August 2009

Hysterectomy, The Saga – Part III: Physical and Emotional Preparation for Surgery

Have you ever had a procedure done or gone to the doctor and had them tell you that whatever they were going to do was going to hurt? Of course, when they tell you that, it almost always does hurt! This is what we call “Medical Hexing”. From the outset, I was told that I would be in a lot of pain after the hysterectomy; I was going to feel really tired and wiped out, and that I was not going to be healed for at least six weeks. In a way, I felt set up. I realized that there were things I could do that might help me avoid or cope with pain and improve my healing in ways that conventional medicine couldn’t or wouldn’t.

In my clinic where I work, we have a wonderful psychologist who is a guided imagery specialist. I knew that he could help me. Guided imagery is a method of treatment that uses your mind to take you to a calm, relaxing wonderful place. It induces a state of relaxation and helps your mind to direct pain control and expedite healing. I had a session with him at which time he had me relax and took me on a journey in my mind to a beautiful beach. While on the beach he had me see myself relaxed, healing quickly and experiencing very little pain. The tape was about 30 minutes long. I listened to it every day for a week before the surgery and I listened to it during the surgery. There are many medical studies that have shown this to be a very effective method to reduce surgical complications, reduce the need for pain medication, and improve the speed of healing.

In addition to the guided imagery, I went to our clinic acupuncturist. She treated me for a two-hour session the day before my surgery in which she worked on the acupuncture points to help prevent nausea, boost my immune system, charge up my adrenal glands and help with pain control. I walked out of her session feeling great. The session had the added benefit of stopping the bleeding that had been going on for almost two months! Between the two therapies, I felt really good and I wasn’t upset or scared anymore.

I was able to do one other thing that helped. I insisted upon being able to choose my anesthesiologist. Once I asserted myself, guess what happened? They let me choose! When you have surgery the anesthesiologist is just as important as the surgeon. I chose the anesthesiologist who was recommended by other doctors and one who understood my need to listen to the guided imagery tape during surgery. He was also trained in acupuncture just in case!

The day of the surgery I felt calm, and I told my doctor all the things I had done to prepare. I predicted to her that I would need very little pain medication, I would have very little bleeding and that I would be out of the hospital in two days. She looked at me as if I was nuts. That was the last thing I saw before the preoperative anesthetic went into my arm and I was in la la land.

Hysterectomy, The Saga – Part II: The Doctor as Patient

Although my doctor wanted to take my uterus out as soon as possible, I talked her into waiting a couple of weeks to give me a chance to prepare. I needed to prepare my family and my practice. I also needed to prepare myself emotionally. She said that as long as my endometrial biopsy was negative, I could wait. It took two days to get the biopsy results back. I walked around for two days thinking that I probably had cancer and going through a mental checklist of what I was willing to do for treatment and what I wasn’t willing to do. I couldn’t sleep, and I couldn’t eat. When the biopsy came back negative, I was incredibly relieved.

I was informed that I was going to need an abdominal hysterectomy since the mass was too large to be done vaginally. They wanted to take my ovaries, just because they were there and I was insistent they leave them in along with my appendix that they wanted to take out! Although I was no longer worried about cancer, I had surgery and the knowledge of the zillions of complications that could occur to contend with.

I realized that I had little control over what was about to happen to me, or so I thought. I could however stop them from taking out healthy organs that would otherwise be taken out simply because they are there. I was told initially that I could not choose my anesthesiologist. I wanted to listen to an audiotape during the surgery and was told that it was up to the doctor in charge of my head (the anesthesiologist). If one doctor was in charge of my head and one was in charge of my uterus, who was in charge of the whole body?! I was told to register for surgery over the phone. I called at the given time and was told that since I was healthy and the registration department was so busy that I didn’t need to go through the procedure. Unfortunately, that meant I had no idea what to expect!

I realized that although this surgery was major to me and would have an impact on my body and my life, for those doing or participating in my surgery, this was routine. It’s their job. Sometimes, I think, those who do it every day forget the true impact of surgery and its implications for the patient. My patients had expressed frustration with various hospital procedures and experiences to me and I have a new understanding of what they were talking about. I decided I needed to take charge and get some of my control back! So, I did.

Hysterectomy – The Saga: Part I

I have always considered myself to be very healthy. In fact, I have prided myself on staying fit, eating a healthy diet, and being as proactive as possible regarding my health. Of course, when, a few years ago at age 53, I started having vaginal bleeding AFTER going through menopause and my life was out of control, I managed to ignore what was going on. When it continued on and off for a couple of months and I caught myself chiding a patient for not letting me know about her intermittent post-menopausal bleeding, I realized I had a problem.

Even then, I was in total denial about anything being wrong with my “very fit” self. I called my doctor and arranged for a pelvic ultrasound. When the ultrasonographer gasped at the site of my ultrasound, I knew I was in trouble. I could see that there was a very large mass filling the space that used to be my very petite uterus. My heart sank. It was so bad that the ultrasound technician walked my ultrasound and me over to my doctor’s office and insisted that my doctor needed to see me right away. I have a doctor who is very calm. When she got upset, insisted on doing an endometrial biopsy and wanted to take out my uterus the next day, I freaked out. She said she didn’t think that I had cancer, but her eyes told me that she was worried.

I am a doctor, I am not supposed to get sick or have problems, right? I realized I had a health issue that I needed to take care of, and I knew it was time for my uterus to come out. I was no longer the doctor I was now the patient. All kinds of feelings were stirred up for me. I have two sons and they were both hatched in my uterus. Now this very important part of me was going to be removed. It is hard to describe, but I felt a deep sadness mixed with a sense of gratitude.. I got very nostalgic when I thought about the births of my children and what I was able to do with the help of the organ I was about to lose. I also was hit with a sense of humility. I realized how insensitive I had been to others who had lost theirs. So many of my patients have had hysterectomies and I dutifully recorded it in the past medical history section of their chart. I never thought about what it meant to so many of those women. Clearly, this was one of many learning experiences for me on this surgical journey.

STAY TUNED FOR PARTS II – V…

Should You Stop Exercising?

Yesterday at the gym, a woman I know asked me if she should stop exercising because of the recent article in Time Magazine.  She was actually kidding, but her question got me to thinking. 

Basically what the article says is that exercise does not help us to lose weight. That it’s the type and amount of food we eat while trying to lose weight that determines our success – not exercise. Well, duh!  It shouldn’t surprise any of us to learn that we can’t lose weight even with extensive amounts of exercise IF, at the same time, we eat anything we want.  What this article also says is that exercise in fact can stimulate appetite such that we become more hungry after being physically active and eat more than we normally would.

So, the overall impression from the article is that regular physical activity is not all it’s been cracked up to be. BUT, losing weight is not the only reason exercise is so heartily recommended by the medical profession. In fact, its other benefits are especially important for us as we age.  To remind you of those other benefits, here’s an article Robin and I wrote about a year ago, which is relevant today as it was then. After you read it, hopefully you will do 2 things: 1) Continue your regular exercise (or begin it!) and 2) Answer NO to anyone who asks you if they should stop exercising!

The Time Magazine article: http://www.time.com/time/health/article/0,8599,1914857,00.html

Our article:

The New Miracle Treatment for Women in Midlife and Beyond: A True Magic Bullet for Staying Healthy and Feeling Good

When you first saw the title of this article, you immediately thought it was hogwash, right?

You were a bit disappointed, too, because doctors are supposed to be honest, and discuss only the treatments that have been scientifically proven to work; and everyone knows that there is no such thing as a miracle treatment that keeps you healthy as you age. But, here’s the thing: we are telling you the truth.

First, let us tell you what this miracle treatment can do.  It can help you to retain your memory, and possibly even prevent dementia, or at least postpone it for years.  It can prevent you from falling, the most common cause of injuries to those of us who no longer even count the number of candles on our birthday cakes.  It can, in some cases, keep you from getting arthritis in your knees, and if you already have it, keep you up and moving.  It can keep your heart healthy, and if you already have heart disease, it can get you back to feeling great. It can prevent some cancers. If you have diabetes, or high blood pressure, or high cholesterol, it can, in some cases, make them go away, and at the very least, it may allow you to lower your dose of medication for each of these three.  It can help you to breathe easy. It can keep you buff and help your sex life. It can help you sleep better, may suppress your appetite, and even increase your metabolism. And it can improve your sense of wellbeing, keep your mood positive, and increase how long you live.  

We know you’re still doubtful because if such a thing really existed, it would be on TV constantly and all over the internet, and you would’ve probably bought a huge amount of stock in it.  But in fact, it not only exists, but all of the effects mentioned above of our miracle treatment have been scientifically proven!

Human beings were meant to move. Every aspect of our bodies’ functioning is geared toward that. On the flip side, movement and mobility are very important to the quality of life. What does this have to do with the miracle treatment? Easy — the miraculous new treatment for all our ills, particularly those accompanying the aging process, is movement.  Because of all the negative connotations, we won’t call it exercise or any of those other clinical-sounding names, like “workout” or “physical activity.”  

It really does all the things we said it can do. In fact, a recent study that followed more than 2500 people over the age of sixty for an average period of twelve years found that those who were fit from regular and adequate movement, whether they were overweight or not, had a significantly lower death rate at a young age than those who were not fit.

Several years ago, a very interesting study was done at the Cooper Institute in Dallas, Texas.  255 volunteers were divided into two groups. One group went to the gym regularly for a standard workout. The other group tried to integrate regular physical activities into their usual daily routines. They would walk up stairs instead of taking an elevator, clean their own houses and apartments, work in their own gardens; in other words, they took every opportunity to do the maximum physical activity with their daily activities.  After six months, both groups had improved their fitness levels, lowered their blood pressures, and lost fat.   But, after two years, only those in the group that had incorporated fitness into their routines were more likely to maintain their fitness level. Exercise lite worked and kept on working!

To receive the full health benefits as we mentioned above, you need to do at least 30 minutes of moderate to vigorous aerobic (cardio) exercise each day.  With exercise lite, you can break it down into 10-minute segments so that the cumulative time is still 30 minutes a day. If you only have a couple of 10 minute breaks a day, go walking for those breaks and then take a quick walk before or after work.  You want to shoot for 15-20 minute miles, and you want to get your pulse rate up but still be able to have a conversation.  If you garden, you need to do it while moving around a lot, in other words, active gardening. Same thing goes for housework. The vacuum can be your best workout buddy!  One easy way to do exercise lite is to wear a pedometer, a little meter you wear on your belt that records your steps. With the pedometer you want to aim for 10,000 steps a day.

Most important, make it fun and you’ll keep doing it.  Do things you like. Find a class that is fun or start riding your bicycle or swimming. Get some great music and use it for your activity. If you need support, grab your friends and family to do an activity with you.  And remember, don’t tell yourself that you are doing the dreaded “exercise”; fool yourself and have it become a normal part of your daily life.

Before starting any exercise program, check with your doctor!


©2008 Janet Horn, M.D. and Robin H. Miller, M.D.

Tanning Beds Officially Declared Deadly

Melanoma, a deadly form of skin cancer, is now the leading cancer diagnosed in British women in their 20’s.We know that in England it probably isn’t because of the intensity of the sun. Anyone who has watched a movie made in England or visited the country knows that sun exposure isn’t likely to cause much harm due to the fact that the sun doesn’t make an appearance very often. What is the cause is the use of tanning beds that is popular especially in those under 30 years of age.

A recent analysis of skin cancer found that the risk goes up by 75% when people start using tanning beds prior to that age. (The Lancet Oncology,Vol. 10 No. 8 pp 751-752) There is no question that tanning beds along with excessive sun exposure is a cause of cancer. Other comparable causes of death include cigarette smoking, exposure to mustard gas and arsenic.

Even now young people are reluctant to stop the risky behavior of going to tanning salons. They think they are invincible. Now that the tanning beds are being equated with things that we all know can be deadly, there seems to be a glimmer of hope that they might understand the risk. Young people who regularly use tanning beds are eight times more likely to get melanoma when compared to those who have never used them.

I think it is time to consider spray on tans. The quality is good and there is no risk. The price is well worth having healthy skin and decreasing the chance of developing melanoma. Share this information and advice with all the young people in your life it can save theirs.

Sexually Transmitted Infections – at our age?! 40th Anniversary of Woodstock – Part II

 In a recent article of the Journal of the American Geriatrics Society, researchers report that adults aged 50 and older account for increasing proportions of HIV/AIDS cases. Specifically, when the trends of people infected with HIV were studied in the state of New Jersey, it was found that in 1992, people aged 50 and older accounted for only 6% of the HIV/AIDS cases; in 2004, this had increased to 26%! The conclusion of the authors of this article states that health care providers need to routinely discuss HIV and other STI’s with this “older population” (that’s us) in order to be able to offer prevention or care earlier. And we all know that getting care early in any disease means a better long term prognosis, or a better chance for a cure.

In addition to the above infections, you could be at risk from a more recent sexual encounter of acquiring other of the STIs, such as Chlamydia or gonorrhea. Although infection with gonorrhea usually presents itself with a discharge from the vagina or urinary symptoms – as can Chlamydia – infection with Chlamydia can also remain silent. Also important to know is that you can become infected with gonorrhea even if you’ve had a hysterectomy; in this case, the major symptoms would be urinary and would include burning or frequency. Although these latter symptoms are usually due to a plain old run-of-the-mill urinary tract infection, if your urine cultures are negative and your clinician cannot find a reason for your symptoms, think back on any recent sexual activity.

So what can you do to protect yourself if you are newly dating after a divorce, or if you just realized that you don’t know your partner(s)’ sexual history?

1) Ask your gynecologist to test you for STI’s when you get your routine pelvic exam or sooner as the need dictates (ie you are having symptoms; or you have a new partner; or are thinking about a new partner). Diagnosis of STIs is easy: it simply involves extra samples taken from your cervix at the time of your Pap smear and blood tests.

2) Be open and honest with your partner(s) about this issue, and ask directly about their sexual history; if they have not been tested recently (or ever), ask them to get tested for STIs;

3) Use protection during sexual activity; although in recent years it has been found that unfortunately condoms do not protect 100% against getting infected, they do lessen the risk, as do vaginal/dental dams. Only latex and polyurethane condoms should be used.

For further information, go to the CDC’s website on STIs:

http://www.cdc.gov/std/default.htm

 

 

 

The 40th Anniversary of Woodstock: Remember “Free Love”?

All the talk about this August being the 40th anniversary of the famous Woodstock Music Festival got me thinking.

Do you remember those years? The invention and availability of “The Pill,” and the then-new practice of “free love” (remember, “Make Love, Not War?”) led directly to the sexual revolution for which our generation became famous.

What you maybe did not hear so much about was the increase in sexually transmitted infections (STIs) as a result of that revolution. Take genital herpes (HSV) infection for example. The levels of the total number of cases in the North American population increased by over 30% in the late 70’s, 80’s and 90’s. Similarly, data on first-time treatment-seekers for genital warts (caused by Human papillomavirus – HPV) show an increase (in their presenting for medical care) of about 500% over the past three decades.

What does that mean for us now? We came of age sexually at the same time that many of the STIs were increasing; therefore, there’s a good chance that we may have been exposed to one of these infections in the past thirty or so years that we’ve been sexually active. And since several of these infections can stay in the body indefinitely but cause no symptoms, there’s also a chance we might not even know that we’ve been infected.

Which of the STIs am I specifically referring to in the above paragraph? The so-called “persistent viruses,” which include herpes virus, Human papillomavirus (HPV), the viruses which cause hepatitis B and hepatitis C, and the Human immunodeficiency virus that causes AIDS. Exactly how long can these viruses remain in the body after you become infected with them? Forever. And how long can they remain “hidden” and cause no symptoms? The first four of the viruses listed above may never cause symptoms, or alternatively, can cause symptoms at any time after you’ve been infected. The HIV virus can remain silent and cause no symptoms for up to 10-15 years. In addition, you can become infected with syphilis and have no symptoms for several years as well.

Think about the import of that. It means that if you don’t know your current, or past, sexual partner’s (or partners’) sexual history, you could be at risk for having one of these infections and not knowing it. Even if you haven’t seen the person who gave it to you in 15 years! This is especially worrisome to those of us who are just beginning new relationships now, after a divorce or break-up.

If you don’t think any of this applies to you, please read a list of the known factors which put people at risk for acquiring an STI. These have been extensively studied and are well known.

They include:

1) young age (teens and twenties),
2) a history of being sexually active with multiple partners, and
3) a history of having had even one STI in the past.

Even though the first risk factor doesn’t apply to us now, the other two definitely do. Even if you have not had multiple partners, do you know the answers to the 2nd and 3rd risk factors about your current partner?

Or do you know if your partner(s) knows of past exposure to an STI but doesn’t know if he/she acquired it?

Scary thoughts – but very important to think about. In the next blog, I’ll give you specific recommendations about how to approach these issues.



 

The More Things Change, The More They Stay The Same – Part II

As a physician with conventional medical training, I often used to look at home remedies with skepticism. I have had several patients who have sworn that apple cider vinegar was good for whatever ailed them. Apple cider vinegar has been around for ages.Hippocrates used it to treat wounds; soldiers in the civil war used it for digestive problems and to prevent pneumonia and scurvy. Apparently Cleopatra used it to dissolve her pearls to make a love potion for Mark Antony.

Studies Showing Benefit

There have been recent studies done at the University of Arizona that have caused me to take a second look at apple cider vinegar. One study looked at 29 patients with either insulin resistance (prediabetes) or type 2 diabetes. They were given either a drink of vinegar, water and saccharine or placebo followed by a meal with 87 grams of carbohydrate. Compared to placebo, blood sugar decreased by 64% in the prediabetes group and 19% in the diabetes group.

Another study looked at weight loss in healthy women.The women were given a morning drink of vinegar or placebo followed by a bagel breakfast. Not only did the vinegar group have a 54% lower blood sugar one hour later, but they also consumed 11-16% fewer calories throughout the day.

Yet, another study found that taking a drink containing two tablespoons of apple cider vinegar along with eating one ounce of cheese before bedtime significantly lowered fasting blood sugars in the morning.

Some Cautions

There are potential safety and side effect issues. Obviously those allergic to apples need to avoid apple cider vinegar. Raw apple cider vinegar can contain bacteria, so it would be better to use the pasteurized form. Apple cider vinegar capsules can cause burning in the esophagus if they get lodged there. Apple cider vinegar can also irritate the stomach. There are potential drug interactions if a patient is taking digoxin, insulin or diuretics. Vinegar can lower potassium levels.

And…..

Of course, as with everything, moderation is the key. Taking a mixture of apple cider vinegar in juice or water in the morning may help with both blood sugar and weight control. It is important to discuss this with your doctor before you do it.

What’s the Story with Acetaminophen (Tylenol)?

You’ve probably heard or read recently that acetaminophen – the generic name for the pain reliever, Tylenol – is in the news a lot lately. A Food and Drug Administration (FDA) expert advisory panel recently came out with recommendations for the FDA to put restrictions on the use of this very commonly used drug.

Why now? Because after reviewing studies done between 1990 and 1998, this panel of experts came to the conclusion that acetaminophen is not as safe as previously thought.  Due to overdose of this medication, there were 56,000 emergency room visits, 26,000 hospitalizations, and 458 deaths ANNUALLY over the time period of the reviewed studies. The most common problems seen were that of liver damage, liver failure and even death.

The interesting aspect of these findings is that not only did massive doses above the recommended dosages lead to illness, but even normally recommended doses could do the same, especially in people who already have liver disease. From this data, the expert panel came to the conclusion that restricting acetaminophen, and lowering the maximum doses advised, would protect people from the potential toxicity of this drug.

Since acetaminophen is so readily available without a prescription ( over-the-counter; OTC), and is so widely recommended for pain relief  by healthcare professionals, it almost goes without saying that a majority of people use this drug routinely. In addition, it is known that many people do not pay attention to the recommended doses listed in the package insert or on the bottle, and routinely exceed the highest recommended dose per 24 hours.  Besides being the main ingredient in Tylenol, acetaminophen can also be found in Excedrin, aspirin-free Anacin, and wide variety of OTC cold medications.

In addition to the OTC medications, acetaminophen is found in many prescription combination pain relievers, such as Vicodin, Darvocet, and Percocet, to name a few. The amount of acetaminophen in most of these prescription combination drugs often exceeds the maximum dosage recommended  for a 24 hour period.

It will probably take the FDA many months to put restrictions on the amount of acetaminophen that can be found in OTC medications as well as prescription pain relievers. So, what should you do until then? Look at the label for the amount of acetaminophen contained in both the OTC medications you buy, as well as the prescription pain-relievers prescribed by your clinician. The FDA recommends that the highest one-time dose (two tablets) of acetaminophen for adults should be no more than  650 mg. That means that the individual tablet should contain no more than 325 mg of acetaminophen. FYI – currently two tablets of Tylenol contain 1000 mg of acetaminophen.

In addition, the currently recommended maximum recommended dosage for an adult for 24 hours is 4000 mg (4 grams). The FDA thinks that this amount should be lowered as well, and definitely should not be exceeded.

Let’s do some quick math here. Say you have a headache or your old tennis elbow pain has flared up. Although people are supposed to take only 2 tablets every 6 hours (which would reach 4000mg per day), many of my patients have told me that they take this amount every 3-4 hours; that comes to 6000 mg per day IF they only take 2 tablets of Tylenol, and some people even take 3. That’s obviously way above the highest dose recommended per day, and definitely can lead to toxicity from this drug. Also, be aware that your health care practitioner may change your longterm prescription pain reliever by ordering one in which the amount of acetaminophen is lower. The narcotic portion of your combination medication may well stay the same.

Until the FDA officially restricts acetaminophen in OTC and prescription medications, here’s what you should do: 1) Remember the maximum safe dosage per day of acetaminophen (4000mg;4 grams); 2) Remember the maximum safe dosage for a one time dose of acetaminophen (625mg); 3) Read all labels of OTC medications you buy to see how much acetaminophen is contained; 4) Discuss with your clinician if you should change your prescription medication for pain relief if acetaminophen is in it.

 

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