A Family Doctor's Tale - ASTHENIA

DOC I FEEL VERY TIRED

Asthenia is a sensation of weakness without the actual loss of strength.


There are 2 main causes of asthenia:


Psychological Asthenia:
Anxiety
Depression
sedentary lifestyle
Sleep disorders


Pathological Asthenia:
Anemia
Chronic fatigue syndrome
Dehydration and electrolyte disturbance
Diabetes
Fibromyalgia
Heart disease
Hypothyroidism
Infections
Narcotics
Paraneoplastic syndrome
Pulmonary disease
Renal disease
Chemotherapy

A Family Doctor's Tale - SUDDEN WEIGHT LOSS

DOC I HAVE SUDDEN WEIGHT LOSS

A sudden weight loss of 10kgm over 1 month is considered as abnormal unless the person is on a special weight loss regime. In the case of the sudden loss the most common causes must be considered before jumping to the diagnosis of possible cancer. The 5 most common causes of sudden weight loss are :
1. Diabetes
2. Gastritis or malabsorption
3. Hyperthyroidism
4. Tuberculosis
5. Stress
Also look for symptoms of thirst, frequent passage of urine, stomach discomfort, diarrhea, palpitations, trembling of hands and legs, chronic cough with night sweats and insomnia.
Exclude all these conditions first below looking for rarer conditions such as cancer.



Genetic factors

--------------------
Diabetes

Environmental factors
-----------------------------
Hyperthyroid
high metabolism -
Some people has a higher metabolic rate burn up more energy and hence loses weight
Stress is a factor


Gastritis or poor digestion


Pulmonary TB


Psychological factors
---------------------
Stress
burns up more energy
Anorexia nervosa
bulimia


Rare illnesses:
------------------
cancer


Loss of weight of 20 kgms in 1 month is serious

Health effects
------------------
weaker,
lethargy
tired

Emotional effects:
------------------

stress
depression



Diet:
-------------
Choose a  healthy diet with with reduce calories and which is nutritionally balanced
Take plenty of vegetables and fruits.
Eat more food which is high in fat and sugar

Medication:
------------------
look for and treat 
1.Diabetes
2.Hyperthyroid
3.Gastritis
4.Pulmonary Tuberculosis
5.Stress
6.Cancer

A Family Doctor's Tale - OBESITY

DOC I AM TOO FAT

Obesity is defined as having a weight 20% above the desirable weight which is having a BMI (Body Mass Index) of 22 or less.
It is a chronic medical condition where fat accumulates in the body due to excess calories.
Obesity is harmful to the person's health and well being.


Many factors contributes to obesity:


Genetic factors

Obesity runs in the family and is hereditary.
Family members who share the same diet and lifestyle may have the same overweight condition.


Environmental factors

The environment is an important factor in determining obesity.
1.Overeating -
many people have an increased craving for food. It has found that these people lack a hormone called serotonin in the brain which acts to decreased appetite.


2.low metabolism -
some people has a lower metabolic rate tends to accumulate the excess energy from food as fats in the body. Classic example is hypothyroidism where the low thyroid hormone reduce the capacity of the body to burn off energy so they become lethargic and fat.


3.lack of exercise -
Exercise helps to burn up calories. People who tend to have a sedentary life without exercise tends to be overweight


4.Certain medication:
some medications like corticosteroids, female hormones aand antidepressants tends to cause increased appetite and water retention and contributes to weight gain.


Psychological factors

Psychological factors may be the cause of tendency to overindulge in food.
Some people eats more out of boredom, sadness, or anger. Others overeat as a way of dealing with stress or depression.


Rare illnesses:

Some rare illnesses like hypothyroidism, Cushing's syndrome, depression, and certain neurological problems  can lead to overeating. These conditions are believed to be responsible for only about one percent of all obesity cases.


The most widely used method is the body mass index (BMI).
BMI is the gauge of the amount of body fat in adults.


BMI      =                    Your Weight (kg)            
                            ---------------------
                        Height (metres) x Height (metres)


The risk of developing heart disease and diabetes begins at BMI values of 23 kg/m2 and above.


BMI (kg/m2) (for adults)
 Risk of Heart Disease and Diabetes


27.5 and above
 High Risk


23.0 - 27.4
 Moderate Risk


18.5 - 22.9
 Low Risk (healthy range)
  
Less than 18.5
 Risk of nutritional deficiency diseases and osteoporosis


Knowing your BMI will motivate you to lower your weight.


Health hazards

Obesity is not just a cosmetic problem.
Many serious medical conditions are associated with it:

1.High blood pressure
2.High blood cholesterol
3.Diabetes
4.Coronary heart disease
5.Stroke
6.Gallbladder disease
7.Liver disease
8.Degenerative joint disease
9.Cancer (colon, uterine, breast and other cancers).
10.Gout,caused by high levels of uric acid in the blood from the high purine proteins consumed.
11.Sleep apnoea


Emotional effects:

1.Feelings of rejection, shame, or depression 
2.Feeling undesirable compared with a slim person.
3.Some face prejudice or discrimination.
4.Some may be seen as lazy or lacking in self-control.



Motivation:

Motivation is the key to weight control.
Knowing the dangers of obesity will help to motivate a person to lose weight.
Set realistic goals for losing weight eg. reduce 10% in 6 months
Gradually reduce weight and maintain it at a healthy weight.
Even if you fail to reach your targeted healthy weight, any reduction helps your health and prevents diseases associated with obesity.


Exercise:

Regular exercise daily, or at least three times a week is good for the body.
It helps to improve blood circulation and breathing.
Start with a regime of walking or cycling or swimming.
Slowly increase the level of activity to more intense physical exercise like jogging.
Lead an active lifestyle.


Diet:

Choose a  healthy diet with with reduce calories and which is nutritionally balanced
Take plenty of vegetables and fruits.
Eat less food which is high in fat and sugar
Low Fat and high carbohydrate diets may reduce the weight but may have long term bad effect on your health.


A combination of diet and exercise is more effective in reducing than either one alone.


Medication:

Two main types of medications are available to help control weight:
1.Appetite suppressants:
help promote weight loss by reducing appetite or increase the sensation of being full.
They increase serotonin or catecholamine - brain chemicals that affect mood and appetite.
They also help by increasing metabolism thus burning away the fat.
They may have limited effect on weight loss as the patient's weight loss level off after 4 to 6 months.
They have the side effects of irritability, insomnia, palpitations and tachycardia.
They should be avoided in heart disease, anxiety, insomnia.
They should be used for short term (6-12 months) as there is also a danger of dependency.


2.Fat absorption suppressant:
prevents the absorption of fats by interfering with the enzymes which dissolves the fat and absorbs the fat into the body.
Instead the fat is not absorbed into the body and passes out in the stools undigested.
The fat in the body is then used up to provide energy and production of hormones.  
Less fat is available for putting on weight.
They should be avoided in malabsorption syndrome, liver disease or pregnancy.
The side effects of these medicines are usually diarrhea due to the fat passed out in the stools.
They can be taken for a longer peroid of 2 years.


Surgery:

Surgical treatment may be required for the severely obese (those with a BMI of 40 or greater) or with other health problems).
Surgery should be used only drug therapy, diet, exercise have failed.
Minor surgery may involve liposuction (sucking out the fats in the abdominal wall,under the chin, buttocks and other obvious parts of the body.
Lapband surgery is done for the very obese when other methods have failed and there is a risk of obesity related disease. A band is placed over the middle of the stomach making it narrow and not capable of taking much food. Surgery has some complications such as infections.


Many studies showed that most people will regain weight within 5 years.
You can maintain your weight by
1.eating a low calorie diet, low in fats
2.maintaining a healthy exercise regime
3.maintaining motivation and self esteem
4.monitoring your weight food intake and exercise

A Family Doctor's Tale - GYNECOMASTIA

DOC I HAVE A LUMP IN MY MALE BREAST AREA

My own brother has unilateral gynecomastia at the age of 18 years probably from eating chicken injected with female hormones. He was operated and had the excess breast tissue removed without any complications.
Recently one of my patient was given Aldactone or spironactone for 3 months by a heart specialist. He developed swelling and pain on the right breast area. I reassured him and told him that it was due to the medicine.He was worried that there may be cancer of the breast.

Gynecomastia is unilateral or bilateral enlargement in the glandular tissue of the breast in males.


The causes of gynecomastia is not completely clear.
It is believed to be caused by an imbalance of sex hormones especially during puberty.


A.Hormonal:

1.In  male babies the painless swelling of the breast may occur due to the effects of the mother's female hormones.The swelling usually subsides after a few weeks.


2.At Puberty for boys the development of breasts is due to the increased ratio of free estrogen to free testosterone. 
In most cases the breasts may disappear after 1 year.


3.Some cases of Gynecomastia may be due to ingestion of female hormones injected into chicken and ducks


B.Genetic

Some cases of  male hypogonadism causing reduced testosterone.


C.Liver cirrhosis

Failure of metabolism of circulating estrogen can increase the female hormones in the adults and cause Gynecomastia


D.Medications:

a.Spironolactone
b.digoxin
c.cimetidine
d.maxolon


E.Tumors

Testicular or Pituitary Tumors may cause increased estrogen and reduced testosterone and hence increase the production of breasts.


The Symptoms of Gynecomastia are:

1.Pain usually present in all cases except in babies


2.swelling of the breasts or the nipple area in males


Signs:

1.redness of the breast


2.swelling of the breast tissue


3.Local tenderness of swollen area


Diagnosis is based on:
1. clinical features


2. Endocrine blood tests including HCG levels


3. Liver function tests


4.Ultrasound scan of the breasts


Treatment is by:
1.treating the underlying cause


2.Medications causing Gynecomastia should be stopped.


3.cosmetic surgery-liposuction, gland excision, reduction mammoplasty,


4.Tamoxifen if necessary


5.Radiation therapy may prevent gynecomastia in patients with prostate cancer prior to estrogen therapy.


Most cases has good prognosis.


Adolescent cases may regress spontaneously.

A Family Doctor's Tale - MASTITIS

DOC I HAVE A BREAST INFECTION
Mastitis or inflammation of the breasts are commonly seen at puberty or in breast feeding mothers.
Engorged breasts during breast feeding are quite common and be treated easily with antibiotics and proper expression of milk. The mastitis of puberty are usually transient and most adolescents will adjust to the enlargement of the breasts.

Mastitis is inflammation or infection of the breasts, resulting in pain and swelling.


The causes of Mastitis are mostly due:

A.Hormonal:

1.In babies whether male or female, the painless swelling of the breast may occur due to the effects of the mother's female hormones.The swelling usually subsides after a few weeks.


2.At Puberty for girls the development of breasts may cause some pain and swelling. 
It may occur first on one side and then subsequently on the side.
The nipples may be red and tender and this may cause worry for the adolescent girl and her mother.


3.Premenstrual pain and swelling of breasts may occur


B.Infections:

Infections of the breasts may occur due to
1.poor skin hygiene


2.Injuries or wounds allowing micro-organism to enter the wound


3.Breastfeeding as a result of the baby sucking the nipple incorrectly or as a result of blockage of the milk ducts. 
In either case bacteria can enter through the injured nipple or the inflammation of the blocked milk ducts may cause suppuration and abscess formation.


4.Mastitis may occur as a rare complication of mumps.


5.Most common bacteria infection is staphyloccus aures.


6.Other rare causes of mastitis are tuberculosis, syphilis or actinomycosis


The Symptoms of Mastitis are:

1.Pain usually present in all cases except in babies


2.swelling of the breasts or the nipple area


3.Pus discharge from the nipple


Signs:

1.redness of the nipple or areola


2.red, warm swelling of the breast tissue may indicate presence of formation of abscess.


3.Local tenderness of inflamed area


4.Fever and general malaise


5.Axillary lymph nodes may be swollen and painful


Complications are:
1.Abscess formation


2.Cystic formation


3.Chronic mastitis or fibroadenosis


Diagnosis is by :
1. clinical features of mastitis


2. Mammograms to exclude malignant tumors


3. Ultrasound scan of the breasts


Treatment is by:
1. antibiotics are given to cure the infections.
The antibiotics may need to be taken for 10 days by mouth.
They must not be stopped just because the discomfort stops, or the infection will NOT be cured.


2. Painkillers may be given if there is pain


3.Rest and support of the breasts with soft bras


4.Warm water bottle to apply to areas of inflammation due to blocked milk to soften the milk and induce flow.


5. surgery with drainage of abscess if antibiotic do not work.
Aspiration of cysts may also be necessary


6.Reassurance in hormonal cases of mastitis


Most cases of mastitis usually will recover with proper treatment.


Practice good personal and skin hygiene
Wash hands frequently
Clean the beasts properly before and after breastfeeding
Patients should be taught to do breast self examination and to do it frequently

A Family Doctor's Tale - MENOPAUSE

DOC MY MENSES HAVE STOPPED COMPLETELY

Menopause is a change of life in most women occurring between 45 to 55 years of age. Every woman will experience menopause. Some will welcome it as it means less worries about having pregnancies or others may feel discomfort, depression and uncomfortable symptoms of menopause such as flushing, irritability and signs of aging as a result of the lower female hormones. Since menopause is inevitable, all women should try to adjust to it either by themselves and their families or with the help of doctors and psychologists.

Menopause is the cessation of menstruation occurring in women between the ages of 45 and 55 years. 
It is important to stress that it is NOT an illness but a natural event. The age that menopause occur may vary with different women.



Natural Menopause

From puberty a woman starts releasing eggs from their ovaries. Both the ovaries and eggs produces female hormones. 
These hormones thickens lining of the womb in preparation for a pregnancy.If the pregnancy does not occur, the lining of the womb is shed off as blood and cells(menses).
As the woman grows older, less eggs are produced resulting in reduced production of the female hormones. This causes the menstrual periods to be less or more than usual. When no more eggs are produced, the amount of the hormones produced are not enough to cause the lining of the womb to thicken.As a result menstruation will stop.


Menopause is said to be established when the woman does not have any menstruation for one year.


Premature Menopause

Premature menopause occurs when the menses stop in a woman before the age of 40 yrs. 
Causes of premature menopause are surgery to remove the womb or ovaries in the case of cancer, chemotherapy and radiotherapy. 
Without the protective effect of estrogen,  these women will have a higher chance of having osteoporosis and heart disease later in life .

Women who smokes usually have menopause 2 years earlier than non-smokers.


Most women do not have any symptoms except for the loss of their monthly periods.


In the others, the change in female hormones may cause the following symptoms:
1.Irregular menstrual patterns - usually the menses can become lighter or further apart. One or two periods may be missed.


2.Hot flushes -sudden feeling of heat starting from the chest to the face. There may be associated sweating, fast heart beats, fainting and insomnia.
The exact cause is not known and may be due to vasomotor disturbances related to the fluctuating hormone levels. 
It usually improve after 1-2 years.


3.Vaginal tract changes - With menopause, the walls of the vagina become thinner, dryer because of less secretions, and more prone to infection. Because of these changes, sexual intercourse may be uncomfortable or painful.


3.Incontinence - With age and onset of menopause, the muscles around the bladder opening may  weaken, leading to leakage of urine with straining or coughing  (incontinence).
Muscles of pelvic floor loses tone with possible prolapse of uterus.


4.Breasts tissues may  become atrophied with decrease in size of the nipples. The breast may become more pendulous.


5.Skin may be less smooth and wrinkles may appear. 
Hair may also become thinner and drier.


6.Mood and memory: irritability, anxiety, depression, insomnia (difficulty in sleeping), poor concentration and poor memory may be due to the lowered female hormones or psychological due to change in the body, skin and appearance.


7.Osteoporosis:
The bones may become brittle, fragile and fracture easily after menopause because estrogen is important in maintaining bone mass.  Hormone replacement may be able to reduce the bone loss and prevent osteoporosis.


8.Cancer:
Menopause itself does not cause an increased risk of women cancer. It is rather the age group that they are in which may increase the risk of cancer.


9.Heart disease and stroke
After menopause, women are more likely to get hypertension or high blood cholesterol which increases the risk of a heart attack and stroke.


10.Metabolic disease
Again after menopause some women tend to burn less energy and gain weight.
Decrease metabolism leads to accumulation of sugars which can increase the risk of Diabetes


In most cases of menopause, no treatment is necessary as it is a normal physiological event.
It is important that there is reassurance and psychological support from family and friends.
Menopause may mean the end of fertility but it also means the freedom from all the discomfort and inconvenience of monthly menstruation and fear of pregnancy.


Hormone replacement therapy used to be the best solution for all the symptoms and problems of menopause at one time. They help to prevent heart disease and osteoporosis as well as to reduce the symptoms of menopause such as hot flushes, skin , breast and vaginal changes.
Estrogen and progesterone are the two types of female hormones prescribed for and after menopause. A combination of the two hormones is taken, as progesterone helps to protect the uterus from endometrial cancer. If the woman have had removal of the womb, she will normally be given only estrogen.


HRT comes in the form of pills, patches, implants or vaginal creams to replace the level of sex hormones in your body. There are both benefits and risks to the use of HRT:


Benefits Risks
Relieves hot flashes and vaginal dryness.
Prevents osteoporosis and protects against fractures of the wrist, spine and hip.
Indirectly improves some emotional symptoms by relieving the physical discomfort of menopause.
 Safe for short term use. May increase risk for breast cancer for long term users (more than 5 years).
May cause PMS (Pre-Menstrual Syndrome) symptoms such as bloating or irritability.
May have side effects such as vaginal bleeding, nausea, hair loss and headaches.


Hormone replacement therapy has however recently fell out of favor due to new study which indicate higher incidence of breast and womb cancer.


For premature menopause where symptoms of menopause are more obvious due to their age, hormone replacement therapy is still given at intervals of 6 to 12 months.


The current treatment for the symptoms of menopause in the older women are:
1. A healthy life style.
Exercise
Regular exercise strengthen the muscles and bone.
Exercise also burns up calories to reduce obesity and hence prevent diabetes, hypertension and heart disease.
Walking is one of the best weight-bearing exercises to prevent osteoporosis. Swimming and dancing are also good exercises.


Eat a balanced diet
A good balanced diet helps to prevent obesity, diabetes, osteoporosis, heart disease and colorectal cancer.
More fruit and vegetables will help reduce calories and prevent colorectal cancer.
Foods rich in calcium and Vitamin D such as fish, low fat high calcium milk can prevent osteoporosis.
Alcohol, coffee, tea, canned drinks should be avoided.
Less sugar, salt and saturated fats will reduce the risk of diabetes,hypertension and heart disease.


Control Stress
Meditation, yoga, deep breathing exercises and sufficient sleep reduces stress and heart disease.
Community service work, hobbies, time with family take the mind off work and stress.


Stay smoke-free
The risk of heart disease, lung and cervical cancer can be reduced by not smoking.


2.hot flushes:
Cool showers and cool temperatures may help to reduce hot flushes.
Hot beverages and spicy foods should be avoided.
Thin cotton clothes is more comfortable.
Drinking a glass of cold water, loosening any tight clothing and using a small fan to cool down can stop the beginning of a hot flush.
Soy products like tofu and soya bean burns up less calories.
Meditation and mild exercise may also help by reducing stress.
hormone replacement therapy (mainly estrogen) for a short period may be used as a last resort.


3.vaginal changes 
Water-soluble vaginal lubricants can reduce dryness.
Estrogen replacement creams may be prescribed to reduce the vaginal discomfort.


4.incontinence:
Doing simple pelvic floor exercises will strengthen the muscles surrounding the sphincter of the bladder opening.
Wearing a pad in the underwear may reduce the discomfort due to leaks.
Injection of collagen sometimes worked to tighten the sphincter of the bladder opening.
Surgery to tighten the muscles of the bladder opening may be used as a last resort.


5.mood changes:
Many women going through menopause may become irritable,anxious or depressed.
Avoid stress and depression by learning how to relax and make time for yourself. 
Exercise can help increase your energy level and improve your mood. It is also good for your health!
Take up a hobby or do some volunteer work that you enjoy.
Build up a good support system by nurturing relationships with your family and friends. Talking to friends or a professional counsellor can help you to manage your emotions. It is good to let your family know what you are going through so that they can understand and provide support. Ask other women how they cope with the changes you are going through.
There is a menopause support group in Singapore that you can contact.


If you are concerned about osteoporosis, you should discuss it with your doctor. To minimize your risk, you should have a diet with adequate calcium and maintain an active lifestyle.


Women who are at higher risk are those who
are fair-skinned (white or Chinese)
are thin and small-built
had early menopause or have ovaries removed
have a family history of osteoporosis
have a diet low in calcium and Vitamin D
drink coffee, tea or alcohol regularly
smoke
are not physically active
are on steroids for long term (E.g. asthmatics)
have certain disease such as an overactive thyroid gland


Breast Cancer
Breast Cancer is the most common cancer among women. It is most common in women in their 50s. Early detection and treatment gives the best chance of a cure. Please do monthly breast self examination. Have a mammography once a year in your 40s and once every two years after age 50. If you suspect you have a lump, consult your doctor.



Cervical Cancer
Cervical cancer is the fourth most common cancer among women in Singapore. It can be prevented through regular Pap smear tests. Pap smears can detect precancer so that simple treatment will prevent the development of full blown cancer.


Regular check-ups
Blood sugar test once every 3 years to detect diabetes early if you are not at risk. Early management can prevent complications such as heart disease and stroke.
Check your blood pressure yearly and blood cholesterol once every 3 years to monitor risk for heart disease and stroke.
Pap smear tests for cervical cancer once every 3 years from age 25 to 65 years if you have had sexual intercourse before. If at age 65, previous smear tests were normal, you can stop your screening for cervical cancer.
Do monthly breast examination. Have a screening mammogram once a year if you are in your 40s, and once every 2 years if you are 50 years and older.



Stay active and be confident about the future. Take care of your health and personal appearance so that you both look and feel good.



Hormone replacement therapy is a treatment that replaces the hormones your ovaries stop making at menopause.



Your decision on HRT need not be permanent - you can always change your mind. Discuss your needs with your doctor to decide what's best for you. Make a decision based on your family medical history and weigh the benefits against the risks.



A New Chapter
Although menopause marks the end of fertility, it is NOT the end of health, attractiveness, or a satisfying and enjoyable life. For many women, menopause means freedom from the inconvenience and discomfort of monthly periods. 
Menopause is a turning point which can lead to the best years of your life.


Every Woman Goes Through Menopause
Every woman's experience with menopause is different. It is important to be informed about menopause so that you know what to expect.


Some women may welcome the cessation of periods, while others may feel a sense of loss that their childbearing ability is gone. By understanding the physical and emotional changes during this period of time, you may be more able to cope with life in the golden years.


The average woman now has a life expectancy of 80 years. This means that the average woman will live more than one-third of her life after menopause!


Because of longer life expectancy, women will also experience age-related health problems.
Heart Disease and Stroke:
Heart disease and strokes are more common in men but when a woman reaches menopause, the incidence of these diseases is similar to that in men. It is important to remember that the fundamental way to a healthy heart is a healthy lifestyle.


Hence it is important to have regular exercise, maintain your weight and have a healthy diet low in fat and sugar.
It is still not clear whether depression or mood swings during menopause are a direct result of the changing hormonal levels. It is possible that other changes in mid-life may contribute to the mood swings or depression. This is usually the time when women retire or have more difficulty finding a job and become financially dependent. For others, their children may leave home because of studies, work or marriage and they may suffer the "empty nest syndrome". They may also have to bear the responsibility of looking after their aged or sick parents. Sometimes the hot flashes can disrupt sleep and cause fatigue and irritability. If you feel depressed, do not hesitate to speak to your doctor. You may benefit from hormone replacement or anti-depressants.


There are other ways to cope with this difficult time.

A Family Doctor's Tale - FIBROID

DOC I HAVE A FIBROID

All women have fibroids some small some bigger. In fact fibroid is very common especially after menopause. The fibroid is believed to be thickened muscle tissue in the uterus or womb. Most of the patient with fibroid do not show any symptoms but those with complications may have severe bleeding or pain. Always send the patient with heavy menstrual bleeding for a comprehensive gynecological examination.


Uterine Fibroids are benign tumors(non-cancerous) of the smooth muscles of the uterine cavity.
They are the commonest tumor found in women(25%) especially after the age of 35.


They are classified according to their location.

1.intramurally(inside the cavity of the uterus(70%)
2.extramurally(outside the cavity of the uterus) on the external wall(20%)
3.Submucous (in the lining of the uterus) 10%
4.subserous(below the lining of the uterus)
5.pendunculated subserous(like a polyp inside the uterus)
6.cervical(at the cervix or beginning of the uterus)


The cause of Uterine Fibroids is still not known.
Generally it is believed that during the thickening and shedding of the endometrium of the menstrual cycle, some uterine muscles and connective tissues overgrow and form a swelling in the wall of the uterus without encapsulation.
Fibroids are generally relatively avascular and may degenerate forming cysts and becoming calcified.


Most women with fibroid are asymptomatic.
Symptoms and signs varies with the size and location of the fibroid.


Common symptoms include:

Heavy menstrual flow sometimes with blood clots
Irregular menstrual periods
Painful menses
Backache
Pain with exercise
Painful and frequent urination
Bloating
Constipation
Fatigue


Signs:
Enlarged uterine mass on abdominal palpation
Anaemia and pallor due to blood loss


Pelvic examination may show enlarged uterine swellings
Ultrasound scan showed presence of fibroid.
Colposcopy may show the location of the fibroid.


Complications are:
sarcoma formation (a type of cancer)
degeneration
necrobiosis
cystic degeneration
torsion of pendunculated fibroid(fibroid on a stem)


If small no treatment is required.
If larger,then treatment depends on the size, extent of the lesions, age of the patient and the desire for pregnancy.


Myomectomy(removal of the fibroid only)
hysterectomy(removal of the womb)
special treatment during pregnancy
correction of anemia

A Family Doctor's Tale - ENDOMETRIOSIS

DOC I HAVE ENDOMETRIOSIS

Endometriosis is not uncommon in Singapore women. Many cases of severe abdominal menstrual cramps are often found to be caused by endometriosis. In patients with menses cramps it is always advisable for them to go for a complete gynecological examination to determine the cause so a referral to a gynecologist is always a must.

Endometriosis is a disorder of the endometrial tissues (which line a woman's uterus )in which these tissues are implanted in places outside the uterus, usually in other parts of the pelvic cavity and abdomen.


 However, in women with Endometriosis, blood from the implanted endometrial tissue is trapped inside, becomes inflamed, and develops into scar tissue. Because of this inflammation, severe pain, infertility and bowel problems occur.




The cause of endometriosis is still not known.
There are a few theories:
1.during menstruation, some of the menstrual tissue is pushed back through the fallopian tubes into the abdomen where it implants and grows. 
2.it may be due to a genetic process
3.certain families are predisposed to endometriosis:
Higher socioeconomic groups
women who marry late and have no or few children
4.Stress may constrict the opening of the uterus .
Some endometrial tissues are pushed backward into the abdominal cavity instead of through the opening of the uterus


Endometriosis occurs usually years after the periods begin.
Symptoms may worsen as the endometrial area increases in size.
However after menopause, the implanted tissue shrinks away and the symptoms subside. 

Common symptoms include:

Severe menstrual cramps
Pelvic pain apart from menstrual periods
Diarrhea or painful bowel movements during menses
Menstrual irregularities
Menorrhagia
Painful intercourse
Backache
Pain with exercise
Painful pelvic exams
Painful and frequent urination
Bloating
Constipation
Fatigue


A diagnosis can only be made via laparoscopy. 
A laparoscope is a tube with a light in it which is inserted through a small incision in the navel area. The  misplaced endometrial tissue can then be found and the location, extent and size of the endometriosis detected.


There is no cure for endometriosis.
If the symptoms are mild, only medication for pain is required.
Treatment depends on the size, extent of the lesions, age of the patient and the desire for pregnancy.


If these women want to be pregnant, the best course of action is to have a trial period of unprotected intercourse for 6 months to 1 year. 

Once pregnancy occur, the endometriosis will clear by itself because there is no menses for nine months. 

Whether the endometriosis will recur after delivery depends on the patient. Most patients do not have a recurrence.


If the patient is not seeking pregnancy and where specific treatment of the endometriosis is required, hormone suppression treatment may be tried. 
This prevents ovulation and less endometrial tissue is formed. Because of this the endometriosis may reduced resulting in less symptoms. A course of treatment may last 6 months.


Where hormone suppression therapy do not work, some patients may require surgical treatment to remove the endometriosis tissue in the abdomen.

 In severe cases, where the uterus and ovaries are affected, removal by surgery of the uterus and/or ovaries is required especially in those nearing menopause or who do not wish to be pregnant.

A Family Doctor's Tale - DIABETES MELLITUS

DOC I HAVE DIABETES


Of all the chronic diseases such as hypertension, heart disease, high cholesterol, diabetes is probably the hardest disease to control because it is very dependent on the patient's ability to control his or her diet, A simple food indulgence may cause the blood sugar level to go up very high and the diabetes to become uncontrolled with consequence to his or her kidney, skin problems or gangrene of his lower limbs. When I have patients with multiple diseases like hypertension, diabetes and high cholesterol, it is usually the diabetes which are not well controlled. You will have to instil discipline in the patient to control their diet.


Diabetes mellitus literally means sweet urine. 
It is a common chronic disease which happens when the hormone insulin produced by the pancreas is missing, lacking or not working well.
Insulin unlocks the cell to allow glucose from the bloodstream to enter the body cells for usage or storage. When this mechanism fail, the high amount of glucose in the blood leads to the glucose being spilled over into the urine, causing diabetes.


The main types of diabetes are
1.Type 1
2.Type 2.


Type 1 occurs commonly in children and young adults although it may occur at any age.
It is more serious because there is practically no insulin produced due to damaged pancreatic cells and therefore insulin injections is needed for treatment.
The cause is unknown. 
Complications are more sudden and life-threatening.


Type 2 is more common. 
It is found in
1.adults over 40 years old, 
2.overweight and
3.physically inactive.
The insulin produced is not enough or may not be working effectively.
Type 2 diabetes can be controlled by proper dieting and exercise.
Most Type 2 diabetics will also need oral medication.


Gestational diabetes occurs only in pregnancy but may be an indicator of diabetes later in life


Diabetes is more likely to occur if you have:
1.Obesity (body mass index > 23)
2.family history of diabetes
3.hypertension (>140/90 mmHg)
4.previous gestational diabetes
5.Coronary heart disease
6.polycystic ovary disease
7.Hyperlipidemia(high blood cholesterol of 4.17 mmol or 200mg/dl and tryglycerides of 200)
8.Inadequate regular exercise
9.age above 40 years,more common in males than females
10.smoking habit


The following symptoms are typical of diabetes:

1.frequent thirst even after drinking lots of water
2.passing more frequent urine during day and night
3.weight loss while having good appetite
4.constant tiredness
5.poor healing of skin wounds
6.itchy skin particularly around the genital area
7.constant hunger
8.blurred vision


Note that some diabetics may not experience any symptoms at all.


Diagnosis is confirmed if:
1.Random blood glucose (anytime) is 11.1mmol/l or higher
2.Fasting blood glucose (after 8 hours of overnight fast) is 7.0mmol/l or higher.
3.Oral 75g Glucose Tolerance Test show presence of diabetes


The high blood glucose concentration in diabetes reduces the blood flow to many organs and nerves resulting in many organ damage especially the kidney, heart, brain, eyes and nerves.
The high blood glucose allows germs to proliferate because the glucose provides nutrition to the germs.
All these lead to many serious complications:
1.high blood pressure,
2.heart attack,
3.stroke,
4.kidney failure,
5.blindness, 
6.impotence,
7.numbness of hands and feet,
8.infections with poor healing,
9.wounds on feet that do not heal
10.coma,


Control of Diabetes

Diabetes is a chronic disease which cannot be cured.
It can be controlled to prevent the development of the above serious complications by :
Living a healthy lifestyle

1.diet -
reduce your intake of sugar and sweet food
Increase intake of more high fiber and wholegrain food like brown rice, wholemeal bread and oats
Take food with less fat content like lean meat,fish,skinless poultry and low fat milk
Have at least 2 servings of vegetables and 2 servings of fruits a day
Use healthier methods of cooking such as grilling and steaming rather than deep frying and use less salt and sauces
Take multiple (4-6) small meals a day that contains enough complex carbohydrates (e.g. rice), some lean meat or fish and vegetables.
Have regular meals and avoid skipping meals
Do not overeat


2.regular exercise-
this helps your body to use glucose more efficiently
Frequency: 3-5 days per week(daily if low intensity)
intensity: 60-85% of maximum heart rate till the patient feels warm or sweats and breathes deeply but easily
Time: 20-60 mins each time
Type: aerobic exercises like walking, jogging, swimming, cycling


For those who have not been active for some time start with walking first, then increase to more active exercises


3.weight control -
lose extra body weight by proper dieting and exercise
Aim for half kg loss per week
Aim for a BMI of 18.5-22.9kg/m2
Insulin works better in a lean healthy body.


4.Avoid smoking-
smoking increases all the risks associated with diabetes


5.Avoid stress by meditation, yoga, deep breathing exercises


Medication

1.oral tablets:
a. Insulin secretagogues - drugs that increase insulin release from pancreas
eg. glibenclamide, repaglinide
Side effects: low blood sugar


b.Insulin sensitizers- drugs that make insulin work better especially in muscles and liver
eg.metformin
side effects:gastric discomfort, metallic taste in mouth
eg. rosiglitazone
side effect:water retention


c. Alpha-glucosidase blocker -slows digestion of carbohydrates in the intestine
eg. acarbose
side effect: stomach discomfort,bloating,diarrhea


If the oral medicines even in combination cannot bring down the blood sugar, the insulin injection may be required either alone or together with oral medication.


2.insulin injections as prescribed by your doctor.
Insulin is destroyed in the stomach so it has to be given as an injection.
Best place to inject the insulin is in the abdominal area where the is a lot of subcutaneous fat.
Avoid 2 fingers around the navel and below the rib cage which is rich in nerve supply and therefore more painful.
Injection is usually done in the morning and evening.
Night injection controls the glucose when the patient sleep and avoid early morning high glucose.


a.Rapid and short acting insulin
eg. regular soluble insulin
onset 30-60min, peak 2-4 hrs, duration 6-8 hrs


b.intermediate and long acting insulin
eg. NPH insulin
onset 1-4 hrs,peak 8-12 hrs, duration 12-20hr


c.premixed or biphasic insulin
eg. NPH/regular 70/30
more convenient and less injections


Important hygiene tips:
use needles once only
mix well by shaking bottle or injection pen 20 times
store all unused insulin in fridge(will keep until expiry date). Do not freeze insulin.
Insulin in use can be kept at room temperature away from sunlight and direct heat and must be discarded 4-6 weeks after use


Follow the instructions very carefully and keep detailed records of your treatment.


If you can, monitor your progress with the help of your daily home blood glucose records.
Monitor;
a.before and after meals
b.before and after exercise
c. when feeling giddy to confirm low blood glucose
d. when sick and not eating well
e.Type 1 diabetes should be monitor 3-4 times a day
f. Type 2 non-insulin diabetes 1-2 times a day  followed by 1 every 2-3 days
g. Type 2 insulin diabetes 2-3 times a day followed by 2-3 days a week.
h. pregnant patient should also monitor their blood glucose daily


Aim for a Fasting Blood glucose 4.0 -7.0mmol/l
          Blood HbA1c 4.5 -7.0


This will check if your diabetes is under control.
If not, you need more medicines or further change in diet.


Reducing high blood and high cholesterol help to keep diabetes under control and protect against its complications.
Aim for a blood pressure of 130/80 or less
          LDL cholesterol of 2.6mmol/l     


Regular checkups are essential:

1. Regular monthly checkups for diabetes.
2. Check for hypertension and heart disease  at the same time
3. Check for high blood cholesterol once a year.
4. Check eyes once a year.
5. Check for kidney problems at least once a year.
6. Check teeth once a year
7. Check you feet for signs of infection, gangrene and neuropathy.


Foot care is particularly important in diabetes::

1. wash feet daily with soap and water
2. After washing ,dry thoroughly especially between the toes
3. keep your toe nails short,trimming them straight across to avoid ingrowing toenails
4. moisturize feet daily to prevent dryness and cracking of skin
5. examine feet daily for scratches, cuts, blisters and corn
6. use a mirror to check the sole of your feet
7. wear shoes that fit well and wear clean cotton socks which has loose fitting elastic tops
8.Avoid going barefoot
9.Seek prompt treatment for cuts and sores
10.annual review for foot ulcers,risk of neuropathy (poor sensation), blood circulation( palpable pulses)   

A Family Doctor's Tale - STROKE

DOC I HAVE A STROKE

Strokes are very common in elderly patients especially those with heart conditions, high blood pressure and diabetes. Because most of them have difficulty in movement of their limbs they may need care givers to look after them.
The problem is worse in patients with dysphasia -difficulty in talking and understanding as it is more difficult to get them to do what the care giver wants them to do or cooperates with them.

A stroke is known also  known as a cerebrovascular accident(CVA). It happens when the blood vessel to a part of the brain is blocked(due to a blood clot) or burst.The brain cells in that part cannot get the oxygen and nutrients so they are damaged and unable to function.


A stroke occurs when:


1.there is a blockage of an artery in the brain by a blood clot, piece of fat or air bubble traveling in the blood from another part of the body. This leads to lack of supply of oxygen and nutrients to the brain cells. As a result the brain cells died leading to loss of function of the  part of the body controlled by the brain cells.
     
2.there is rupture of an artery in the brain leading to internal bleeding and damage to the brain cells. This can be caused by high blood pressure, head injury or a weak artery wall from birth (aneurym).


3.there is compression by a brain tumor or tightening of the artery wall.


Causes of Stroke are:
1.High Blood pressure-
 Hypertension damages the arteries of the brain by causing bleeding or blockage
2.High cholesterol-
Cholesterol deposit thickens the walls of the arteries, making them narrow and reducing blood flow.
3.Diabetes mellitus
The high blood sugar level thickens the arteries hard and make the blood thick so that less blood is able to flow through them.
4.Heart disease
People with heart disease are more like to have poor blood flow to the brain. Some heart disease like atrial fibrillation can throw out blood clots which can block the blood supply of the brain
5.Obesity
A BMI of 23.0kg/m² and above increases the risk of getting high blood pressure, diabetes and stroke.
6.Smoking
Tobacco smoke narrows arteries and reduces oxygen supply to the brain.
7.Drinking of Alcohol
Alcohol can cause liver and kidney damage. increase blood pressure and affect diabetes
8.Cerebral aneurysm, tumor,cancer metastasis,
These can cause blockage and bleeding in the arteries of the brain
9.Trauma or surgery of the brain
These can cause bleeding or form blood clots in the arteries of the brain
10.Stress
Repeated stress, if poorly controlled, can lead to high blood pressure.


TIA or Transient Ischemic Attack:
It is a early warning sign of a stroke
TIA occurs when blood supply to a part of the brain is temporarily cut off causing slight damage to the brain cell.
It may last seconds to up to 24 hours.
The symptoms of a TIA are often vague and temporary:

1.temporary numbness or weakness occurring suddenly in one arm or leg or on one side of the face
2.temporary difficulty in speaking or slurring of speech
3.sudden difficulty in seeing or 'blackout' in one eye
4.temporary dizziness or fainting or loss of balance
5.Temporary confusion,poor coordination or understanding
6.unexplained headaches or a change in the usual headache pattern


Early treatment of a TIA can help prevent a stroke from occurring in the future.


Symptoms of Stroke:
1.sudden  numbness or weakness, usually on one side of the body,often with loss of feeling
2.difficulty in speaking or understanding
3.difficulty in swallowing
4.loss of concentration and memory
5.sudden difficulty walking
6.loss of control of passing urine or passing motion
7.behavior changes such as laughing or crying at the wrong time, feeling depressed or showing bad temper.
8.sudden severe giddiness, loss of balance and coordination
9.sudden severe headache with no known cause
10.sudden vision loss in one eye


Stroke is an EMERGENCY.
Purpose of treatment is to:
1. preserve life
2. limit the amount of brain damage
3. lessen the extent of disability and deformity
4. prevent recurrence.


Admission to hospital is necessary to determine
1. the cause of the stroke
2. the extent of damage to the brain using MRI of the brain
3. immediate treatment with medicines(usually anticoagulant,blood circulation,nerve vitamins).
4. whether Surgery is necessary to stop bleeding or remove a blood clot
5. risk factors for stroke are investigated and treated (diabetes, high blood pressure etc)


During the acute phase of stroke:
1. A clear airway must be maintained
2. Sufficient fluid and electrolyte intake must be maintained
3. adequate nutrition in the form of glucose, proteins and calories must be given
4. adequate nursing care is provided to prevent bed sores etc
5. Proper medicines are given


Once the stroke is stable:
The stroke patient is started on a rehabilitation program
This will include
a.exercises to strengthen his muscles,
b.speech training for patients with dysphasia (difficulty in talking)
c.training on how to carry out his daily activities.
d.advice about his diet


Immediate care improves the chance of a complete recovery. 


A stroke can be very devastating and depressing for a patient.
He will feel that part of his body and brain function is incapacitated.
Therefore he need all the support from everyone involved in the treatment of his condition:
1.doctors,
2.nurses,
3.physiotherapist,
4.speech therapist
5.occupational therapists
6.family members and friends


Family members can provide the most important means of support.
They should be familiar with his disabilities and help him accordingly:
Please do:
1.be understanding and patient.


2. keep the patient cheerful and hopeful


3.learn how to help him with the diet, daily exercises and other care necessary for him


4.allow the person more time to do any task


5.encourage and praise the patient to do as much as possible for himself at his own pace.


6.involve the person in family discussions and activities.


7.be encouraging and praise his daily efforts.


8.encourage the person to look at, touch, and move his affected limbs.  


Do not:
1.ignore him or treat him like a child .


2.encourage the person to do things using the good side only.


3.pull on the affected arm or leg as it can be extremely painful.


4.interrupt or speak up for him.


5.make discouraging remarks.


6.allow the person to squeeze rubber balls as this may tighten his hand muscles.


7.let him be depressed


8.let him develop bed sores. Try to turn his body regularly.


In order to help the person be as independent as possible, there are special aids(such as tripod walking cane) and appliances(wheelchairs) which can be used to help him with his daily activities.
There are also special clothes and shoes which uses velcro instead of buttons or zips.
Make the home a safe place with non-slipmats and grab bars


Prevention of a stroke is the same as the prevention of a heart attack as both involve the avoiding the blockage or bleeding of a major artery to the brain or heart.


1.Control the Blood Pressure
Have your blood pressure checked at least once a year from the age of 40 years.
If there is high blood pressure, lifelong treatment with monthly checkups will keep it under control.


5.Control the Diabetes
Check for diabetes starting from the age of 40 years. If there are risk factors for diabetes, screening should start earlier.
If there is diabetes, take the medicine or injections regularly.
Monitor the sugar levels daily.
Control the diet.
Check with the doctor regularly.


2.Watch Your Diet
Reduce consumption of fat, high-cholesterol food, sugar and salt.
Take more fruit, vegetables and moderate servings of carbohydrates.
Eat more bean curd, dried peas, dried beans, fish and chicken instead of red meat.
Drink low-fat milk.
Avoid full cream milk.
Avoid alcohol.
Drink less coffee, tea and cola drinks.


3.Don't Smoke
Stop smoking immediately.
Don't start smoking if you are not a smoker.


4.Physical Activity
Regular exercise is good for you.
Do moderate intensity physical activity for 30 minutes such that you sweat and breathe deeply without getting breathless. Examples include brisk walking, swimming, cycling. 


6.Learn To Relax
Have adequate rest especially when you feel tense or tired.
Take up a hobby.
Do relaxation exercises such as yoga or deep breathing exercises.
Time management is important.