permissive eating rules. If bottom-line limits are healthy, effective, and balanced, they'll pay off.
  • Examine your role model. Make sure you aren't asking kids to "do as I say, not as I do," says Pawel. If your own diet is based mainly on fat, sugar, and salt, you can hardly expect your child to embrace a dinner salad over French fries.
  • Defuse mealtimes. Don't make your child's eating habits part of the mealtime discussion, says Ward. Otherwise every meal becomes a stressful event, centered on what the child does and does not eat. Ward suggests that parents reserve talks about the importance of good eating for later, perhaps at bedtime or story time.
  • Give it time. "I find that children become much more open to trying new foods after the age of 5," says Ward. "Most of the time, kids will simply grow out of limited eating."

Avoiding the dinnertime battle

Still, there are some gentle ways parents can nudge their kids toward more healthful eating habits. Here are a few thoughts from nationally known nutrition experts on how to get kids to go from being picky eaters to people with sound, varied diets:

  • Avoid a mealtime power struggle. One of the surest ways to win the battle but lose the war is to engage in a power struggle with your child over food, says Jody Johnston Pawel, LSW, CFLE, author of The Parent's Toolshop. With power struggles, you're saying, "Do it because I'm the parent" and that's a rationale that won't work for long, she says. But if your child understands the why behind the rules, those values can lay the groundwork for a lifetime of sound food choices.
  • Let kids participate. Get a stepstool and ask your kids to lend a hand with easy tasks in the kitchen, says Sal Severe, PhD, author of How to Behave So Your Children Will, Too. "If they participate in helping to make the meal, they are more likely to want to try it," he says.
  • Don't label. Severe reminds parents that, more often than not, kids under 5 are going to be selective eaters. "Being selective is actually normal," says Elizabeth Ward, MS, RD. She prefers the term "limited eater" to the more negative term "picky."
  • Build on the positives. "When I sit down with parents, we'll often find that their child actually does eat two or three things from each food group," says Ward. Just as children can get comfort from reading the same story over and over, they enjoy having a set of "predictable" foods. "Even though they aren't getting a wide variety of foods, they are actually doing OK nutritionally," says Ward. When the child goes through a growth spurt and has a bigger appetite, use that opportunity to introduce new foods, she recommends.
  • Expose, expose, expose. Ward says a child needs to be exposed to a new food 10 to 15 times before he or she will accept it. But many parents give up long before that. So, even if your child only plays with the strawberry on her plate, don't give up. One day, she just may surprise you by taking a bite. But don't go overboard, says Severe. Limit exposure to one or two new foods a week.
  • Don't bribe. Avoid using sweets as a bribe to get kids to eat something else, says Pawel. That can send the message that doing the right thing should involve an external reward. The real reward of sound nutrition is a healthy body, not a chocolate cupcake.
  • Beware of oversnacking. Sometimes the problem isn't that the child doesn't like new foods, but that they are already full, says Ward. "Kids can consume a lot of their calories as milk and juice." The same goes for snacks that provide little more than calories, such as chips, sweets, and sodas. "If you are going to offer snacks, make sure they are supplementing meals, not sabotaging them," she says.
  • Establish limits. Having a set of bottom-line limits can help a parent provide some consistency, says Pawel. For example, parents may require that kids eat nutritious foods before snack food. Or that they must at least try a new food before rejecting it. "Consistency only works if what you are doing in the first place is reasonable," she says. So, avoid overly controlling or overly permissive eating rules. If bottom-line limits are healthy, effective, and balanced, they'll pay off.
  • Examine your role model. Make sure you aren't asking kids to "do as I say, not as I do," says Pawel. If your own diet is based mainly on fat, sugar, and salt, you can hardly expect your child to embrace a dinner salad over French fries.
  • Defuse mealtimes. Don't make your child's eating habits part of the mealtime discussion, says Ward. Otherwise every meal becomes a stressful event, centered on what the child does and does not eat. Ward suggests that parents reserve talks about the importance of good eating for later, perhaps at bedtime or story time.
  • Give it time. "I find that children become much more open to trying new foods after the age of 5," says Ward. "Most of the time, kids will simply grow out of limited eating."

Fitting in family fitness

Children need at least an hour of moderate to strenuous physical activity every day to stay healthy, according to experts. But many kids just aren't getting that much exercise. And most groups are unanimous on the prime culprit: sedentary entertainment, meaning the temptations of the TV, computer, and video games.

So, your first step toward encouraging a healthy level of physical exercise should be to limit your children's TV and screen time. Beyond that, here are some tips from the experts on how to help your children (and yourself) stay active:

  • Make an exercise schedule. Exercise doesn't have to involve a rigid routine. But it's a good idea to schedule a regular time for exercise each day. You and your kids will be more likely to get up and get moving if you've set aside a specific time for physical activity.
  • Support physical-education programs in the schools, which may be reduced or receive less emphasis in some school systems. Communicate to your child's teachers and administrators your belief that physical education (PE) is an important part of the curriculum.
  • Plan your vacations, weekends, and days off around fitness fun. Plan a bike ride, take an invigorating hike along nature trails, or pack a picnic lunch and head for the park for a family game of Frisbee.
  • Make use of community resources. When it comes to finding fitness opportunities, take advantage of what your community has to offer. Join the local YMCA or sign up for tennis or other lessons through your Parks and Recreation Department. Look for water aerobics classes and golf lessons at local swimming pools and golf courses.
  • Get the whole neighborhood involved. Organize neighborhood fitness activities for children and their parents. Softball games, soccer matches, and jump-rope contests are fun for kids and adults.
  • Dance! Children of all ages love to dance. Crank up the music, show your kids the dances that were popular when you were a teen, and let them teach you their favorite dance moves.
  • Expose your child to a variety of physical fitness activities and sports. Your child will likely find the combination of activities or sports that are most enjoyable for him or her and will not become bored of one activity.
  • Let your kids take turns being the fitness director for your family. They'll have more fun when they're allowed to choose the activity, and they'll enjoy putting their parents and siblings through their paces.


Tips for Parenting a Child with ADHD

  • What is ADHD?
  • What are the symptoms of ADHD?
  • What should I do if I am concerned that my child might have ADHD?
  • What are some behavioral treatments and parenting strategies for parents of children with ADHD?
  • Think positively
  • Define schedules and routines
  • Set clear rules and expectations
  • Give clear instructions
  • Discipline, rewards, and consequences
  • Use time-out effectively
  • Ignore, within reason
  • Develop organizational aids
  • Eliminate distractions
  • Set small, attainable goals
  • Focus on one or two challenging behaviors at a time
  • Find areas in which the child excels
  • Promote a healthy lifestyle
  • Show your unconditional love
  • Take care of yourself
  • ADHD Resources
  • Find a local Psychiatrist in your town

What is ADHD?

ADHD, or attention deficit hyperactivity disorder, is a behavioral condition characterized by inattention, impulsiveness, and/or hyperactivity. It has been estimated that approximately 5% of US children have ADHD, according to established diagnostic criteria.

What are the symptoms of ADHD?

Symptoms of a child with ADHD can include:

  • difficulty sustaining and paying attention to tasks at home or school;
  • making careless errors, not following through with tasks or completing instructions;
  • being easily distracted;
  • look like they aren't listening;
  • being easily bored;
  • being forgetful, losing things;
  • having difficulty organizing tasks, activities, or belongings;
  • being fidgety, difficulty remaining seated;
  • talking excessively;
  • running or climbing about excessively when it is inappropriate to do so;
  • having difficulty awaiting his/her turn in a game or activity;
  • interrupting or intruding on others;
  • avoiding or disliking doing things that take a lot of effort for a long time.

Many children with ADHD will have symptoms that persist into adulthood. Effective treatments for ADHD include both medications and behavioral therapies.

Not surprisingly, parenting a child with ADHD can pose special challenges.

What should I do if I am concerned that my child might have ADHD?

Many of the symptoms of ADHD are also symptoms seen during normal childhood and development, and exhibiting one or more of the symptoms does not mean that a child has ADHD. In particular, the symptoms of ADHD are very common in toddlers and preschool children, so it can very hard to differentiate ADHD behaviors from normal developmental behaviors in young children. For this reason, the diagnosis of ADHD is more difficult in preschool children than in early school-aged children.

It is also important to note that for a health care professional to make a diagnosis of ADHD, the symptoms must have been present for at least six months in more than one setting (for example, home, school and in the community), usually beginning younger than seven years old and the symptoms must be inconsistent with the developmental level of the child and severe enough to interfere with the child's social or academic functioning.

If you are concerned about your child's behavior, it is appropriate to communicate this to your child's primary health care provider. He or she can help you determine whether further evaluation may be necessary and whether your child's behavioral symptoms are suggestive of ADHD. If a formal evaluation is indicated, this evaluation will involve professionals from various disciplines to provide a comprehensive medical, developmental, educational, and psychosocial evaluation.

What are some behavioral treatments and parenting strategies for parents of children with ADHD?

Think positively

While ADHD can certainly present unique and sometimes what can seem to be daunting challenges, being able to sincerely know and have confidence in your child's strengths can go a long way to help him or her be the very best person they can be. Many famous, accomplished, indeed brilliant people of the past and present have ADHD. An outstanding example of learning to have a positive outlook about ADHD is demonstrated in the children's movie called, Percy Jackson and the Olympians: The Lightening Thief. In that movie, Percy tends to see himself as disadvantaged because he has ADHD and a learning disability. However, it is the very tendency those conditions have to cause him to be able to notice many things at once and to read differently that are important assets to him in a variety of adventures.

Another benefit to thinking positively about your child with ADHD is its infectious nature. It is much easier for the child's teacher, coaches, peers and in fact the child his or herself to accept and harness strengths when the parent communicates and emphasizes those strengths. The challenge for parenting a child with ADHD is to be able to use the child's unique gifts and address his or her challenges to work towards achieving their child's fullest potential.

Define schedules and routines

Clearly defined schedules and routines are essential for children (as well as for teens and adults) with ADHD. Having an established, while not inflexible, pattern for getting ready in the mornings, preparing for bedtime, and managing after school homework and activities provides a sense of consistency and allows the child to know what to expect. It is also easier for the child to follow rules and routines when these do not vary very often. It can be helpful for older children to have plenty of conspicuous clocks to use as cues for time management. Some parents find that the use of timers (for homework time, time to finish up play, etc.) helps for younger children.

To make the process more enjoyable or easier to remember, charts and checklists can be used that list the steps or tasks required for each time of day. For example, the "morning checklist" can include items like making the bed, brushing teeth, and helping prepare school lunch. Hang the checklists in a conspicuous place and allow your child to check off completed items as they are done, if he/she wishes.

Set clear rules and expectations

As with clearly defined schedules, attainable, clearly defined rules and expectations are also essential for kids with ADHD. In both school and at home, children with ADHD need a consistent and clearly-defined set of rules. It can be helpful to create a list of rules for the home and post them in a place where the child can easily see them. It's very important to stick to the rules and provide fair and consistent rewards and consequences (see below) when the household rules are not followed.

Give clear instructions

Avoid vague or open-ended instructions such as "clean up your mess" or "play nicely" that do not accurately convey the specific tasks that you want to be done. Instead, use clear language and specific instructions such as "please put all the dirty clothes in the hamper," "please put all the toys back on the shelves," or "let's allow your friend to have a turn playing with the toy." Speak in a calm and clear voice and be sure to establish kind eye contact with your child when you give instructions so it is more likely he or she is focused on what you are saying. It can be helpful to have your child repeat the instructions back to you. Breaking down instructions for larger tasks into simple steps can also be helpful.

Discipline, rewards, and consequences

Children with ADHD respond very well to a defined and predictable system of rewards and consequences to manage behavior and discipline. Reward positive behaviors with praise or with small rewards that cost little or no money, such as special time with a parent or participating in an outing or favorite activity. Focus on praise or privileges as rewards rather than offering foods or toys as prizes. To avoid boredom and increase motivation, change the nature of the rewards periodically.

It's always best to give more rewards and positive praise than negative comments or consequences. For most parents, the number of negative comments made to their children is far greater than the number of positive comments, and this is particularly true of kids with ADHD, who are often exposed to endless criticism and complaints about their behavior. Remember to catch them being good. For example, smile and say "I like the way you're working on your homework" or "you're doing a great job clearing the table." Ask your child to say what they did well during and activity and help them come up with something if he or she cannot. Even though the positive behaviors may be expected or taken for granted in other children, praising and encouraging your child with ADHD when he or she exhibits positive or expected behavior will likely increase how often they show positive behaviors.

Likewise, consequences for negative behaviors should be fair, appropriate, consistent, predictable, and swiftly implemented and completed. Major events like holidays or the child's birthday should never be completely withdrawn or uncelebrated because of something the child did. Even the most severely acting out child needs to know that the day of their birth is a happy event for his or her parent. If the child impulsively opened presents or angrily broke something before a party, refusing to sing "Happy Birthday" for them is as unproductive as would be buying added gifts. Consequences should ideally be explained in advance and should occur immediately following the negative behavior. Delayed consequences (such as not participating in an event or outing in the following week) are not as effective as immediate consequences. Consequences can include time-out, removal from the situation or setting, or restriction of privileges. It is very important that the consequence occur after every instance of negative behavior. It's normal to feel angry when it seems as if your child is willfully misbehaving, but try to avoid the tendency to impose overly extreme consequences for minor violations. Small, repeated, and reasonable consequences have the greatest effect over the long term.

Use time-out effectively

Particularly for younger children, time-out can be an effective consequence for negative behaviors that serves the additional purpose of removing the child from an overstimulating or stressful environment. Time-out is also an immediate consequence that is likely to be more effective than a delayed consequence. Of course, time-out should never occur in a frightening or dangerous place for your child. If in public, try having time out for a few minutes in a quiet corner or in your car (with an adult present). Many experts recommend that time-outs not last longer in minutes than the child's age in years (for example, a five minute time out for a five year old). Longer than that may be too difficult for the child to complete, leading him or her to be more likely to defy doing the time out at all. That in turn will likely lead to a vicious cycle of parent and child frustration and therefore increasing conflicts. If your child is able, after the time-out, it can be useful to discuss or model the appropriate behavior for the given situation, asking or explaining to the child how the situation could have been handled more positively.

Ignore, within reason

In some situations, ignoring an undesired behavior may be an effective behavior modification technique for children with ADHD. Obviously, behavior that is risky or injurious to the child or to others cannot be ignored, but behaviors such as whining, nagging, and arguing can sometimes be best ignored until the behaviors stop. Many children with ADHD crave attention from others, even if it is negative attention in the form of yelling, shouting, or scolding. Refusing to provide any attention to the child who is behaving inappropriately can be effective if done consistently. For the child who gets increasingly loud or disruptive (escalates) when ignored, another way to respond may involve calmly and quietly telling the child that when they are calm and quiet the conversation can resume. For some children, the parent may need to remove themselves from the room as long as the child is safe to help the child calm down. Whenever the behavior stops, respond to the child as usual in a friendly, non-angry way.

Develop organizational aids

Children with ADHD have poor executive functioning skills, which means, among other difficulties, that they have trouble organizing their belongings and tasks. Some parents (in cooperation with teachers) have found it helpful to provide color-coded binders and notebooks for each school subject, as well as a homework sheet in the front of the binder that lists homework for each school day. Others may find that purchasing a second set of textbooks for the home is useful for the child who frequently forgets to bring the proper materials home. Help your child develop an organizational system for his/her room and belongings and stick to it.

Of course, your home should be well-organized too. Modeling effective organization skills in front of your child can help him/her realize the importance and benefits of good organizational skills.

Eliminate distractions

While this sounds obvious, many home environments are simply chaotic and full of distractions for the child with ADHD. Be sure that your child has plenty of quiet time and space to complete homework and other tasks. A homework space that is free of external distractions like television, video games, or rooms in the home where most people congregate is key to successful completion of assignments.

Set small, attainable goals

Think of changing your child's less positive behaviors like training for a marathon. Just like no one would expect you or anyone else to go from never running at all to completing 26+ miles, it is unfair and unrealistic to expect your child to change 15, or 10 or even five behaviors immediately. Don't expect dramatic changes overnight. If your goal is to have your child sit still politely through a restaurant meal or family outing, break the process down into small and attainable goals like not interrupting a conversation for five minutes, remaining seated for ten minutes, etc. Be sure to offer plenty of praise and rewards when these small goals are met.

Focus on one or two challenging behaviors at a time

Changing all of a child's negative behaviors at once is never possible, and attempting to do so can create unbearable stress for both parent and child, setting both up for failure. Instead, pick one or two challenging behaviors that you'd like to improve and focus on those. Examples might be interrupting, not remaining seated, forgetting to put toys away, or arguing about bedtime. Whichever behaviors you choose to modify, understand the behavior changes must be gradual to be successful over time. Create a system of nonmonetary rewards and fair, swift consequences as described above and stick to it. You might offer the child a larger privilege or reward (for example, going to bed a half hour later one weekend night) when the behavior has been eliminated or significantly reduced (such as a complete week of putting away toys properly). Don't forget to praise the small successes along the way.

Find areas in which the child excels or succeeds

No one enjoys being subjected to constant criticism or complaints about their behavior. As every individual needs to feel good at something, constant criticizing can result in the child unwittingly working more at perfecting negative behaviors they get attention for rather than the positive behaviors if he or she is not praised.

Help your child find an area or interest in which he or she is successful. This can be a sport, music instrument, academic subject, art form, or other hobby. Even less defined strengths like getting along with their peers or adults can promote the child's success and are therefore worthy of praise. Being successful or having a strong interest in a hobby can greatly improve your child's self-esteem and well-being. Many parents have found that martial arts classes that combine physical movement with mental discipline training are helpful for their kids with ADHD. However, there is no single "best" activity for children with ADHD. Let their interests and enthusiasm be your guide.

Promote a healthy lifestyle

A healthy lifestyle will help not only your child but the entire family preserve both physical and emotional health. Stick to a nutrition plan and avoid giving your child junk foods and "empty" calories on more than an occasional basis. While sugary foods are not a cause of ADHD, some parents find that lots of sugary foods may worsen their child's symptoms. Sometimes older children with ADHD are so distracted and disorganized that they may skip meals or eat irregularly. Decreased appetite can be a side effect of some medications that treat ADHD. Try to ensure that your child is eating regularly, and small meals every few hours may be most effective for some children with ADHD. While allowing your child to enjoy childhood by allowing for an occasional treat, it is important to teach your child to make good food choices by modeling these choices yourself.

Exercise can help excitable children "burn off" excess energy, and regular exercise promotes physical well-being and healthy sleep habits. Encouraging your child to participate in organized sports after school can provide both regular exercise and the benefits of a regular and predictable schedule. As mentioned above, many children with ADHD do well in martial arts or yoga classes that emphasize mental as well as physical control over their bodies. In general, it's important to pick a sport that suits your child and his or her abilities, but sports that involve constant activity or motion may be better choices for some kids than sports that have significant "down-time" like baseball or softball.

Sleep is the final factor in ensuring a healthy lifestyle for your child and family on a daily basis. If your child is not well-rested, he/she will have even more difficulty staying focused and on-task. Falling asleep can be difficult for children with ADHD who may be overstimulated and have an increased activity level. As part of your regular and predictable schedule, it's important to have a set bedtime and bedtime routine. You can use a checklist or timer if you like to help your child make the transition to bedtime. Eliminating caffeine in your child's diet as well as providing a calming nighttime ritual (such as cuddling or sharing a book or story) can help your child wind down at the end of an active day. For older children and teens, turning off the computer and storing cell phones and other electronic devices outside the child's room for the night serve to prevent their interfering with sleep.

Show your unconditional love

Be sure your child is aware of your unconditional love and support, no matter how he or she behaves. Withdrawal of love or affection is never an appropriate consequence for undesired behavior. It's OK to let your child know that you are angry or frustrated with his/her behavior at times, but remember to say "I love you" every day and be sure your child knows that he or she is an accepted and valued member of the family.

Take care of yourself

Finally, don't forget to take care of the caregiver. In addition to the joy of accomplishment, parenting a child with ADHD can bring on a variety of upsetting emotions including embarrassment, anger, anxiety, worry, and frustration. In fact, you may feel any or all of these on a given day. Try to keep a sense of perspective and understand that your child's behaviors are due to a disorder and may not always be under his or her full control.

Celebrating the small goals and positive steps in your child's progress and development will improve both your mood and your child's self-esteem. Don't lose sight of the special and unique individual that is your child, and find things you both enjoy to do together.

If you need a break, you shouldn't feel guilty. Parenting is a stressful job, and it's OK to accept help from family and friends in caring for your child. Take time off from parenting to spend time on activities you enjoy or even spend time alone in order to recharge yourself. You won't be an effective parent or role model if you have no energy to devote to the process.

Take advantage of all the resources that are at your disposal. If you don't know where to look, talk with your child's teacher, school counselor, or health care provider. School systems vary in the level of support they may be able to provide for parents and students with ADHD, but in all cases, parents and educators should work as a team to address the whole needs of the child. While the health and educational professionals you work with on your child's behalf have specific expertise, know and be confident in your unique expertise in knowing your child in ways no one else ever will. You are therefore your child's best advocate.

You may find that a therapist or support group may be helpful, for either you or your child. Many health care practitioners offer social skills and positive behavior workshops and classes for children that are geared toward having fun while learning to manage their condition. Your health care provider can also be a valuable resource and may have information about parent support groups or community resource.

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Last Updated on Monday, 19 December 2011 18:39
 
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