Articles

Dem Bones

The Clothes-horse of the body, our skeleton... in it’s blueprint. Perfectly created to carry, protect and shape the content of our lives. In the absence of a skeleton, we would be but an amorphous mass, with an amoebic... something like a giant slug...yeugh!

OK, so maybe I have your attention now?...or at least, maybe your skeleton has your attention now. Bones are not plastic. Your skeleton is an organ, a vital organ, dynamic in the way of the tortoise in it's race with the hare. Your skeleton needs your attention, your love and appreciation for the role it plays in the enjoyment you get from living.

Bone undergoes a continual cycle of resorbtion and regeneration. Peak bone mass is obtained between 20 and 25 years of age. In good health, a plateaux exists between 25 and 30 years. Followed by a gradual decline in bone strength thereafter. Bone is a mineral & cellular warehouse, playing an active role in haemopoesis (the formation of blood cells) and homeostasis (metabolic regulation). Bone loss is accelerated by chronic disease, malnutrition, menopause and a sedentary lifestyle. Structural degeneration and loss of bone density can lead to severe osteoprosis...fracture following minimal trauma. Genetic factors also play a big role.

Clearly, we need to focus on our children, to ensure optimal peak bone mass is obtained. Calcium is the primary mineral in bone, but magnesium and boron and a host of others are also important. Calcium rich foods include dairy products such as low fat milk, yoghurt, cottage cheese... and yes, ice cream (shhh...don't tell anyone : )! Veggies such as Broccoli, cabbage and spinach and seafoods such as salmon, sardines and prawns (especially the crunchy shell : )! Add to this a healthy dose of sunlight (vitamin D) and plenty of excercise and you have a winning combination!

Girls, as always, are a special case. Women have a lower peak bone mass, mobilise considerable calcium and minerals from the bones during pregnancy and lose up to 2% bone mass per annum over the 5 years of perimenopause. Excessive excercise, especially when it leads to absent menses, and early menopause also lead to accelerated bone loss.

So, what to do? Make sure children get plenty of calcium rich, fresh foods, and adequate sunlight & excercise. Supplement calcium if you are a female marathon runner or prone to irregular or absent menses. Supplement calcium during pregnancy (in addition to your regular multivitamin supplementation). Take additional calcium and Vit D supplementation in the peri and post menopause, and ensure weight bearing excercise at this time. Discuss the advisability of having a bone scan with your doctor if you have a parent with a fragility fracture or stoop and if you yourself have suffered a fracture or sudden back pain. Certain medications such as steroids, or thyroid placement and conditions such as arthritis and colon problems, may accelerate your risk. The National Osteoporosis foundation recommended that all women should have a bone density or DXA scan at age 65 and all men at age 70, even without underlying risk.

Your bones support you...... isn’t time you support them?


Sensible Breast Care

Breast cancer is the leading cause of death from cancer in Western women and as such, is the cause of much anxiety. Unfortunately there is also considerably ignorance about a sensible screening program and ostrich politics seem to rule the day. This article provides a simple cancer detection program applicable to most women.

As you get older, your risk of breast cancer heightens and vigilance must increase. Know your genes! A family history, particularly a first degree relative with breast cancer, places you in high risk category – inform your doctor.

Prolonged exposure to oestroegen – either from your own ovaries or from an external source does increase your risk as does a diet in saturated animal fats. Pregnancy & breast feeding appear to reduce risk.

There is significant advantage in routine screening for breast cancer. Patients on screening programs have a better prognosis, including improved survival, due to theirtumours being discovered at an earlier age. There is nothing in treatment that matches early diagnosis.

Monthly Breast Self Examination (BSE) should be commenced at 25 years of age, cancer being extremely rare and the high incidence of benign breast conditions prior to that age, resulting in more anxiety than necessary. Between the ages of 20 and 39, women should have a clinical breast examination by a health professional every year.

Diagnostic mammography, usually with an additional ultrasound examination, will be performed on those patients with symptoms of abnormal findings during examination. A screening mammogram is used to look for breast disease in women who appear to have no breast problems. A baseline screening mammogram should be performed between 45 & 50 years. A noteable exception would be those patients with a first degree relative suffering from breast cancer, in which case the baseline mammogram can be conducted ± 10 years prior to the age of her relative's diagnosis or at least 40. Routine 18 monthly mammography should be performed on all women above the age of 50 years and particularly on those women using hormone replacement therapy. Many people are concerened about exposure to X-Rays, and rightly so, but the level of radiation is extremely low and does not significantly increase the risk of breast cancer. To put this into perspective, radiation treatment for breast cancer consists of several thousand Rads, the radiation of a mammogram is 0,1 to 0,2 Rad per X-Ray i.e: 1 Rad for 10 X-Rays.

Breast Self Examination

Start at age 25. Exmaination should be performed monthly, a week after the period's end. If you are not having regular periods, do the BSE on the same day every month. I find the following technique very useful: Lie flat on your back, with a pillow under the left shoulder and your left hand behind your head. Divide your breast into 4 quadrents by drawing an imaginary line horizontally and vertically throught the nipple. The nipple and the area beneath the arm from the 5th and the 6th areas. Use the straight fingers of your right hand to move in head to toe direction over each quadrant, firmly enough to feel your ribs. Examine the nipples area and the areaof the breast under the arm with circular motions.
Place the pillow under the opposite shoulder and repeat the excercise on the right breast.
Stand in front of a mirror with hands on hips and look at breast and nipple symmetry. Slowly raise your arms above your head and look for a skin retraction or dimpling.
Breast cancer is generally not painful and not related to cycle changes. Suspicious areas include:

If you are uncertain, approach your doctor for an option


The PAP Test

The PAP test owes its name to one Papanicalou, who developed the staining technique to expose the nucleiof cells under going maligant change. The test is designed to identify women at risk of developing cancer of the entrance to the womb (the so called cervix).

The cervix is accessed with the aid of a spectrum and cells from the cancer prone area are collected by means of a small brush or wooden spatula. At the laboratory the smear is stained using the Papaniclou technique and examined by a cytologist.

The common form of cervix cancer has a fairly predictable and rather slow progression. The early stages generally resolve spontaneously, although between 5% and 15% may progress to eventuallybecome cancer.

Who is at risk of Cervix cancer?

Essentially all women who are sexually active are at risk. Sexual activity at a young age (i.e. in adolescence) is a particular risk factor due to the relative immaturity of the cervical cells at this stage. These cells are particularly susceptibles to carcinogens, especially virus cells which may be transmitted in seminal fluid. The viruses associated with cervix cancer are certain types of the Papiloma Virus (the wart virus) and the Herpes Virus.

How often should a PAP smear be performed?

your first PAP should be performed about a year after commencing sexual intercourse. Provided the resluts are negative, it should be repeated each year for a further two years. This is necessary as the test is unfortunately not very sensitive and will only identify about 40% of abnormal cells the first time round. In a monogamous relationship, PAP tests can thereafter be performed at 3 yearly intervals, unless advised different by your doctor.

Not being in a monogamous relationship does increase your risk and annual smears should be performed. If viral cells or pre-maligant cells are noted, the smear will need to be repeated in 3 - 6 months and you may be advised to go for a coloscopic examination (essentially examination of the cervix through a microscope).

Not all pre-maligant lesions need to be treated and in those that do, treatment is generally fairly simple and does not affect fertility. A regular PAP test will essentially exclude the possibilty of advanced cervix cancer and still remains an important inconvenience for the health conscious woman.


What else can go wrong?

In this article, I will briefly discuss other screening tests wich may be indicated or requested. Remember, a screening test is a test performed largely in the absence of specific signs and symptoms (which may warrant a diagnostic test), but in the presence of certain risk factors.

Cancer of the lining of the womb (endometriosis) is predominantly a post – menopausal condition and is particularly prevalent in overweight women, late menopause, those with no children and those with a history of irregular menstruation. The use of oestrogen alone in a woman who still has her womb, is also a strong risk factor. Fortunately most cases present with post menopausal bleeding – which must be reported to a doctor. A biopsy of the lining of the womb will be submitted for pathology analysis. In those at high risk, a vaginal ultrasound can measure the thickness of the endometrium which can then be sampled, if it is greater than 5mm.

Cancer of the ovaries is, unfortunately, fairly common and tends to present late. Protection against this cancer is afforded by early childbirth, tubal occulsion (sterilization) and the contraceptive pill. Risks include a genetic predisposition, exposure to certain carcinogens (such as talc) and infertility treatment. Ovarian is a silent disease giving very few clues. Sysmptoms generally involve the digestive system – such as increased pressure or bloating but may be as diverseas knee pain or backpain. In high risk patients, those with a palpable ovary in the menopause and those with vague symptoms, a screening vaginal ultrasound (with doppler, if a mass is found) is indicated. Blood tests for tumour markers can also be helpful.

Colon cancer is also a condition which becomes more prevalent as one gets older. It is one of the cancers which have a strong genetic predisposition, so family history is also of importance here. A sensible screening test where risk factors are prevelant or where a change of bowel habits are noted, is the occult blood stool test. This is available in the form of a specially designed envelope with included spatula, which takes a little of the 'shudder' out of the test. If the test shows hidden blood in the stools, more invasive tests may be ordered.

The thyroid is an endocrine organ which, like the ovaries, may decide to call an early time out. Symptoms are often confused with menopause – – – – – weight gain, memory loss, lethargy and menstrual irregularity to name a few. Both an over active and under active thyroid may present with a goiter or palpable lump. Thyroid stimulating hormone can be tested on a blood sample taken by your doctor and provides the ideal screening test for thyroid dysfunction.

Ischaemic heart disease still remains the number one killer as in men. Women have the advantage of the beneficial effects of oestrogen on the cardiovascular system up to menopause. Thereafter, an unfavourable lipid profile has the same deleterious effect as the male. It is important to have a full lipid profile taken at least once. This is a 12 hour fasting study which is sent to the pathologist. It gives an indicationof the ratio of low (bad) to high (good) density lipids which may indicate a risk despite a normal total cholesterol. In the absence of a family history, questionable diet or excessive lifestyle, a normal screening cholesterol at the pharmacy is sufficient follow up. Remember, a ¼ disprin a day in the post-menopause is always a sensible medication.

Well, that wraps up some of the common screening tests!


Lessons in Health

Living a healthy life is spectacularly easy. It's also not particularly expensive. In fact, it is simple common sense! Dr Bob Rakowski from the Natural Medical Centre in Houston, Texas, is the epitomy of a US marine drill sergeant. He is a commanding presence and even on DVD, had the delegates to a Natural Medicine symposium out of their seats and doing an obligatory 4 minutes of tabatas (Byte sized bits of intense physical exercise to focus the mind and stimulate the senses). The symposium was recorded in Cape Town at the beginning of April and was presented by Amipro's Dr Wayne Naude for Garden Route practitioners who who were unable to attend Dr Rakowski's presentation in person.

The core of his message, which he rattled off at regular intervals, is that for great health you have to 'Eat right, drink right, poop right, move right, sleep right, think right and talk right....the Magnificent Seven! He has achieved outstanding results with a spectrum of chronic diseases ranging from diabetes to Alheimers and from depression to autism. He has a direct, no nonsense approach based on, as he puts it, 'wiping the slate clean and starting over!'

The basic pattern is to use a medical food (Amipro import the Metagenics Neutroceutical products which he uses) and organic vegetables ( predominantly the green leafy variety), spring water and certain teas only in the first week. He then tailors the dietry & neutroceutical intervention from the second week onward.

Gluten (particularly) and lactose are common allergens and it is not as hard as we might imagine to avoid in the diet. The massive increase in chronic and auto-immune disease, particularly in the US can largely (in about 70% of cases) be attributed to chemicals, pharmaceuticals, pesticides and genetic manipulation used, quite legally in the commercial production of food and in the conventional management of chronic disease. His contention was incontrovertibly supported by the medical literature and numerous case reports. The knowledge is readily available and undisputed, however the political and economic will is completely lacking.

The soils of commercial farmland are denuded and fertilizers come nowhere near replenishing the entire complement of minerals that are in organically grown crops. A video clip, a 'ham' up, called 'The Meatrix' (available on u-tube) gives a sobering picture of factoy farming and it's implications on the environment and on ourselves.

It is virtually impossible in human society to obtain all the required nutrients for good health and vitamin and mineral supplementation are globally advisable. Dr Bob recommends a multivitamin/mineral product made from organic superfoods such as Metagenics Phytomulti and highly purified Omega 3 fish oil as a basic necessity.

Typical of his vast clinical experience and thorough knowledge of physiology, he took on the contentious issue of infant vaccination. He noted, that in first world communities, where standards of hygiene and health are high, it is unjustifiable and unnecessary to expose neonates to multiple vaccinations. The neonatal immune system is immature and cannot mount the necessary response to the vaccination.

The massive rise in peanut allergy can be attributed largely to the peanut oil base used to constitute many neonatal vaccines. Vaccines can be potentially neurotoxic and the first claim for compensation for Autism occasioned by vaccination has been settled in the US. A neonate receives passive immunity from it's mother through breast feeding while it's immune system is developing and where mothers have the ability to home - care their children, they need to be advised on an alternative and safer approach to vaccination. Dr Bob's advice is to approach vaccination after 6 months and as a single exposure per event, which, from a medical, physiological point of view, makes complete sense.

The huge role of stress in chronic and debilitating disease was highlighted. The physiological importance of regular exercise, adequate sleep and avoiding toxins which we may not initially realize, such as negative personalities, violence on TV and sensation in the media was demonstrated as was the failure of most of the recognised drug classes to provide an outcome better than placebo. The side effect profiles, such as loss of libido, significant weight gain, insomnia and impaired concentration are such that these drugs need to be reserved for severe impairment.

The significant harm caused by certain groups of pharmaceuticals such as statins and antidepressants and the mechanisms behind the potential damage where discussed. The considerable potential for adverse drug interaction when multiple drugs are prescribed was illustrated (it is 100% if there are 8 or more drugs in the cocktail) . As in all cases, it is foolhardy to rely on medication to relieve the symptoms of disease while ignoring the basics of heathy nutrition, adequate hydration and regular exercise. Regular exercise? ...as simple as tensing up all your muscles from your toes to your forehead at regular intervals through the day! Time for my Tabata!



Litigation, Private Practice and Medical Insurance

Years ago I heard an American coin the phrase 'litigenous society' in explaining the arms-length, high cost, impersonal medical service in the States. I remember feeling grateful that I could be a doctor in South Africa and practice medicine to the best of my ability, relatively free from fear of litigation and financial ruin. Unfortunately times have changed. Pregnancy and child-birth are life threatening conditions. The 'punishment' visited on Eve in the Old Testament was well understood in the times before intervention. It made the disaster of the death of a young mother and infant more bearable when seen in terms of our collective sinful nature.

Human birth is risky business. Our ability to reason and debate the issue is indeed the source of the problem! We have big heads! In nature, up to 30% of pregnancies could end in death or debilitating injury to either mother, child or both. Our memories are however, thankfully short. We now live in a zero defect world and in a culture of blame. If a cancer is diagnosed, it is caused by something external or missed by someone. If a death occurs under anaesthetic in a highly stressed, overweight, chronic smoker, someone must pay. If a baby is born handicapped, someone should have offered a termination, made a diagnosis or performed an intervention. And yet, not even this is to blame for doctors abandoning their professions, their life-time work and often their passion.

I have seen my professional indemnity insurance increase from a modest R20 000 per annum in 1997 to an astronomical R450 000 in 2015. The last straw being the 37% hike from 2014. There are few alternatives and those there are provide limited cover and no protection into retirement. An unpleasant prospect at the end of a long career. In comparison, delivery fees have gone up 7% and are as low as around R3300 on the national price reference list. It simply doesn't add up.

So what has changed. Interestingly enough, the legal stripping of the Road Accident Fund, it's subsequent collapse and eventual capping of the quantum was the trigger. This precedent is now the reason for the same collapse and the remedy applied probably all that can save my profession from the same fate.

The legal firms, and there are several, which made their substantial living out of multi-million rand settlements from the road accident fund have had their life-blood cut. They have now turned their attention to medical litigation. It is a fertile culling ground. The statistics are clear. Only 3% of the possible claims for medical negligence and disaster ever make it to court. There is no shortage of justification either. 97% of those compromised by a fall in hospital, a missed fracture, an hospital acquired infection or a birth defect may receive a measure of compensation for their loss, pain and suffering.

There are many ways to acquire the work. Some legal, such as expensive TV advertising, others illegal, such as bribing often poorly paid staff to provide patient details. Such a patient is then contacted with an offer to attempt to get compensation, without obligation or cost. Who would say no?

Medicine is part science and part art. It is not an exercise in engineering or mechanics or even quantum physics. Its training is rigorous and prolonged (my specialty took 13 years to acquire and an excellent matric to access) There are no fools who practice medicine. Those who would fool rarely make it past the second year. Yet the insurance paid by a mechanic or an engineer is not comparable.

Why then, is minding child-birth such an insurance risk?

The reason is simple. If a child is compromised, the quantum may consider the cost with escalation, of caring for the compromised child and can come to the conclusion of birth injury up to the age of 21. Settlements may amount to millions! If a doctor is unfortunate enough to have a claim instituted against him, particularly in a small community, his practice is over. A prolonged court dispute is sensational and newspapers love a good story. Very few doctors want their day in court. They will press for a quick settlement. The legal teams (from both sides) know this....and the money flows. There is a price to pay. It is a heavy one. The community loses excellent caregivers, who simply can't afford to pay the insurance from their smaller practices. They lose, have lost, in fact, the Good Samaritans ...insurance will not cover a General Practitioner or uninsured gynaecologist for any claim arising from an incident where they involved themselves with a pregnancy beyond 24 weeks. Fees for delivery in the larger centers are excluding all but the wealthy (in Cape Town the average is R14 000, here we are still around R6 000, which is unsustainable but a reflection of our association with the smaller communities in which we live) There will also necessarily be more caesarean sections. Natural birth is the primary source of litigation, particularly assisted delivery.

The government has already identified the problem, as the majority of litigation is aimed at the public sector. They have already elicited an angry retort from the legal fraternity and, regrettably, the parliamentary opposition. One thing is certain. If something doesn't happen soon, private child-birth will no longer be available.



Menopause

It's urban legend that everything that ever goes wrong with women has men in it...and so we come to men-o-pause. This is, of course the time that women pause to consider if they need men in their lives at all! ...well ....thats only part of it....

Menopause occurs in all women and is essentially the cessation of menses. It can only be diagnosed retrospectively when 12 consecutive months have passed without a menstrual period. Perimenopause, on the other hand, is that uncertain time when cycles are skipped and symptoms are sporadic. Age at menopause is also variable. The mean is generally accepted to be 50 years of age with range 45 to 55. In my practice the range of natural menopause is from 40 years to 60 years! (Way to go Ria!) Anything below age 40 would be classified as premature and would be subject to investigation.

Clearly the menopausal transition signifies an end to the ability to reproduce naturally ( I have to add that as those crazy Italians are forever pushing the boundaries with ART ....and I'm not talking Michelangelo here...but Artificial Reproductive Techniques). This fact on its own can often result in distress and a feeling of loss....or a sigh of relief and a burden lifted!It is, however, the physical symptoms, signs and physiological changes that make this phase so important

First a riddle: What do women and killer whales have in common? ...... ( I sense I may be treading on dangerous round with this one! ) ....The answer is: Menopause a significant time prior to a natural demise (Pilot whales too, but that would have ruined the riddle)

Now some philosophical anthropology: Woman potentially undergo menopause at mid life to prevent competition with their offspring ...who are now also reproducing. Careful study of indigent and tribal custom will note that it is the menopausal women that tend the young while the women work in the fields (bedroom/kitchen) and the men hunt or fight (play with the remote/drink beer with other men).

And some physiology: a woman is born with a finite number of oocytes (around 400 000) in the ovaries. Over the years the numbers fall dramatically until there are essentially too few left to ovulate. The pituitary gland of the brain produces a substance called Follicle Stimulating Hormone or FSH which stimulates the oocytes to develop. These oocytes in turn produce estrogen which prepares the lining of the womb for a potential pregnancy and by means of feedback, suppresses FSH release and precipitates a pituitary surge of Luteinising Hormone or LH. This hormone triggers release of the ovum. As oocyte numbers diminish, estrogen levels fail to suppress FSH and the levels remain consistently high (above 30 IU/L). This is then the biochemical marker for menopause.....This is of course important if your gynaecologist has for whatever reason, deprived you of your womb.

Now on to symptoms:

The bodies temperature regulating mechanism is situated in the hypothalamus, intimate next door neighbour to the pituitary. The persistently high FSH plays havoc with the mechanism, resulting, among other things, in the release of stress hormones such as adrenalin and nor-adrenalin which in turn causes sweating, vasodilation and palpitations. Hot flushes / flashes last anything between 30 seconds and 10 minutes and tend to diminish with years from menopause. About 85% of women will be afflicted to varying degrees by this phenomenon. Most women will experience a natural cessation over time. The good news is that 15% of women will never experience a hot flush, the bad news is that 15% of women will have them for good!

Low estrogen levels affect the skin. Estrogen is largely responsible for skin turgor or hydration ...that thing that gives women soft, smooth skin and men that craggy, Marlboro look. So, menopause means more laugh lines and crows feet. It also means thinning of the vaginal skin and dryness. Combine this with a concomitant reduction in testosterone levels and we have very bad news in the bedroom.

Changes in hormones traditionally cause emotional mayhem ( I have a friend who habitually refers to his wife's pre-menstrual phase as 'mad cow disease'...in confidence to me, of course!) so its not hard to imagine the effect of changes as profound and permanent as menopause. There are changes in the levels of neurotransmitters in the brain which can lead to depression, aggression, irritability or plain and simple irrationality!

More disturbingly is an acceleration in bone loss and an increase in the risk of vascular disease including heart attacks. The lipid profile often becomes less favourable and an exacerbation of joint pains and stiffness is not uncommon.

So what to do?

The adage of 'if it doesn't itch, don't scratch it' holds true for menopause too. Menopause is a natural occurrence and not a disease. Our extended life-span is however a new phenomenon and a knowledge of the subject, it's physiology and effects are essential. From a medical point of view, its important to ask the questions ... Are you experiencing 'hot flushes' or sweating unduly at night? Is this affecting your quality of sleep? Have you lost interest in your partner (for no good reason that is) and is sex painful? Do you experience painful joints or have you (or others) noticed a change in mood or patience?

There are good menopausal questionnaires that can help you assess your own status

To treat or not to treat:

That is the question!
Menopausal management with hormones was dealt a significant and largely unfair blow in 2002 with the preliminary results from the Woman's Health Initiative trail and compounded by the Nurses study. These studies showed an increase in breast cancer, heart attacks and strokes in users. To be fair, these studies heightened awareness and lead to vociferous debate and analysis which has benefitted knowledge. The initial findings, however, scared millions of women and thousands of physicians away from a very effective form of therapy and fueled an explosion of sales for the naturopathic and herbal industries alike

Where are we in 2016? :

Hormones taken appropriately in the perimenopause and early post menopause, say up to age 60, reduce the incidence of breast cancer, heart disease, colon cancer, osteoporosis and sexual dysfunction and do not cause an increase in thrombosis or stroke.




 





 

Dr Douglas Seton, Obestetrician & Gynaecologist Knysna © 2017

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