uterus?remove it!

Remedial removal retraced

YOUR HEALTH DR GITA MATHAI

The ancient Greeks believed that women developed bizarre behaviour or “hysteria” because they had a hystera (Greek for womb or uterus) while men did not. Removal of the uterus, therefore, came to be called “hysterectomy”, a nomenclature in use even today. Women are advised to have their uterus removed for a variety of medical conditions. In the developed countries 35 per cent of the women over the age of 60 have had this surgery. Ninety per cent of the surgeries were done for harmless illnesses, which perhaps could have been tackled with medicine. We, in India, are fast catching up and the surgery is performed for a multitude of indications. If you are a woman, it pays to be informed about the surgery, its indications, contraindications and after effects. It is easy to fall into the trap of “my child bearing days are over, what do I need this organ for?” Or, “it bleeds irregularly without warning, hurts and needs to be regularly evaluated for the presence of cancer.” If it really was that useless, in all probability, it would naturally fall off at a certain age, just like our milk teeth. A hysterectomy can be total, when the entire organ is removed, or partial when the lower part, called the cervix, is retained. The ovaries, which produce the eggs (ova) and the female hormones, can be removed at the same time, or left behind. Even if the ovaries are preserved, they usually cease to function in one or two years once the uterus is removed. If the cervix is left behind, any disease process that may develop in it at a later date is difficult to tackle. The subtotal operation has fallen into disrepute and is rarely done. (If you are having a hysterectomy make sure that the surgeon is going to remove the whole organ). There are several techniques for surgery. It can be done through a curved incision along the bikini line. The visualisation is good; the scar disappears into a natural crease and is barely visible. The person is less likely to develop a hernia at a later date. A straight incision leaves a long visible scar. A hernia may develop if the person puts on weight, or there is post operative infection. Surgeons can remove the uterus through “button holes” using a laparoscope. It can also be removed through the vagina without an abdominal incision. The operation is required — • If there is cancer of the uterus, cervix or ovaries. • Sometimes, as a follow through for cancer of the breast, since that tumour may be dependent on the hormones produced by the ovary. • If the uterus itself has descended (prolapsed) and can be seen partially outside the body. • Frequently for uterine fibroids called myomas. These are non-cancerous tumours in the muscle of the uterus. They can be troublesome as they can grow to a large size, press on the urinary bladder and interfere with urination. They also cause stomach pain and increased bleeding. • Sometimes if the menstrual tissue, which lines the uterus and should be shed during menstruation, grows abnormally into the muscle of the uterus (adenomyosis) or into the abdomen (endomteriosis). • If there is uncontrolled and frequent bleeding. Fibroids can be tackled without hysterectomy, with alternative surgical procedures like myomectomy (the uterus remains preserved and the woman retains her reproductive potential) or uterine artery embolisation (a minimally invasive means of blocking the arteries that supply blood to the fibroids). The lining of the uterus, which bleeds uncontrollably or irregularly, can be destroyed by a surgical process called ablation. Medications and hormones, if used appropriately, can control pain and bleeding. An open hysterectomy allows an excellent view of the abdomen so that the surgery can be meticulously done and bleeding controlled. However, it is a major procedure. There can be unexpected bleeding or infection. Recovery takes four to six weeks. Surgical menopause occurs abruptly if the ovaries are removed at the same time. It is different from the natural menopause, in which case the hormone levels fall gradually over a period of time so that the body adjusts to the changes. The sudden lack of hormones leads to night sweats, weakness, depression and insomnia. The bones lose calcium and become osteoporotic. This can lead to fractures, particularly in the vertebrae. As the protective effect of the female hormones disappears, the lipid profile changes and the risk of heart disease increases seven fold. The vagina becomes dry and sex may become painful. The urinary bladder loses part of its supporting wall. It may prolapse into the vagina and urine may be retained. There may be urinary incontinence (involuntary leakage of urine). Recurrent infections can occur. Similarly, the rectum can protrude into the vagina causing constipation. Problems with uterus are also time bound. They will cease with menopause. The after effects of a hysterectomy persist for a lifetime. Before contemplating surgery, consider. Is the disease worse than the cure? Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

killing heat

Summer blues

YOUR HEALTH DR GITA MATHAI

The killing heat” is not just a figure of speech. Every summer, newspapers report deaths from sunstroke, heat and dehydration. This may only be the tip of the iceberg as medical documentation and statistics on illness in India are still unsatisfactory. We really do not know exactly how many people are affected. Human beings are sensitive to outside temperature. To survive, the body has to maintain its internal body temperature at 98.4°F. If it is cold outside, we have to insulate the body by covering ourselves. If it is hot, the temperature has to be brought down. The skin is provided with four million sweat glands distributed all over its surface. As the temperature rises, the brain sends chemical signals to these glands and they start functioning. The body becomes drenched in a film of sweat. As this evaporates, the temperature drops. The volume of water lost in sweat daily is highly variable, ranging from 100 to 8,000 millilitres a day, depending on the outside temperature and the extent of physical activity. Sweat is not pure water. It contains small amounts (0.2 - 1 per cent) of chemicals like sodium (0.9 gram/ litre), potassium (0.2 gram/litre), calcium (0.015 gram/litre), magnesium (0.0013 gram/litre) and other trace elements. When a person moves from a cold climate to a hot climate, adaptive changes, called acclimatisation, occur in their sweating mechanisms, regulating not only the fluid lost but also the chemical content. Summer months are vacation months when people travel to the hills from the plains and vice versa. If you are travelling to a warmer environment, it takes your body a couple of days to adjust to the new temperatures. The maximum rate and quantity of sweat has to increase and it has to become more dilute. This acclimatisation period is the time when people are most vulnerable to the effects of heat. The sweating mechanism is inefficient and immature in children till the age of about four. It does not function well in the elderly, the obese and those with diabetes. The system also breaks down with some of the medications taken for high blood pressure and depression. This subset of the population is, therefore, more vulnerable to the effects of heat. The body’s natural cooling mechanism can fail: • If sweat cannot evaporate because the outside environment is humid. The internal temperature continues to rise even though the body remains bathed in sweat. • When inadequate fluid intake with dehydration prevents adequate sweating. • Due to continuous physically taxing work or exercise in a hot environment without sufficient intake of fluids. Heat exhaustion occurs first. You may get a headache, giddiness, a feeling of weakness, palpitations and painful cramps in the leg muscles. The body temperature rises and may eventually be as high as 104°F. If heat exhaustion is not recognised and treated, this can progress to a heat stroke. The temperature rises even to 105°F. There may be confusion, disorientation, seizures and even death. Unfortunately, children often cannot express the early symptoms of heat exhaustion. The only sign noted by the parents may be the temperature. Fearful of fever, they may cover up the child with inappropriate warm clothing and bed sheets. Thirst may be ignored. This accelerates the progress to a heat stroke. To deal with the summer • Try to stay indoors as much as possible, going out only before sunrise and after sunset. • Confine exercising outdoors to the same time. Even swimming in the hot sun can lead to heat exhaustion and stroke. • Avoid synthetic garments. Wear clothes made of cotton, linen, jute and other natural fibres. • Drink plenty of fluids. Do not wait to feel thirsty. The best liquids are tender coconut water or lightly salted lime juice and buttermilk. • Avoid aerated drinks. They add unnecessary calories. Many of them are hypertonic and will not quench your thirst. • Dehydration and the ill effects of heat are aggravated by caffeinated beverages, whether they are colas, tea or coffee. • nAlcohol has a similar effect. If you suspect heat exhaustion • Immediately move the person to the shade, under the fan or to an air-conditioned or air-cooled place. • Give plenty of fluids, preferably with salt. There are many commercially available oral rehydrating solutions that conform to World Health Organization standards. These sachets can be reconstituted and administered. Most of us live in heat radiating concrete jungles where we have to go out to work in the summer. Frequent power cuts and inadequate voltage make amenities like fans, coolers and air conditioners dysfunctional. In this scenario we have to be careful about the effects of the summer heat, particularly on the vulnerable young and old members of our families. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

letters

Hole in my ear

YOUR HEALTH DR GITA MATHAI

Q: I developed a hole in my eardrum and I think it is due to prolonged use of the mobile phone. I cannot manage without my phone. A: The hole (perforation) in the ear drum is unlikely to have been caused by the use of a mobile phone. Usually it develops as a result of an ear infection (otitis media), an injury with a sharp object or a sudden loud sound near the ear. It needs to be evaluated. You should consult an ear, nose and throat (ENT) surgeon. It may heal and close with antibiotics and the use of ear drops. A long-standing non-healing perforation may require an operation called a tympanoplasty. In any case, why not use the speaker phones option? Tingling feet Q: My 72 years old father, is a diabetic, whose blood sugar is well controlled by oral medications. He has a lot of discomfort in his lower legs and feet. He had consulted a neurologist and after certain tests was found to have neuropathy. Although he was given vitamin combinations he has had no relief. A: Diabetic neuropathy is a nerve disorder that can occur as a complication of diabetes usually if there is poor blood sugar control. It can cause problems with the sensation in the feet. The symptoms are numbness, pain, or tingling in the feet or lower legs. There may be difficulty in walking and balance. The first step is to bring blood sugar levels under control. You could purchase a glucometer and check the sugar level regularly at home. Make sure he always wears well fitting shoes. Walking regularly, taking warm baths, or using elastic stockings may help relieve leg pain. Analgesics, low doses of antidepressants, and some anticonvulsant medication can be prescribed, in addition to vitamins, in severely affected individuals. Potty tot Q: I have a son who is three and half years old. He has been suffering from acute constipation for the last one year. He passes hard stool, with pain. Sometimes small amounts are passed 10-12 times a day. He eats well and his diet includes 1,000ml of milk, which I give in a bottle at night. A: The quantity of milk that you are giving is far in excess of what he requires. He needs only 400ml of milk a day at the very most. It can be split into two 200ml feeds, in the morning and evening, not at night. At three and a half years he is far beyond the stage of feeding bottles. Encourage bowel movement in the morning by making him sit in the toilet at a fixed time even if he does not feel the urge. If the constipation persists a further evaluation with a paediatrician can be done to rule out thyroid deficiency or bowel malfunctions. Worried about AIDs Q: Does a married couple need to have sex with a condom? I want to prevent HIV infection in myself and my wife. I am worried about AIDS. A: If either party has had prior sexual encounters, it is better to use a condom until you check for HIV and hepatitis B. It is better to check again after six months when the window period for HIV infection is over. If you go to a Voluntary Counselling and Testing Centre, the tests are free. Married people need to use condoms as a contraceptive device if they wish to prevent pregnancy, or if one of the parties is HIV or HbAg positive (hepatitis B). Seeking perfect eyesight Q: I want perfect eyesight. What diet should I eat and what can I do? A: Green leafy vegetables like spinach, beetroot, carrot and drumsticks help eyesight because of their vitamin and antioxidant content. Overcooking destroys heat sensitive labile beneficial vitamins of the B group. Steaming or microwave cooking vegetables or eating them raw is, therefore, better. Eating two raw tomatoes a day will give you all the vitamins you need. There are eye exercises in yoga which, done regularly, help to maintain and improve your eyesight. More children Q: I am 41 and my wife is 35. We have an eight-year-old daughter. We decided to try for a son. Despite our best attempts over the last one year, we failed. Although my wife’s periods are irregular, no tests have been done. We have received all kinds of tablets from various doctors. Now we read that some of them have potentially dangerous side effects. A: All medicines have some side effects even if they are aryuvedic, homeopathic or herbal. The tablets used to induce ovulation can be dangerous if given for too many cycles in improper doses. Before proceeding consider • You already have a healthy daughter. • Do you really want another child? •Test yourself — do a semen analysis • Do an ultrasound for your wife to see why the periods are irregular. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

irritating itches

That irritating itch!

	YOUR HEALTH   DR GITA MATHAI

Eczema is a strange disease. If you have it, the frustrating itching and scratching starts and then just never seems to go away. The number of people with eczema is increasing. One in five now develops it in childhood. Many factors, such as early weaning, chemicals (preservatives and pesticides) in the human diet, perfumes and pollution, have been blamed. The fact is no one really knows the cause of eczema, but we do know that exclusively breast-fed infants are less prone to it.

Eczema appears as red, itchy, dry and flaky skin, with or without small pustules. A few months of constant itching may make the skin permanently rough, thick and hyperpigmented.

The classification of eczema is not very clear. It can be due to atopy (tendency to develop allergy), allergic contact, infantile seborrhoea (dandruff-like condition of the head that occurs in infants) or varicose veins.

Atopic eczema is the commonest form. It usually occurs in childhood as an itchy rash distributed on the head and scalp, neck, inside of elbows, behind the knees and on the buttocks. It has a hereditary component and runs in families.

Infants can develop an eczema variant called cradle cap — with a greasy, itchy flaky scalp. This can extend to the eyebrows, face and the trunk. Although the condition is self limiting and harmless, the physical appearance can be distressing to the family.

Irritant contact eczema can be distinguished from the atopic form by the typical distribution and family history. It occurs as an immediate or delayed reaction to contact with an allergen. It may be nickel in the safety pins used on clothes, fashion jewellery containing unacceptable metals or colouring, plants in the garden or chemicals in the workplace. Makeup or face powder can cause an idiosyncratic reaction. Sometimes the contact eczema may be photosensitive and flare up only when the skin is exposed to sunlight. Eczema caused by a specific chemical or disease process can be cured if the underlying factor is removed.

Bacterial, viral or fungal infection of the skin, or infestations with skin parasites like scabies or body lice can cause secondary itching and eczema. Poor blood circulation to the legs as a result of varicose veins can lead to itching and discolouration, particularly near the ankles. These forms are totally curable and tend to disappear forever when the infection is treated or the blood circulation is improved.

Unfortunately most varieties of eczema do not fall into the curable category. They recur time and again, and sometimes become self perpetuating as scratching and picking the skin becomes a habit.

Dry skin aggravates eczema. Therefore it pays to keep the skin moist and oiled. Coconut oil can be applied to the skin half an hour before a bath. A teaspoon can also be added to the bath water. Mild and non-perfumed soaps should be used. The body should not be scrubbed with a loofah. The skin should be patted dry, and not wiped. After the bath a non-greasy oil or lotion can be applied.

There are several baby oils, aloe vera preparations, ceramide (a natural oil in the skin) and vaseline-based creams available in the market. If it says "non greasy" it means that it is unlikely to stain your clothes. Traditional oils, like coconut, stain the clothes and that is why they need to be applied before a bath.

Salt water reduces eczema. People who immerse themselves regularly in the sea improve gradually over a period of time.

Detergents are widely used to wash clothes. Most contain chemicals like sodium lauryl sulphate, which remain behind in the clothes in small quantities. They can penetrate the skin when sweating occurs, aggravating eczema. Commercially available "hypoallergic" or "doctor tested and recommended" detergents have unsubstantiated claims and have not been proven safer. Since clothes have to be washed and kept clean, it is preferable to use non-allergic soaps made from neem oil. They are marketed in India by the government run chain of khadi stores.

Eczema disappears when steroid creams are applied. These should be used under medical supervision for a short period, till the symptoms subside. After that antihistamines (to control itching) and moisturisers should be continued. Patients, unfortunately, purchase and apply the ointments themselves. Prolonged use of topical corticosteroids causes side effects like thinning of the skin and secondary bacterial or fungal infection. Small quantities of the more potent steroid creams can become absorbed in the body through the skin. If they are inadvertently applied to the eye, cataracts and glaucoma can result.

Specific pinprick allergy testing can be done to identify allergens. Without this, drastic potentially harmful changes should not be made to the diet (particularly a child's) presuming that the eczema is precipitated by allergies to milk, fish or certain vegetables.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in