Skin Health

Overview

The importance of keeping your skin healthy can’t be overemphasized. It’s the body’s first defense against disease and infection, and it protects your internal organs from injuries. It is, in fact, the largest organ in the body. The skin helps regulate body temperature and prevents excess fluid loss, and it also helps your body remove excess water and salt.
Skin conditions can affect anyone—young and old, men and women. Acne, psoriasisand eczema are just a few examples of common skin disorders. The good news is that there are a number of simple ways to keep skin healthy, and there also are now many options available to treat skin conditions, if treatment is necessary.
If you think you may have a skin problem or need to learn how to better care for your skin, consultation with a dermatologist—a physician who specializes in treating the skin and keeping it healthy—may be in order. Skin problems can be difficult to diagnose because many skin conditions share similar symptoms. An evaluation is key to effective treatment.
The Structure of Skin
To understand how to keep your skin healthy, it may help to learn about your skin’s structure.
Skin is composed of three layers: the epidermis (the outermost layer of skin—about the thickness of a piece of paper), the dermis (the middle layer) and the subcutaneouslayer (the deepest layer). The thickness of the dermis varies depending on the location. For example, eyelid dermis is quite thin, but back dermis is about half an inch thick. The epidermis has three sub-layers: the stratum corneum, the squamous cell layer and the basal cell layer.
The stratum corneum or outer layer of the epidermis is the layer of skin that can be seen and felt. Proteins known as keratin, a fatty, waterproof envelope, and flat, closely packed dead cells make up the stratum corneum. This layer is the barrier between your body and the outside world.
The squamous cell layer produces keratin for the stratum corneum and also transports water.
The basal cell layer is the lowest layer of the epidermis. This is where the skin cells are reproduced and give rise to the more superficial layers of the epidermis. The most common form of skin cancer, basal cell carcinoma, arises from this cell layer.Melanocytes, which produce melanin, or skin pigment, sit along this layer among these cells. Melanoma, one of the three most common forms of skin cancer, originates from these pigment-producing cells.
It takes about one month for skin cells to move from the basal cell layer to the top of the stratum corneum and slough off.
The dermis is the middle layer of skin. It is a diverse combination of blood vessels, nerves, hair follicles and sebaceous (or oil) glands. The proteins collagen and elastinare found in the dermis. They provide support and elasticity to the skin. The sun’s rays can break down these proteins and, eventually, the skin begins to wrinkle and sag.
The subcutaneous layer, or subcutis, is a layer of fatty tissue that provides nourishment to the dermis and upper layers of skin. It also conserves body heat and cushions internal organs against trauma. Blood vessels, nerves, sweat glands and deeper hair follicles extend from the dermis into the fat (hypodermis).
Look Your Best—Limit Sun Exposure
Facial skin typically looks its best during a woman’s 20s. As you age, your skin becomes thinner and often drier. Thinning skin is a result of a breakdown of collagen and elastin fibers. As it ages, skin loses elasticity—especially if it has been exposed to excessive sunlight—and becomes more fragile and drier. However, there are a number of dietary and lifestyle changes that you can make to help keep your skin healthy and young-looking.
Because exposure to the sun causes most of the skin changes associated with aging, protecting the skin from the sun is the single most important skin care practice you can adopt. Significant exposure to the sun will wrinkle and dry the skin. Uneven pigmentation—from freckles to small or large brown spots—is another side effect of frequent sunning. Melasma, commonly associated with pregnancy, is brought out by the sun and produces large brown patches on the forehead and cheeks.
The most serious consequence of sun exposure is skin cancer. Skin cancer is the most common type of cancer, making up nearly half of all diagnosed cases of cancer, according to the American Cancer Society (ACS). Most sun damage occurs prior to the age of 18, but skin cancer can take up to 20 or more years to develop; children who experience just a few serious sunburns are believed to have an increased risk of developing skin cancer later in life.

Diagnosis

Primary care physicians are able to evaluate many skin conditions. They may be the first health care professionals you discuss your skin problems with. However, dermatologists are physicians with extensive training in skin care and skin disorders. Skin conditions can be difficult to diagnose because there are so many skin problems and symptoms may be similar. Consultation with a dermatologist is recommended to get an accurate diagnosis and treatment plan. It may be the more cost-effective means of diagnosing and treating skin disease.
Acne. This aggravating condition may be mild with small blackheads and whiteheads; moderate, with some inflammation, pustules (closed pus-containing pockets) and red pimples; or severe, with large cysts or nodules. Severe acne can result in permanent scarring. Contrary to popular belief, greasy foods and dirt do not cause acne. Acne is caused by genetic influences—if your parents had acne, you are more likely to develop it. Hormones, specifically male hormones called androgens, of which testosterone is the best known, also play a major role in acne’s development.Acne is a buildup of oil, microorganisms and dead skin cells in the hair follicles under the skin. When the hair follicle ruptures, the rupture triggers an “acne cascade,” which inflames surrounding tissue. Androgens are a major influence on acne because they stimulate the hormone-sensitive sebaceous glands, which produce sebum. That’s why you don’t see acne before puberty. In women, birth control pills can either aggravate or improve acne. This probably depends on your response to progestin—one of the hormones used in many birth control pills. Greasy hair and skin products, perspiration, headbands and other things that can plug up pores make acne worse. Stress may trigger acne flare-ups. Squeezing pimples can make acne worse and more likely to leave scars.
Rosacea. According to the National Rosacea Society, more than 16 million Americans have rosacea, but most of them don’t know it. It is most common in fair-skinned women between ages 30 and 50, although it can occur in all races. Rosacea can present itself in different ways. It may appear as pink or red flushing or dilated blood vessels alone or with pus-filled bumps or deeper red bumps. It can also cause skin thickening and enlargement, usually around the nose. Rosacea may worsen with exposure to certain factors such as hot or cold temperatures, sunlight, alcohol, spicy foods, stress and heavy exercise. Chronic use of topical steroids on the face may lead to steroid rosacea. The cause of rosacea is unknown.
Eczema. An estimated 15 million people in the United States have some form of eczema. Also known as atopic dermatitis, this condition causes an itchy, red, cracked, scaly rash that can occur anywhere on the body, but most commonly on the arms and the backs of the knees, as well as on the hands, feet, face and neck. It is hereditary and often occurs in individuals who suffer asthma or hay fever. Dry skin, certain soaps and bathing too frequently worsen the condition; moisturizers and humid air may improve it. Adults may get a form called nummular eczema, which tends to be scaly, coin-shaped spots on the arms and legs.
Dandruff. Mistakenly attributed to dryness because of the flaking it causes, dandruff is caused by inflammation in the scalp. The microscopic scales accumulate and then fall off in visible flakes.
Hives. Called urticaria, hives are an allergic reaction. It’s rarely clear what triggers hives. They can be stress-related. These pink, itchy swellings are caused by the release of histamine and other chemicals in the skin. Eggs, chocolate, seafood, nuts, milk and medications are occasional triggers of hives for some people, as are exposure to cold temperatures or infections. Individual hive lesions generally fade in 24 hours or less. When hives develop in the throat, breathing can become difficult and may be life threatening, and immediate treatment is required.
Psoriasis. A chronic disease affecting up to 7.5 million Americans, psoriasis causes the skin to become inflamed with red, thickened areas that become covered with flaky, silvery scales. The condition is not contagious, and the ultimate cause is not known, although it is thought to be an immunologic genetic disorder. Because of this immune stimulation, the uppermost layer of skin cells multiplies at an accelerated rate. A normal epidermis is replenished about every 28 days, but psoriasis causes the skin cells to multiply so quickly that it replenishes every two to four days. This new skin grows so fast the cells don’t have a chance to slough normally. Psoriasis typically appears on elbows, knees and scalp, but it can also arise on your lower back, buttocks, palms, soles and genital region. Psoriasis can occur in areas of trauma such as severe sunburns or surgical scars. Psoriasis may be associated with a specific type of arthritis, known as psoriatic arthritis. Lesions can be triggered by stress, infection, climate changes and medications. There is no cure for this condition, but treatments can reduce skin inflammation.
Stretch marks. During pregnancy, as a woman’s skin stretches to accommodate her baby’s growth, stretch marks may appear. They are initially light pink or purple lines that eventually fade to white. Stretch marks are most often found on the breasts, thighs, abdomen or hips. Stretch marks may also be caused by pubescent growth spurts or other rapid weight gain or muscle buildup.

Skin Cancer

An early warning sign of severe sun damage is the development actinic keratoses. Most common in people over age 40, this precancerous condition develops as a result of cumulative, extensive sun exposure and can lead to skin cancer, specifically squamous cell carcinoma. Actinic keratoses are responsible for more than 2 million visits to dermatologists each year in the United States. These lesions appear as scaly red/brown bumps on the face, ears, neck, lips and forearms or on the backs of the hands. These lesions may itch or feel tender, especially when exposed to sunlight.
There are two main groups of skin cancer: nonmelanoma skin cancer, the most common type of skin cancer, and melanoma (sometimes referred to as “malignant melanoma”) skin cancer.
Basal cell carcinoma and squamous cell carcinoma are the most common forms of nonmelanoma skin cancers. There more than 1 million cases each year in the United States. These types of cancer start in the skin’s basal cell layer or squamous cell layer. Men are at higher risk than women for basal cell carcinoma and squamous cell carcinoma.
Melanoma is the least common but most aggressive of the three most common types of skin cancer. Melanoma originates in the skin’s melanocytes—the cells that produce pigment, or melanin. Melanoma typically appears in or around a mole, but it may also develop on clear skin. It may be a flat, brown, black or tan spot or a raised bump. Unlike a noncancerous mole, melanoma often is irregularly shaped.
About 68,720 new cases of melanoma were diagnosed in 2009—less than 5 percent of all diagnosed skin cancers. But melanoma accounts for a large majority of skin cancer deaths, according to the ACS.
Anyone may develop skin cancer, but people with fair complexions are more susceptible to precancerous conditions and skin cancer than people with darker skin tones. Caucasians have a tenfold increased risk of developing skin cancer than African Americans. Darker skin has more melanin, which provides some natural protection against the sun’s damaging rays. In addition to fair skin, other risk factors for skin cancer include:
exposure to toxic materials, such as arsenic
radiation therapy
chronic non-healing or scarred skin such as long-standing ulcers or severe burn scars
a family history of melanoma skin cancer or other conditions that are more likely to develop into skin cancer (such as dysplastic nevus syndrome)
a personal history of skin cancer
a tendency to freckle or burn easily
lots of sun exposure throughout your life
many sunburns as a child or adolescent
outdoor summer employment during adolescence
burns
tanning bed use (Frequent use of tanning beds may increase your risk of melanoma by 40 to 75 percent, depending upon frequency of use and age you began tanning.)
Check Your Skin Regularly
Precancerous skin changes and skin cancer are usually easy to recognize and are often curable when detected and treated in early stages.
The first step in detecting abnormalities that may be skin cancer begins with you. Examine your skin once a month for any suspicious changes. Sores that won’t heal may also indicate skin cancer or precancerous conditions that need attention.
The American Academy of Dermatology has developed an easy-to-use method to evaluate your skin for melanoma. Look for the “ABCDEs”:
Asymmetry: One half of the spot is not shaped like the other half
Border irregularity: Poorly defined or “scalloped” border
Color: Shades of tan, brown, black and sometimes red, white and blue, vary across the spot
Diameter: The spot is larger than six millimeters, the diameter of a pencil eraser, however, skin cancers can also be smaller
Evolving: The mole looks different from the other moles on the body and is changing in size, shape or color.
A condition called dysplastic nevus/melanoma syndrome can increase a person’s risk for developing melanoma. A “nevus” is a mole. These particular moles are often irregularly shaped and may be larger than other moles. They can appear anywhere on the body—sun-exposed or not. This condition tends to run in families. A person with this condition may have many moles on her body or just a few. Researchers believe that a genetic predisposition for dysplastic nevus syndrome may exist.
Diagnosing Skin Cancer
There are several types of skin biopsies that health care professionals may perform if you have suspicious-looking growths that could be skin cancer. A skin biopsy involves giving you a local anesthetic, after which a sample of skin will be taken for examination under a microscope. You may feel minor discomfort—a small needle stick and burning—for a few seconds. Types of biopsies are as follows:
Shave biopsy. The epidermis and the upper part of the dermis are shaved off in a thin slice. This procedure is performed with local anesthesia.
Punch biopsy. A sample of the entire thickness of the skin is taken (about 1/8 inch) with an instrument that takes a cylindrical core sample of the skin and a small part of the underlying fat layer.
Incisional biopsy and excisional biopsy. With a scalpel, a wider and deeper sample of skin with various amounts of the underlying fat will be removed, and then the wound is closed with stitches or staples. Incisional biopsy removes a portion of the growth, and excisional biopsy is used to remove or sample broad or deep growths.

Treatment

There are many new and refined treatment options available today for skin conditions. Consultation with a dermatologist is recommended to determine which option is best for your condition as well as for recommendations about how to keep your skin healthy. Here are a few treatment options for common skin conditions.
Acne. Treatment can include topical or oral antibiotics and creams to remove plugs at the opening of the oil glands. Birth control pills can sometimes improve acne. When washing, you should use a mild soap and avoid scrubbing. Topical benzoyl peroxide can help reduce bacteria, and retinoic acid can help unblock pores. Acne washes and nonprescription preparations may also be helpful. Isotretinoin (Accutane), a prescription medication, can provide long-term remission of severe acne in some people. Accutane often causes side effects such as dry eyes, lips, nose, mouth and skin, itching, nosebleeds, muscle aches, sun sensitivity and poor vision at night. In rare cases, the drug may also increase risk of depression and suicide. Discuss these risks with your health care professional, and if you feel unusually sad or overwhelmed while taking Accutane, seek medical attention immediately.When not treated, moderate and severe acne can cause significant scarring. Cosmetic treatment for scarring includes chemical peels, dermabrasion, microdermabrasion and laser resurfacing. For deep, crater-like scars where laser resurfacing is ineffective, there is soft tissue augmentation. This is a procedure in which the patient’s fat (from another part of the body) is used to correct the deep contour, or soft tissue fillers like collagen, hyaluronic acid or fascia lata may be used.
Rosacea. While the cause of rosacea is unknown, there are a number of lifestyle factors, triggers and habits that may contribute to flare-ups. Your health care professional, specifically a dermatologist, can help you determine your personal triggers and provide guidance on the right skin care routines for you. Triggers may include stress, alcoholic beverages, spicy foods and intense weather conditions such as heat, humidity and wind. Practice “sun safety” whenever possible and use sunscreen; wear light-colored, tightly woven protective clothing; and avoid the sun. Using fragrance-free skin care and make-up products and avoiding deodorant soaps can help reduce skin irritation. Rosacea also may be aggravated by ingredients such as menthol, alcohol and peppermint. Consult your dermatologist on which products are best for your skin.Your dermatologist may also prescribe medications for your rosacea. There are topical creams and gels, as well as an oral anti-inflammatory medication FDA approved for rosacea. To treat persistent facial redness, the most common symptom of rosacea, a new treatment option is now available. Mirvaso® (brimonidine) topical gel, 0.33%, is the first FDA-approved medication developed to treat the persistent facial redness of rosacea. Mirvaso is thought to work by constricting dilated facial blood vessels that increase blood flow to the skin and cause the face to look red and flushed. Used daily, topical Mirvaso works quickly and reduces redness for up to 12 hours. Erythema, flushing, skin burning sensation and contact dermatitis are the most common side effects of brimonidine. Because Mirvaso is an alpha-2 adrenergic agent, it can lower blood pressure and should be used with caution in patients with uncontrolled cardiovascular disease.
There are several medications approved to treat the bumps and blemishes of rosacea, including topical metronidazole and topical azelaic acid. Common side effects of metronidazole include cold symptoms, upper respiratory tract infection, and headache. Other topical treatments may include sulfacetamide/sulfur cream or wash, but many find the odor unpleasant. An oral anti-inflammatory, doxycycline, is approved in a low-dose formulation to treat the bumps and pimples associated with rosacea. This once-daily pill is a convenient alternative to creams and gels and has not been shown to cause bacterial resistance. Common side effects include cold symptoms, sinus infection, diarrhea, hypertension and increased liver enzymes.
Eczema. Treatment includes oral antihistamines for relief of the severe itching, as well as topical steroids to relieve inflammation and itchiness. The U.S. Food and Drug Administration has approved two ointments—tacrolimus (Protopic) and pimecrolimus (Elidel)—to treat eczema. Both are in a class of drugs called topical immunomodulators (TIMS), which are steroid-free and appropriate and effective for patients seeking an option to avoid the side effects associated with steroids. However, because the effect of extended use of these medications is unknown, the FDA recommends that Elidel and Protopic only be used when a person cannot tolerate other eczema treatments or when all other treatments have failed.Your doctor may prescribe a short course of oral corticosteroids, such as prednisone, to relieve inflammation. Low-potency corticosteroids are also available over-the-counter, but check with your doctor before taking them. Moisturizers are an essential part of eczema therapy but should be chosen carefully because they can inflame sensitive skin. Newer products called barrier repair creams have no topical steroids and may repair the skin disruption caused by eczema. These may be an adjuctive therapy or solo therapy. Petroleum jelly is an excellent bland lubricant for this condition. And anti-itch lotions like calamine lotion and Benadryl can also provide some relief.
Dandruff. Medicated shampoos containing coal tar (Ionil T, T/Gel, Pentrax), salicylic acid (X-Seb T Plus, Meted), selenium (Selsun Blue), zinc (Head & Shoulders, ZNP) or sulfur (Sebulex) can help this condition. For best results, buy two or three types and alternate them. Prescription shampoos and topical steroid medications may be necessary in difficult-to-treat cases.
Hives. Antihistamines and sometimes oral steroids are prescribed to treat hives. In the case of a severe attack of hives, an emergency adrenaline (epinephrine) injection and a trip to the emergency room may be necessary.
Psoriasis. There is no cure for this condition, but treatments can reduce skin inflammation. Topical steroid medications are frequently prescribed, but the condition often returns quickly once treatment ends. UVB light therapy, sunlight, oral and topical vitamin A derivatives, coal tar, salicylic acid, hydroxyurea (which can be combined with light therapy), anthralin and topical vitamin D derivatives often help. Anthralin (Dritho-Scalp), a medication believed to normalize DNA activity in cells, can help improve smoothness of the skin. The oral medication tacrolimus (Prograf) and new injectable medications used for treating arthritis, such as etanercept (Enbrel) or infliximab (Remicade), seem to be very effective for some individuals with psoriasis. For more severe forms of psoriasis, methotrexate (Trexall), an immunosuppressant drug used to treat rheumatoid arthritis and other conditions, is sometimes prescribed. This medication, which can be taken by pill or injection, slows cell production by suppressing the immune system. Patients taking methotrexate must be closely monitored to avoid possible liver damage and/or decreased cell counts. Pregnant women or those who are planning to become pregnant should not use methotrexate. Cyclosporine, another immunosuppressant drug, is also sometimes prescribed. This medication increases risk for high blood pressure and kidney problems.
Stretch marks. There is no cure for stretch marks, although topical retinoic acid and laser treatments may lighten them. Treatment may not be worth the cost since it won’t completely eliminate stretch marks. Topical camouflaging makeup provides a quick cover-up for stretch marks.
Skin Cancer Treatments
There are three primary kinds of treatments your health care professional may use to treat your actinic keratoses (precancerous lesions) or your skin cancer:
surgery, which removes the cancer, or destroys these abnormal cells
chemotherapy, which uses drugs to kill these abnormal cells
radiation therapy, which uses x-rays to kill cancer cells
immunotherapy, which encourages a person’s own immune system to recognize and destroy cancer cells
Most often, your health care professional will choose surgery. Common types of skin cancer surgery techniques include:
Cryosurgery freezes the tumor, which kills it.
Electrodessication and curettage involves your health care professional coring out the skin cancer with a special tool and using an electric current to burn the tumor and destroy any additional tumor cells.
Simple excision cuts the cancer from the skin in a football shape, along with a border of some of the healthy tissue around it.
Mohs micrographic surgery removes the cancer and is a tissue-sparing technique. The specialized surgeon removes the cancer and maps it out, then examines the skin under a microscope, only taking additional pieces if any cancer remains. This method allows a complex repair to be done that day and know that the cancer is gone and that a second procedure will not be required. This type of procedure is used for recurrent skin cancers or on delicate areas of the face such as the nose.
Lymph node surgery. If the doctors are concerned that skin cancer may have spread to the lymph nodes, they will perform a lymph node dissection and check the nodes for signs of cancer under a microscope (a biopsy).
Laser therapy uses a highly focused beam of light to destroy the cancer cells with minimal bleeding, swelling and scarring and little damage to surrounding tissue. Laser therapy is usually used to treat superficial skin cancers.
Removal of large tumors creates large defects, so sometimes skin is taken from another part of your body and grafted over the area where the cancer was removed.
Chemotherapy can be a topical cream or lotion placed on the skin to kill cancer cells, an orally ingested drug or a drug that is injected directly into the tumor or a vein or muscle.
Radiation therapy shrinks tumors with x-rays aimed at the affected area from outside the body.
And certain drugs called immune response modulators can cause an immune response to the cancer, which causes it to shrink.
A more recent and less common technique called photodynamic therapy uses a certain type of light and a special (light-sensitive) chemical to kill cancer cells. Photodynamic therapy can be used to treat actinic keratoses and is also used to treat or shrink non-melanoma skin cancers.

Prevention

Skin care starts with you. Many simple lifestyle changes—such as improving your diet and learning basic skin care techniques can improve your skin’s appearance. Discuss prevention tips with your health care professional, and consider these steps:
good nutrition
drinking six to eight glasses of water per day
avoiding alcohol
stopping smoking
using sunscreen regularly
avoiding sun exposure during peak sun hours between 10 a.m. and 4 p.m.
wearing protective clothing when outside
Most health care professionals recommend a simple cleansing regimen as the best approach to keep skin healthy: a gentle cleanser using warm (not hot) water, no abrasive scrubs and, when necessary, a moisturizer with sunscreen protection. In addition, you should gently pat your skin dry rather than rub it vigorously after a bath or shower to help avoid irritation and itching.
Dry Skin
Moisturizers for dry skin come in three preparations: lotions, creams and ointments. Lotions are least effective at replacing and retaining lost moisture in very dry skin. But they disappear after application very quickly, making them the most convenient to use and possibly helpful for normal and oily skin. Creams are heavier than lotions and are therefore more effective at sealing in moisture for normal to dry skin. Ointments, such as Vaseline, are thick and are best for preventing moisture from escaping from the skin, but you may find that they are inconvenient to use regularly. Health care professionals advise women with very dry skin against using soap and also alcohol-based astringents (toners), which typically dry out the skin.
Making Skin Look Younger
Alpha hydroxy acids (AHAs) (AHAs, glycolic acid, lactic acid), antioxidants (vitamins A, E, C) and vitamin A derivatives (Retin-A, Renova and retinol) in moisturizers are frequently promoted as products that can make skin younger looking. Here’s what to expect from these and other newly available products:
AHAs. They contain lactic acid (found in milk), fruit acids and glycolic acids (found in sugar cane). AHAs, like tretinoin derivatives, work by peeling away dead and thickened areas of the skin. Cosmetic treatments containing highly concentrated AHAs, known as chemical peels, have long been available from dermatologists. AHAs used by trained cosmetologists contain 20 to 30 percent concentration of AHAs and provide a superficial smoothing of the skin’s texture similar to microdermabrasion. These treatments must be repeated every three to six months to maintain results. Doctors can use AHA products with concentrations of up to 70 percent in chemical peels to erase fine wrinkles and remove surface scars; the results of these treatments can last up to five years. Over-the-counter (OTC) preparations are required by the FDA to contain less than 10 percent concentration of AHAs. They may provide a little improvement of scaly skin. Higher concentrations of the active ingredients in OTC products are buffered and therefore neutralized to prevent peeling. These OTC AHA products are not known to improve skin wrinkling. Improvements with these or prescription products last only as long as the product is used. Long-term effects of AHAs are unknown. They can irritate the skin and make it more sensitive to sunlight. Signs of sensitivity are redness and burning.
Antioxidants. Vitamins A, E and C are known as antioxidants. Their claim to fame as skin health aides is in their ability to fight free radicals, the highly reactive molecules generated by oxygen, sunlight, smoking and pollution that can break down the collagen fibers of the skin. Some studies show some promise, but overall, research is inconclusive about how effective antioxidants are for improving the skin’s appearance. Ingestion of large amounts of some of these vitamins can be toxic. High doses of vitamin A, when taken during pregnancy, are suspected of increasing the risk of birth defects. Topical treatments of antioxidants can cause rashes, but small amounts are probably not harmful for most skin types.
Renova. This prescription cream is basically Retin-A in a moisturizing base that decreases the redness and burning associated with Retin-A. The active ingredient in Retin-A and Renova is tretinoin, a vitamin A derivative. You must use these products daily for months to notice improvement, and it will probably last only as long as the cream is used. Renova and Retin-A may make the skin sun-sensitive, so wearing sunscreen and protective clothing during treatment is important. Side effects include redness, dryness and sensitivity. Oral or topical use of retinoids during pregnancy or while planning a pregnancy should be avoided.
Injectable wrinkle fillers. Botox is the best known of these, but there are several other injectable wrinkle fillers also approved by the FDA. Here’s a look at some:
Botox injections. Botulinum (or botulism) toxin type A (Botox Cosmetics, Dysport) is a prescription drug that may be used to temporarily improve the appearance of moderate to severe frown lines between the eyebrows. Botulinum toxin type A is a protein produced by the bacterium clostridium botulinum. When used as an anti-aging agent, small doses of a purified, sterile form of the toxin are injected into certain facial muscles to temporarily paralyze and weaken them. When the muscles can’t contract normally, frown lines disappear. According to the FDA, Botox treatments should not be injected more frequently than once every three months, and the lowest effective dose should be used. The most common side effects following injections include headache, dry eyes and mouth, flu-like symptoms, nausea and weakness of the muscles near the injection site. Check with your doctor if any of these side effects persist. Less frequent adverse reactions include fever, bleeding at the injection site, irregular heartbeat and vision changes. If you experience any of these side effects, seek medical attention right away. These reactions were temporary but could last as long as several months.
Restylane and Perlane are soft-tissue fillers used for moderate to severe wrinkles around the nose and mouth. They use a synthetic form of hyaluronic acid. Perlane contains more hyaluronic acid and therefore works better for filling deep lines, while Restylane is used in fine lines or in thin-skinned people. One injection is needed for six to 12 months of effectiveness, depending on the patient and the area being treated.
Juvederm, also a soft-tissue filler for moderate to severe wrinkles, is a natural hyaluronic acid, which works similarly to Restylane, but degrades more slowly and lasts longer. The treatment may last 12 months.
Hylaform is used for moderate to severe wrinkles and folds. It is a form of hyaluronic acid made from rooster combs.
Captique is used for wrinkles around the nose and mouth. Results are immediate. Two to three touchups a year are usually needed to maintain results.
Juvederm, Restylane and Perlane now come with lidocaine in the product, which makes the procedure much more comfortable.
Natural products. The pharmacological effects of materials such as seaweed and oatmeal, often used in face masks or peels, are unknown. Papain, an enzyme found in papaya, is helpful in sloughing off dead skin cells, but can be expensive.
Synthetic fillers (Artefill, Radiesse, Sculptra). Synthetic fillers are used for filling facial wrinkles and folds. It takes less than an hour for synthetic filler injections, and the results can last anywhere from six months to five or more years, depending on the filler product. Synthetic fillers differ depending on the brand:
Artefill contains 20 percent polymethyl-methacrylate (PMMA) beads suspended in 80 percent collagen. A few months after injection, the collagen breaks down, sparking your body to produce its own natural collagen to fill in the space. Unlike other fillers, Artefill is not absorbed by the body.
Radiesse is an injectable calcium hydroxylapatite gel. Calcium hydroxyapatite is found in teeth and bones and is used for numerous medical applications including cheek, jaw, skull and chin implants. Another brand name is Radiance.
Sculptra is an injectable polylactic acid. This compound is used in numerous medical products, such as stitches and screws used to repair broken bones. Although Sculptra has only been approved to restore shape and contour to the faces of those with AIDS, it is often used “off label” for cosmetic treatments. Sculptra usually requires three monthly treatments to rebuild the lost volume. It may take up to four to six weeks to see the full effect, and while Sculptra is considered semi-permanent, you may need an occasional touch-up treatment.
Collagen products. Collagen products have been on the market for over 20 years. Some of the most popular are CosmoDerm, CosmoPlast, Zyderm and Zyplast. Other collagens used in cosmetic procedures include Artefill, a mixture of bovine collagen and tiny plastic spheres; Autologen, collagen from your own skin; Isolagen, collagen taken from your own skin and cloned and processed into a liquid form; and Dermalogen, collagen from human cadaver skin that has been sterilized, purified and processed into a liquid form.
Protect Your Skin from the Sun
Reducing your exposure to the sun is the best way to keep your skin healthy. Here’s why:
Sunlight consists of two main types of ultraviolet (UV) rays that damage skin—UVA and UVB rays.
UVB rays are the main cause of sunburn and skin cancer. This type of sunlight intensifies during the summer and can do more damage more quickly than UVA rays. The epidermis absorbs most of the intensity of UVB rays. UVB rays cannot pass through glass, although UVA rays can. UVC rays, another spectrum in sunlight, are also potentially harmful, but the ozone layer blocks them from reaching the earth. UVA and UVB rays are present all year and are hazardous whether they are direct or reflected.
When the sun’s ultraviolet radiation reaches the surface of the skin, the skin reacts by producing melanin—otherwise known as a tan—to protect itself. UVA rays are milder than UVB rays, but because their wavelengths are longer, they penetrate deeper through the skin’s layers. UVA rays contribute to wrinkling the skin, as well as to the development of skin cancer.
UVA rays also are used in tanning booths. UVA rays in tanning booths not only inflict damage similar to sunlight, they are also more intense in a tanning booth than the equivalent time spent in natural sunlight.
Sunscreens
Sunscreens should be an important part of your skin health routine because they absorb or block UV rays. Sunscreens are rated by how much sun protection factor (SPF) they offer. SPF calculations are based on laboratory comparisons of how much sunlight will cause mild sunburn on the unprotected skin of a person with a fair complexion and on the same skin area protected by sunscreen.
The effectiveness of a sunscreen is dependent on the types of sun protective chemicals used, the thickness of the cream or lotions and the amount of product applied to the skin. Not all sunscreens provide protection against UVA radiation. Be sure that the sunscreen you purchase states it provides UVA/UVB protection. While sunscreen use helps to minimize damaging sunburns, it doesn’t completely prevent burning.
A sunscreen with SPF-30 or greater should be used all year for all skin types. If you develop a rash or other type of allergic response to a sunscreen, try a different brand or form (lotion vs. gel, or protective clothing, for example) or switch to a sunscreen containing the active ingredients of titanium dioxide or zinc oxide. These products don’t require chemical interaction with the skin to be effective, provide a protective shield-like barrier and rarely cause rashes. All sunscreens need to be reapplied after water contact or sweating.
For the best protection from the sun’s harmful rays:
Apply sunscreen with an SPF of 30 or higher 15 to 30 minutes before sun exposure, with careful attention to sun-exposed areas such as the face, hands and arms.
Apply lip balm that contains a sunscreen to protect sun-sensitive lips.
Avoid the sun between 10 a.m. and 4 p.m., when its rays are strongest.
Wear a large (three-inch), brimmed hat and sunglasses to protect your scalp and eyes.
Reapply sunscreen at least every two hours, but you should apply it more frequently if you have been swimming or sweating. Use about 1 ounce of cream—about one shot glass—to cover your entire body with each application.
Stay in the shade whenever you can.
Limit the time you spend in the sun.
Be aware that the sun’s ultraviolet rays can reflect off water, sand, concrete and snow, and can reach below the water’s surface as well as burn on an overcast day.
If you are taking an antibiotic or other medication, ask your health care professional if it may increase your skin’s sensitivity to the sun and what you should do about it.
Don’t forsake the sun altogether. Learn how to protect your skin from the sun’s harmful rays and practice “sun safety” whenever you can—cover up with sunscreen and wear light-colored, tightly woven protective clothing and be sensible about how much time you spend in the sun. These steps can help reduce your risk for developing skin cancer and keep your skin looking its best.

Facts to Know

When the skin becomes dry it needs water and oil to help rejuvenate it.
The skin is your body’s first defense against disease and infection. It is the largest organ in the body. It helps regulate body temperature and prevent fluid loss; furthermore, it helps your body remove excess water and salt.
The process of producing healthy new skin cells and removing or shedding old cells takes about 28 days.
As you age, your skin becomes thinner and often drier. Thinning skin is largely a result of a breakdown of collagen fibers. As it ages, skin loses elasticity and becomes more fragile, especially if it has been exposed to excessive sunlight.
Because exposure to the sun influences how well your skin ages, protecting the skin from the sun is the single most important practice in skin care.
Continuous exposure to the sun will wrinkle, dry out and age the skin, leaving it coarse. Uneven pigmentation—from freckles to brown spots—is another side effect of frequent sunning.
The most serious consequence of sun exposure is skin cancer. Skin cancer is the most common type of cancer, making up nearly half of all diagnosed cases of cancer, according to the American Cancer Society.
Skin cancer can take up to 20 years or more to develop; it’s important to remember that a person’s average lifetime sun exposure risk is determined by age 18.
Anyone can develop skin cancer, although people with fair complexions tend to be more susceptible to specific types of skin cancer and precancerous conditions than people with darker skin tones.
The earliest warning sign of severe skin damage is the development of actinic keratoses. Lesions appear as scaly red/brown bumps on the face, ears, neck, lips and forearms or on the backs of the hands.

Key Q&A

What causes acne?Acne is caused by genes and male hormones called androgens, which women have, too. Hormones are a major influence on acne. That’s why you usually don’t see acne before puberty. Bacteria contribute to acne—which is why either oral or topical antibiotics help. Greasy ointments, perspiration, headbands and other things that can plug up pores make acne worse. Stress may also make it worse. What you eat is generally not a major contributing factor to developing acne, although some research has suggested that a heavy sugar diet may aggravate acne in some select patients
Are tanning beds safer than the sun?No. Tanning beds not only inflict the same type of skin and eye damage as the sun, but their rays are also stronger than natural sunlight. Tanning beds typically use UVA rays. Although UVA rays are milder than UVB rays—the main cause of sunburn and sun cancer—UVA wavelengths are longer, and they penetrate deeper through the skin’s layers. UVA rays contribute to wrinkling the skin, as well as to the development of skin cancer. Some diseases, such as discoid or systemic lupus, and some oral medications, such as those containing sulfur, are aggravated by light exposure, especially in the UVA range. Regular tanning bed use especially in teenagers may increase the risk of melanoma up to 75%.
Can dermabrasion, chemical peels or laser treatments get rid of wrinkles? What are the risks and benefits of each and how long do the effects last? What other treatments are available?Yes, they can. Although the improvements can last many years, they are usually not permanent and may have to be repeated periodically. Dermabrasion and medium-depth chemical peels have both been used for many years to improve the appearance of superficial wrinkling, to eliminate sun-induced pigmentation and keratoses and to improve the overall surface texture of the skin. In the past decade, laser resurfacing has grown popular because it may be easier to control and therefore produces a more predictable outcome. Laser resurfacing, however, is usually more expensive and frequently involves longer healing times, possibly requiring the patient to remain at home until healing is complete. The newest laser resurfacing procedures are fractionated. These include ablative (which disrupts the epidermis) and non-ablative (which sends heat into the dermis and leaves the epidermis intact). These procedures require multiple treatments, but have reduced healing times. All of these procedures, if done correctly, are relatively safe, although localized scarring and pigment alterations can occur in a small percentage of patients.
Botox or Dysport, (botulism toxin type A) helps smooth moderate to severe facial frown lines for up to six months. Small doses of a purified, sterile form of the toxin are injected into certain facial muscles, which temporarily paralyzes and weakens them. When the muscles can’t contract normally, frown lines disappear. According to the FDA, Botox treatments should not be injected more frequently than once every three months, and the lowest effective dose should be used. Side effects may include nausea, rash, localized muscle weakness, flu-like symptoms and redness at the injection site. These side effects are usually temporary. If they persist, call your doctor.
If I have dandruff, does that mean my scalp is dry?No! Mistakenly attributed to dryness because of the flaking it causes, dandruff is actually caused by inflammation of the scalp. Medicated shampoos can help this condition.
Do Renova and Retin-A work to reduce acne and wrinkles?Yes. Retin-A was developed nearly 40 years ago as an acne treatment. It works on acne mainly by altering the growth of the top layer of the skin to unplug pores. Retin-A can be irritating for some people. Retin-A is typically used at night. Several years ago, researchers found that Retin-A had a beneficial effect on the dermis and worked for wrinkles as well. Truthfully, it doesn’t work for the deeper wrinkles on the face, but does have an effect on the more superficial wrinkles. The company that makes Retin-A also produces Renova cream, which is basically a less irritating form of Retin-A.
What type of SPF should I look for in sunscreen?Look for a sunscreen with an SPF of 30 or higher that blocks both UVA and UVB rays. The SPF number only relates to the UVB protection. Zinc oxide and titanium dioxide preparations provide good protection and little problem with skin rashes.
Should I avoid the sun altogether?No! Who wants to stay inside all the time? Bright, beautiful days should be enjoyed. Plus, sun exposure helps your body make bone-protecting vitamin D. Sunlight isn’t entirely bad, but tanning and long-term exposure are. Learn how to protect your skin, and protect it whenever you’re outside. Certain companies sell specialized sun-protective clothing and hats providing additional protection to the skin. These are also good for children. Ask your dermatologist about these or look for them on the Internet.
Does sunscreen prevent sunburn?While sunscreen helps to minimize damaging sunburns, it doesn’t completely prevent burning. You still need to avoid the sun between 10 a.m. and 4 p.m., when its rays are strongest; wear a large-brimmed hat and sunglasses to protect your scalp and eyes; cover other sun-exposed parts of your body; stay in the shade when possible; and limit the time you spend in the sun.
My skin is sensitive and acne-prone and sunscreen irritates it. What can I do?If you’re prone to rashes, try different brands and types of sunscreen until you find one that doesn’t cause a rash. Gels may be drying, but they may be preferable to lotion or cream sunscreens if you have oily skin and are acne-prone. Discuss your skin reactions with a dermatologist for other suggestions.
I’ve never had moles before but I just noticed a brown spot on my skin. Should I be worried?Although melanoma may begin in or around a pre-existing mole, it often appears without warning on clear skin. You should bring your condition to the attention of your health care professional for further evaluation and an accurate diagnosis.

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Smoking

Overview

Fifty years ago smoking was thought of as a primarily male “pastime.” But in the decades since, women have just about closed the gender gap while at the same time experiencing dire health consequences, just like men. According to the most recently available statistics from the U.S. Centers for Disease Control and Prevention in 2010, 19.3 percent of American adults (45.3 million people) smoke. Every year, smoking kills an estimated 443,000 people through smoking-related diseases, including lung and other cancers, heart disease, stroke and chronic lung diseases such as emphysema.
Smoking has long been the leading cause of preventable death and disease among women. And, according to recent surveys, many women do not realize that lung cancer, once rare among women, surpassed breast cancer in 1987 as the leading cause of female cancer death in the United States.
In fact, it has been proven that smoking can cause disease in nearly every organ of the body, in women as well as men. The list of diseases caused by smoking has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract, cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis and stomach cancer. These are in addition to diseases previously known to be caused by smoking, including bladder, colorectal, liver, esophageal, laryngeal, lung, oral and throat cancers, chronic lung diseases, coronary heart and cardiovascular diseases, as well as reproductive effects and sudden infant death syndrome.
Smoking also harms many aspects and every phase of reproduction: menstrual function, oral contraceptive use, fertility, problems in pregnancy and giving birth to low-weight babies, among other conditions.
In addition, smoking increases your risk of developing osteoporosis. Smoking is related to an increased risk for hip fracture as well, especially among postmenopausal women (studies have shown that bone mineral density and body mass are lower in smokers). Smoking also affects your appearance. Long-term smoking will cause your skin to wrinkle prematurely and lose its elasticity, your nails and teeth to turn yellow and your breath to smell foul.
While smoking rates have fallen among women since 1965—33.9 percent of women were smokers in 1965, as compared with 18.3 percent in 2008—teenagers are still lighting up. According to the CDC, each day, more than 3,800 teenagers younger than age 18 smoke their first cigarette, and 1,000 teenagers younger than 18 begin smoking on a daily basis.
Adolescents who smoke are generally less physically fit and have more respiratory illnesses than their nonsmoking peers. In addition, smoking by adolescents hastens the onset of lung function decline during late adolescence and early adulthood. Smoking by adolescents is also related to impaired lung growth, chronic coughing and wheezing.
Why Teenage Girls Smoke Despite Known Risks
With all of the negative publicity about smoking, why do so many women and teenage girls continue to smoke? Teenagers vastly underestimate the addiction potential ofnicotine. A woman who begins smoking when she is young will have a very difficult time quitting as she ages and becomes more concerned with the health consequences.
It is well documented that there are social, political and economic forces that influence tobacco use, particularly among youth. A major factor influencing susceptibility to and initiation of smoking among girls, in the United States and overseas, is the tobacco industry’s long-standing (75 years or more) targeted marketing to women and girls. Tobacco marketers know that if they can hook children, these children are more likely to become lifelong customers.
The tobacco industry spends more than $9.94 billion dollars annually in the United States to advertise and promote its products, including print media advertising (cigarette ads are banned from television and radio); distribution of free samples, cents-off coupons, T-shirts and other giveaways; movie product placements; cultural programs; donations to a wide range of national and local organizations; and political contributions to elected officials.
Women’s Greater Vulnerability to Tobacco
Some research has revealed that women might be more susceptible to the addictive properties of nicotine and have a slower metabolic clearance of nicotine from their bodies than men. Also, women seem to be more susceptible to the effects of tobacco carcinogens than men.
Women also tend to smoke for different reasons than men, citing more emotional triggers, such as relief of stress, anxiety, anger or depression.
Smoking and Addiction
Nicotine is what keeps smokers addicted to tobacco, and it doesn’t take long to get hooked. Nicotine is one of the most powerful addictive drugs—more addictive than heroin—yet it is also easily available and more socially accepted than other highly addictive substances.
Nicotine is the addictive chemical in tobacco but most of the negative health consequences of smoking are caused by the other 4,800 chemicals inhaled when tobacco products are burned. Carbon monoxide is also produced. It becomes attached to the red blood cells and decreases the oxygen available to the body tissues.
Nicotine’s effect on the central nervous system is what makes smoking pleasurable. Nicotine has a calming effect and can relieve anxiety, boredom and irritability. Nicotine also has a stimulant effect, increasing alertness and improving concentration.
Within seven to 10 seconds of inhaling, your brain feels the effect of nicotine. Repeated inhalations maintain a steady blood level of nicotine. When you stop puffing, the blood level goes down. You light up again to deliver more nicotine to the brain. Pretty soon your brain and body consider it normal for you to have a certain blood level of nicotine. When that level goes down, you feel uncomfortable, irritable and unfocused. That’s withdrawal. Now you are addicted. You smoke to keep from going into withdrawal, and you may find yourself smoking more and more.
Combined Effects of Smoking and Oral Contraceptives
Smoking cigarettes while taking birth control pills dramatically increases the risk ofheart attack for women over 35. Smoking is far more dangerous to a woman’s health than taking birth control pills, but the combination of oral contraceptive pill use and smoking has a greater effect on heart attack risk than when each factor is considered alone.
Smoking cigarettes while taking birth control pills increases a woman’s risk of having an ischemic stroke (three times more likely in pill users than in nonusers) or ahemorrhagic stroke (three to four times that of nonusers), according to a large World Health Organization study.
Effects of Smoking on Reproductive Health and Pregnancy
Smoking affects ovarian function and decreases the female hormone estrogen. If you are planning to become pregnant, cigarette smoking can impair your fertility by adversely affecting ovulatory and tubal function, egg production and implantation. Smoking may cause you to have irregular menstrual cycles. Women who smoke also have an earlier menopause, which may increase their risk of osteoporosis, heart disease and other conditions for which estrogen provides a protective effect.
Nearly 11 percent of pregnant women continue to smoke throughout their pregnancies. If you smoke while you are pregnant, you are putting yourself and your unborn child at increased risk for complications. Risks of smoking during pregnancy include:
complications from bleeding
low-birth–weight babies
increased risk of sudden infant death syndrome (SIDS)
premature birth
stillbirth
placenta previa (the placenta grows too close to the opening of the uterus, a condition that often leads to Caesarean delivery)
placental abruption (the placenta prematurely separates from the uterus wall)
premature rupture of uterine membranes
preeclampsia (a condition that results in high blood pressure and excess protein in the urine)
reduction of the newborn’s lung function
If you are a smoker and a nursing mother, it is important to know that nicotine is found in breast milk, and therefore enters your baby’s system.
If you have children, your smoke puts them at risk, too. Secondhand smoke has been shown to make children more susceptible to infections, including colds and flu, ear infections and lower respiratory infections such as bronchitis and pneumonia. It also causes new cases of asthma, and it makes existing cases of asthma worse.

Diagnosis

Regardless of how much you smoke, you need to quit.
Researchers now know that there is a strong family component to addiction. If you have a family history of addiction, you should be aware of the risk for developing dependency, especially during stressful periods in your life.
The vast majority of smokers are addicted or dependent on nicotine. In addition to overcoming nicotine addiction, the quitting smoker must fight the actual habit of smoking, the behavioral activity of lighting up a cigarette so many times a day for so many years. For many smokers, smoking becomes associated with many daily activities (driving, talking on the phone, watching TV, for example) and often, these activities won’t feel right without the cigarette. For many women, there is an emotional dependence on smoking. Maybe you smoke when you are stressed or sad. All of these issues combine to make smoking a powerful adversary if you are trying to kick the habit.
Even if you don’t smoke, but you live, work or socialize with smokers, your health is at risk if these people smoke indoors or around you. Secondhand smoking is the third leading cause of preventable death in the United States, killing close to 50,000 nonsmokers per year. Consider asking the person to “take it outside” and not smoke in your presence to protect your own health.
Six Stages of Quitting
There is strong scientific evidence that being able to successfully quit smoking is not a matter of luck or willpower or simply flipping a light switch—making one quick change or decision that transforms you suddenly from smoker to nonsmoker. One concept is that the struggle to quit smoking is a series of stages, with your success being dependent on determining what stage of change you are in.
Psychologist James O. Prochaska and colleagues have developed a framework for the stages of change that people go through when trying to overcome an ingrained habit. These are described in his book, Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward (Harper Paperbacks, 1995). Smokers can cycle through this predictable set of stages, often multiple times, until they achieve success:
Pre-contemplation:You have never tried to quit or even considered giving up smoking.
Contemplation:You are considering the need to quit smoking someday. You are waiting for something to motivate you or give you a reason to quit smoking. You are open to information and advice about quitting.
Preparation:You are preparing to stop smoking. You have either reduced the amount that you smoke or restricted your smoking. You are considering what to do the day you quit smoking. You are planning strategies for coping with urges to smoke.
Action:You are in the act of quitting. Congratulations! This phase includes the quit date and the first few months of quitting.
Maintenance:You are a former smoker! Being off tobacco products for any amount of time is a tremendous success…and even smokers who have quit for years occasionally relapse to smoking. That being said, the first year after you’ve quit is an important landmark, which should be celebrated. Smoking cessation experts say your risk of returning to smoking is low at this point.
Termination:The new behavior has become an integral part of your life to the point that the likelihood of relapse is almost nonexistent.

Treatment

For many smokers, it takes multiple serious attempts at quitting before they become lifelong nonsmokers. You may be successful on your first try, but if you aren’t, don’t give up. Cigarettes hook smokers in three powerful interlocking ways, each of which needs to be addressed when you are trying to quit:
physical addiction
habit
emotional dependence
Before 1985, cold turkey (quitting completely and in one step without cessation aids) was the only option for smokers. Today, smokers can take advantage of many effective medications or drugs and behavioral treatments. In addition, there are many successful cessation programs and materials (self-help and others) to help you quit. And as fewer and fewer people smoke, there is increasing social support for anyone trying to quit.
Preparing to Quit: What to Do
The first step in quitting smoking is making the decision to quit. The decision to quit smoking should not be taken lightly. It is a serious commitment and a serious challenge. But the rewards are worth the effort. Here’s how you can prepare to quit smoking:
Make a positive decision to quit smoking.Avoid negative thoughts about how difficult it might be. Compare reasons to quit smoking with reasons to continue smoking; add to those reasons for quitting daily. Develop strong personal reasons, in addition to your health and obligations to others. For example, think of all the time you waste taking cigarette breaks, rushing out to buy a pack, hunting for a light, etc.
Discuss the decision with your health care professional.Ask about the many medications available for quitting and which might suit your lifestyle and personal health profile best.
Begin to condition yourself physically.Start a modest exercise program, drink more fluids, get plenty of rest and avoid fatigue. Many of the effects of nicotine, including stress relief, increased metabolism and mood and weight control can be achieved with exercise.
Set a target date for quitting.This could be a special day such as your birthday, your anniversary or the Great American Smokeout. (The Great American Smokeout takes place each year on the third Thursday of November.) If you smoke heavily at work, quit during your vacation so that you’re already committed to quitting when you return. Make the date sacred, and don’t let anything change it. This will make it easy for you to keep track of the day you became a nonsmoker. Plan to celebrate that date every year.
Prepare mentally for quitting.Have realistic expectations about quitting smoking before you begin. Quitting isn’t easy, but it’s not impossible either. Visualize yourself smoke-free in difficult situations.
Let your friends and family know.Tell them in advance that you are planning to quit. They can provide helpful social support.
You will likely experience withdrawal symptoms most severely during the first one to two weeks without nicotine. Understand that withdrawal symptoms are temporary. Be aware that this may be your hardest time, and use all your personal resources (your health care professional, your family and your friends) to get you through this critical period successfully.
Symptoms of Nicotine Withdrawal
Nicotine withdrawal symptoms are temporary sensations that result after reducing or stopping tobacco abruptly. They usually begin within 24 hours. You may experience four or more of the following:
Depressed mood:In the first couple of weeks after quitting, many people experience mood changes. Regular aerobic exercise, adequate sleep and refusing to listen to thoughts that will keep you spiraling down may help you avoid these mood changes.People with a history of major depression may relapse when quitting smoking and people with current depression may actually be medicating themselves with the nicotine in cigarettes. A serious bout of depression can occur in someone quitting smoking. Feeling blue, sad, crying a lot, and losing interest in normal life activities are all symptoms of depression. If you feel these symptoms overtaking your life, you should see your health care professional promptly for diagnosis and treatment.
Trouble sleeping (insomnia):Your brain chemistry is readjusting to new patterns without nicotine’s influence. Treat yourself to a hot bath, avoid caffeine in the evening or begin a relaxation or meditation routine. Get enough exercise every day so that you earn your rest. You may also need to have extra sleep while you are recovering, so go ahead and take a nap. You deserve it. A full seven to eight hours of sleep per day is optimal to help the brain chemistry stabilize.
Irritability, frustration or anger:Planning ahead will allow you to pick the least troublesome period for your “quit week” when you need to avoid or minimize stresses and demands. Let those around you know and ask them to have patience. Practice your new stress coping skills before quitting so they are ready to use when you need them. Move away from a bothersome situation, take a walk or plan to avoid familiar aggravation, if possible, for several days until this period is over. Deep breathing exercises can help to calm your “on edge” sensations. Don’t set expectations too high at work or home during the first couple weeks after quitting.
Anxiety:Common sensations after quitting tobacco, particularly in the first week or two, are a growing sense of anxiety, restlessness and overwhelming worry. But if you know what you are dealing with, you can have a plan to divert your attention, get busy doing some preoccupying task or talk with someone who cares. If the feelings of anxiety persist and are disabling and interfere with your life, talk it over with your health care professional. You may have a condition known as an anxiety disorder, which can be helped with medication.
Difficulty concentrating:Nicotine stimulates the norepinephrine levels in the brain that affect the attention span, alertness and vigilance. Until your brain chemistry gets readjusted, it is difficult for many people to stay focused. Again, this is temporary.
Restlessness:Part of this is due to missing the routine of lighting cigarettes and bringing them to your mouth hundreds of times per day. Your hands feel awkward and useless. Exercise can ease the agitation and restless feelings. Take a walk or get some other form of exercise.
Weight gain:There are many reasons why people can gain weight after quitting smoking. The most important reasons are that nicotine stimulates body metabolism and suppresses appetite, so that with the same food intake and no increase in exercise some weight gain will occur. In addition, some people increase their food intake as well, eating instead of smoking. Without the dulling effects of cigarette smoke on taste and smell, food is more appetizing and you may eat more. If you are aware of these effects, you can take steps to counteract the risk for weight gain.
Decreased heart rate:Nicotine is a significant stimulant to the heart’s electrical system and speeds up the heart rate. After quitting, the heart can slow down to the healthier normal pace. This is an effect that you are unlikely to notice.
The good news is that within two to six weeks these symptoms will resolve and your brain will learn how to manage the balance of chemical messengers without nicotine’s influence.
As your body begins to repair itself, you may feel worse for a short while. It’s important to understand that healing is a process that begins immediately and continues over time. Immediately after quitting, you may experience “symptoms of recovery” such as temporary weight gain caused by fluid retention, irregularity and dry, sore gums or tongue. You may feel edgy, hungry, tired and more short-tempered than usual. You may have trouble sleeping and notice that you are coughing a lot. These symptoms are the result of your body clearing itself of the effects of chronic nicotine and the other chemicals in cigarette smoke. Although most of the nicotine is gone from the body in two to three days, these symptoms will take longer to resolve.
Critically Important: Know Your Triggers
During those first critical weeks, be aware of situational triggers, such as a particularly stressful event or a social event where friends or family will be smoking. These are the times when you reach for cigarettes automatically because you associate smoking with relaxing. It is important to prepare yourself for these situations before they happen.
There are several types of situations that put smokers at risk for relapse:
A negative mood, such as feeling sad, anxious or stressed out: These feelings are particularly risky when you are alone. You may find yourself rationalizing why it’s OK to have “just one.”
“Happy relapse” situation: This occurs when a smoker finds herself in a social situation where she once smoked, often while drinking alcohol and enjoying the company of friends. Avoid these settings until you’re comfortable as a nonsmoker and not easily tempted to smoke.
Alcohol: This can be a powerful trigger, weakening your resolve not to smoke. Many smoking cessation experts advise staying away from alcohol and alcohol settings (bars, cocktail parties, cookouts, etc., where smoking is sometimes allowed) until your resolve to remain a nonsmoker is firm.
Tips to Help You Quit
Change your smoking behavior.What follows are some common techniques, but bear in mind that these techniques won’t work for all:
Smoke only half of each cigarette.
Each day, postpone the lighting of your first cigarette one hour.
Decide you’ll only smoke during odd or even hours of the day.
Decide beforehand how many cigarettes you’ll smoke during the day.
Change your eating habits to help you cut down. For example, drink milk, which many people consider incompatible with smoking.
End meals or snacks with something that won’t lead to a cigarette.
Reach for a glass of juice or fresh fruit instead of a cigarette for a “pick-me-up.”
Chew on cigarette-sized celery or carrot sticks.
Don’t smoke automatically.Smoke only those cigarettes you really want. Catch yourself before you light a cigarette out of pure habit. Don’t empty your ashtrays. This will remind you of how many cigarettes you’ve smoked each day, and the sight and the smell of stale cigarettes butts will be unpleasant. Make yourself aware of each cigarette by using the opposite hand or putting cigarettes in an unfamiliar location or a different pocket to break the automatic reach.
Make smoking inconvenient.Stop buying cigarettes by the carton. Wait until one pack is empty before you buy another. Stop carrying cigarettes with you at home or at work. Make them difficult to get to, such as locking them in your car trunk.
Make smoking unpleasant.Smoke only under circumstances that aren’t especially pleasurable for you. If you like to smoke with others, smoke alone. Turn your chair to an empty corner and focus only on the cigarette you are smoking and all its many negative effects. Collect all your cigarette butts in one large glass container filled with water as a visual reminder of the filth made by smoking.
Prepare quitting skills.Practice going places without cigarettes. Don’t think of never smoking again. Think of quitting in terms of one day at a time. Tell yourself you won’t smoke today, and then don’t. Clean your clothes to rid them of the cigarette smell, which can linger a long time. Clean your car or one room of your home and never smoke there again.
Make plans to enjoy the first day of your smoke-free life.
Throw away all your cigarettes and matches.
Hide your lighters and ashtrays.
Visit the dentist and have your teeth cleaned to get rid of tobacco stains. Notice how nice they look and resolve to keep them that way.
Make a list of things you’d like to buy for yourself or someone else from the money you save. Estimate the cost in terms of packs of cigarettes, and put the money aside to buy these presents.
Keep very busy on the big day. Go to the movies, exercise, take long walks, go bike riding.
Buy yourself a treat or do something special to celebrate.
Remind your family and friends that this is your quit date, and ask them to help you over the rough spots of the first couple of days and weeks.
Immediately after quitting, make an effort to enjoy life as a nonsmoker and to overcome the symptoms of withdrawal—they are temporary.Develop a clean, fresh, nonsmoking environment at work and at home. Buy yourself flowers. You may be surprised how much you can enjoy their scent after the first few days. Spend as much free time as possible in places where smoking isn’t allowed, such as libraries, museums, theaters, department stores and churches. Drink large quantities of water, low-fat milk and fruit juice. Try to avoid alcohol, coffee and other beverages you associate with cigarette smoking.
Strike up a conversation instead of a match for a cigarette.If you miss the sensation of having a cigarette in your hand, play with something else—a pencil, a paper clip, a marble. If you miss having something in your lips, try toothpicks, a cinnamon stick or a straw.
Avoid temptation.After meals, get up from the table and brush your teeth or go for a walk. If you always smoked while driving, listen to a particularly interesting radio program or your favorite music or take public transportation for a while, if you can. For the first one to three weeks, avoid situations you strongly associate with the pleasurable aspects of smoking, such as watching your favorite TV program, sitting in your favorite chair or having a cocktail before dinner. Until you are confident of your ability to stay off cigarettes, limit your socializing to healthful, outdoor activities or situations where smoking is not allowed. If you must be in a situation where you’ll be tempted to smoke, try to associate with the nonsmokers there.
Develop new habits.Change your habits to make smoking difficult, impossible or unnecessary. For example, it’s hard to smoke while you’re swimming, jogging or playing tennis or handball. When your desire for a cigarette is intense, wash your hands or the dishes, take a shower or try new recipes. Do things that require you to use your hands. Try crossword puzzles, needlework, gardening or household chores. Go bike riding or take the dog for a walk; call a friend; give yourself a manicure; write letters or surf the Internet. Enjoy having a clean mouth taste and maintain it by brushing your teeth frequently, flossing and using mouthwash. Get plenty of rest. Pay attention to your appearance. Look and feel sharp. Find time for the activities that are the most meaningful, satisfying and important to you.
The Facts About Weight Gain
Many women rationalize their smoking habit by saying that they will gain weight if they quit. Women are more likely than men to continue smoking to maintain their weight or to lose weight. Also, unsuccessful cessation due to weight gain or concern about weight gain is more likely among women than among men. If you are concerned about weight gain, keep these points in mind:
Quitting doesn’t mean you’ll automatically gain weight, though on average, people do gain. As noted previously, it is entirely possible to make no change in eating behavior after quitting and gain weight.
The benefits of giving up cigarettes far outweigh the drawbacks of adding a few pounds. You’d have to gain a very large amount of weight to offset the many substantial health benefits that a typical smoker gains by quitting. When you quit smoking, particularly if you have been smoking for many years, the effects can be noticeable—some pleasant, others unpleasant. All of these changes are a sign that your body is adjusting to life without the nicotine and chemicals you have been inhaling for so long. Here’s what to expect when you quit:
Immediate Benefits of Quitting:
Within 20 minutes of your last cigarette, your blood pressure and pulse rate drop, and the body temperature in your hands and feet increase to normal levels.
In 24 hours the carbon monoxide level in your blood drops to normal and oxygen carried in the blood increases. Your risk of heart attack decreases.
In 48 hours the nerve endings in your nose start regrowing, and your senses of taste and smell are enhanced.
You will breathe easier, although you may notice that your cough worsens for a while as your lung function returns to normal and your lungs rid themselves of the toxins from smoking.
You will be free from the mess, smell, inconvenience, expense and dependence of cigarette smoking.
Long-term Benefits of Quitting:
You’ve greatly improved your chances for a longer life. You have significantly reduced your risk of death from heart disease, stroke, chronic bronchitis, emphysema and many kinds of cancer.
Pharmacotherapy
There are now seven FDA-approved medications to help smokers quit. The combination of medication and behavioral therapy dramatically increases the chance of successfully quitting. The new guidelines recommend that health professionals offer pharmacotherapy to ALL smokers who want to quit. Below is a summary of each medication to help you decide which one fits your needs.
Nicotine Replacement Therapies
Nicotine replacement therapies help calm cravings and withdrawal symptoms by giving your body some nicotine while you adjust to coping with life without cigarettes. Because of its effects on the heart and blood vessels, nicotine medications should not be used when serious conditions like recent heart attack, very high blood pressure or serious heart rhythm disturbance are present. Nicotine products are not advised in pregnancy unless the benefits of quitting outweigh the risks of continuing to smoke when pregnant. And results of a recent study published in the New England Journal of Medicine revealed that although nicotine replacement therapies do not appear to have significant adverse outcomes in pregnancy, they do not increase quitting rates among pregnant women, and pregnant women are unlikely to stick to them. You should consult your health care professional in these situations.
There are five forms of nicotine replacement medications. Three are nonprescription, over-the-counter medications: the patch, the gum and the lozenge. Two require a prescription: the oral inhaler and the nasal spray.
The patchThe patch, available in several brands and generically, is applied directly to a hairless area of skin on the arm or the trunk above the waist. The patch provides a steady dose of nicotine through the skin (transdermal). A new patch is used each day. The patch should be placed at a different location on the upper body each day to minimize skin irritation. The usual length of treatment is two to three months, depending on your needs.The advantages of patches are few side effects and ease of use. The patch only needs to be applied once a day. Some disadvantages include limited dosing flexibility and slower delivery of nicotine to the brain. Some people get vivid dreams while on the patch. If so, remove it before going to bed. In addition, some people will develop mild skin rashes.
The gumThe nicotine compound in the gum (Nicorette) is absorbed through the lining of the mouth. For that reason, users are told to bite the gum a few times until you feel a tingling or peppery taste and then “park the gum” between the cheek and the jaw. If you chew the gum rapidly and swallow the saliva, you may become nauseated, get heartburn or hiccups. The gum is available in 2 mg and 4 mg doses. Heavier smokers (25 or more cigarettes per day) should use the 4 mg strength. When properly used (chew and park), it takes about 30 minutes to absorb all the nicotine from one piece of gum. Smokers are instructed to chew the gum on a regular schedule, every half hour to an hour to maintain a steady level of nicotine, then gradually taper as they feel more confident, using the gum for up to three months. No more than 24 pieces per day should be used by any smoker who is trying to quit.Advantages include convenience and flexibility in changing the dose. The nicotine in gum will not be absorbed if the mouth is acidic. Do not drink orange juice or coffee before or while you use the gum. If you have had an acidic beverage, thoroughly rinse your mouth before using the gum. If you have dental problems, the gum may not be right for you. The gum is good for people who crave a mouth activity or sensation and may be helpful in avoiding weight gain, since you are unlikely to eat or drink when using the gum.
The lozengeThe lozenge (Commit) contains the same nicotine compound as the gum, has a “light mint” flavor and is calorie-free. It comes in 2 mg and 4 mg doses. A dosage selector helps determine when to take a lozenge, based on how soon you smoke your first cigarette of the day. It should be dissolved completely in the mouth over about 30 minutes and not chewed or swallowed. Swallowing can lead to nausea, heartburn or hiccups. The dosing schedule is similar to that of the nicotine gum—one to two lozenges an hour for the first six weeks, with a dose reduction over the second six weeks.
The nasal sprayThis nicotine product (Nicotrol NS) requires a prescription. It may be used along with the patch. It is sprayed directly into each nostril and provides the fastest delivery of nicotine to the brain of any of the nicotine replacement products, producing a brain nicotine peak as soon as five minutes after use. Do not inhale while spraying, or you may get severe sinus pain. One to two sprays per hour are recommended for about three months. Ask your health care professional for instructions.The advantages of the nasal spray are flexibility of adjusting dose to your needs. Much like a cigarette, it delivers nicotine rapidly for quick reduction in cravings. You may find that during the initial days of treatment, the spray can be irritating to the nose, causing a hot, peppery feeling along with watery eyes, runny nose, coughing and sneezing. These effects decrease with use.
The oral inhalerThe oral inhaler (Nicotrol Inhaler) is a plastic cylinder about the size of a cigarette holder. It is available only by prescription and can also be used along with the patch. The nicotine compound is in a small cartridge that you puncture and place inside the cylinder. When you “puff” on the inhaler, the aerosolized nicotine is absorbed through the lining of your mouth and upper respiratory tract (as opposed to through the lungs). The recommended daily dose is six to 16 cartridges per day for the first six to 12 weeks followed by a gradual tapering of the dose over the next six to 12 weeks. This treatment most closely mimics the use of actual cigarettes and can satisfy the urge to handle something, as you did when smoking. Mouth and throat irritation are the most common side effects, which decrease with use of the product.
Antidepressant
BupropionA promising treatment for nicotine dependence is the non-nicotine, prescription antidepressant bupropion (Zyban, Wellbutrin SR). It was approved under the brand name Zyban in 1997 as an aid to smoking cessation because research showed that people taking the drug for depression had an easier time quitting smoking. It is believed to work by affecting brain chemicals involved in nicotine addiction and withdrawal.One difference between bupropion and nicotine replacement therapy is that you start the pill one or two weeks before your quit date and continue it for six to 12 weeks after quitting smoking. Zyban is approved for up to six months to prevent relapse. The Zyban pill contains 150 mg of bupropion and is formulated to release the drug over eight hours. You start by taking one pill daily, and then increase the dose to two pills daily at least eight hours apart. The most common side effects are dry mouth and difficulty sleeping. If you have trouble with insomnia, try to take the second dose exactly eight hours after the first dose, so that the effect is decreasing at bedtime. Do not take the second dose sooner than eight hours after the first dose.
The main adverse effect of bupropion is seizures. Seizures can occur at high doses of the drug or in people susceptible to seizure. Bupropion should not be given to people with an increased risk for seizure. That would include people with epilepsy, history of a head injury or heavy drinkers (more than three alcoholic drinks daily). In addition, the FDA recently warned consumers about a potential link between bupropion and suicidal events. Bupropion should not be taken by people with a history of anorexia or eating disorders. Bupropion is the same drug as the antidepressant Wellbutrin. People on Wellbutrin should not also take Zyban. Patients being treated for depression with a class of drugs called MAO inhibitors should not take Zyban. Bupropion is a prescription drug and should be taken only under the guidance of a health care professional.
Other medications
VareniclineIn addition to nicotine replacement and antidepressants, smokers now have another option to help them quit. In 2006 the FDA approved varenicline (Chantix), a prescription drug that is not nicotine but works like nicotine. Varenicline attaches to nicotine receptors in the brain and delivers a nicotine-like effect, reducing cravings for cigarettes and withdrawal symptoms. Because the drug is attached to the receptors, it blocks nicotine from cigarettes so that smoking does not provide the stimulatory and pleasurable effect it once did. The bottom line is that you have less difficulty with the immediate effects of quitting and less reason to smoke because it doesn’t provide the effects you expect. To date, studies on varenicline have shown the best quitting rates.Like Zyban, Chantix is started at least seven days before the quit date, and dose starts low and is slowly increased to the treatment level. The drug is available in 0.5 mg and 1.0 mg tablets, and the recommendation is to begin with 0.5 mg once daily for the first three days, then 0.5 mg twice daily for three days, then 1.0 mg twice daily. The typical treatment length for varenicline is 12 weeks. Studies have shown that long-term quit rates are higher if treatment is continued for another 12 weeks, so treatment is approved for up to 24 weeks. The most common side effects are nausea, constipation, abnormal dreams and sleep disturbances.
There is also a concern about the association of varenicline with serious mental health problems like agitation, behavior changes, depression, suicidal thoughts and suicide. These concerns have emerged from reports received by the FDA since Chantix has been on the market and have prompted the FDA to issue a warning to practitioners and the public. No study of Chantix has detected these effects, so a cause and effect relationship has not been proven. However, before starting Chantix, you should tell your health care provider about any mental health symptoms you have or have had, and when you are taking the drug, you should promptly consult your health care provider if you experience such symptoms.
Remember that many people experience mood changes in the first couple of weeks after quitting smoking, and a serious bout of depression can occur. Feeling blue, sad, crying a lot and losing interest in normal life activities are all symptoms of depression. If you notice these symptoms in you or in someone you know who is quitting smoking, you should see your health care professional, or encourage your friend or relative to do so, for prompt diagnosis and treatment.
In summary
Remember, medications make it easier to quit smoking, but you still have to do the work. None of these medications are a substitute for the desire to stop smoking. They are most successful when used in combination with a smoking cessation program or behavioral therapy. While the medication helps you cope with the physiological effects of smoking, other programs, such as counseling, help you deal with the psychological and behavioral dependence upon smoking.
Preventing a Relapse
Quitting smoking is the first half of the battle; next you need to prevent a relapse. Becoming a nonsmoker requires more than just licking withdrawal symptoms. You have to become accustomed to your new smoke-free habits.
One of the keys to life as a former smoker is not letting your urges or cravings for a cigarette lead you to smoke. Don’t kid yourself. Even though you have made a commitment not to smoke, you will be tempted. Instead of giving in to the urge, use it as a learning experience. Remind yourself that you have quit and you don’t smoke. If you are like many new former smokers, the most difficult place to resist the urge to smoke is the most familiar: home. The activities most closely associated with smoking urges are eating, socializing and drinking. And, not surprisingly, most urges occur when another smoker is present.
Seven Coping Tools to Prevent Relapse
Here are seven tools you can use to cope with urges and tempting situations. These tools will help you make the transition from smoker to former smoker. And there will come a time when the urges diminish.
Think about why you quit.Go back to your list of reasons for quitting. Look at this list several times a day, especially when you are hit with the urge to smoke. Your best personal reasons for quitting are also the best reasons to stay a nonsmoker.
Watch for rationalizations.It is easy to rationalize yourself back into smoking. A new nonsmoker in a tense situation may think, “I’ll just have one cigarette to calm myself down.” But one cigarette is never enough. If thoughts like this pop into your head, stop and think again! You can learn ways to relax, such as taking a walk or doing breathing exercises. Concern about gaining weight may also lead to rationalizations. Learn to counter thoughts such as, “I’d rather be thin, even if it means smoking.” Remember that a slight weight gain is not likely to endanger your health as much as smoking would. After all, cigarette smoking is the single most preventable cause of death in the United States.
Anticipate triggers and prepare to avoid them.By now you know which situations, people and feelings are likely to tempt you to smoke. When you can’t avoid them, be prepared to meet these triggers head-on and counteract them. Practice the skills that helped you cope with quitting. For example, if you know that spending time with a friend who smokes will be difficult for you, avoid that person until you feel strong enough to resist your urges.
Reward yourself for not smoking.Congratulations are in order each time you get through a day without smoking. After a week, give yourself a well-deserved reward of some kind. Buy a new CD or treat yourself to a movie or concert. It helps to remind yourself that what you are doing is important.
Practice positive thoughts.If self-defeating thoughts start to creep in, remind yourself that you are a nonsmoker, that you do not want to smoke and that you have good reasons for it. Putting yourself down and trying to hold out using willpower alone are not effective coping techniques. Mobilize the power of positive thinking!
Use relaxation techniques.Breathing exercises help to reduce tension. Instead of having a cigarette, take a long deep breath, count to 10 and release it. Repeat this five times. See how much more relaxed you feel? Take a bubble bath.
Seek social support.The commitment to remain a nonsmoker may be easier if you talk about it with friends and relatives. They can celebrate with you as you check off another day, week and month as a nonsmoker. Tell the people close to you that you might be tense for a while, so they know what to expect. They’ll be sympathetic when you have an urge to smoke and can be counted on to help you resist it. Remember to call on your friends when you are lonely or you feel an urge to smoke. A buddy system is a great technique.

Facts to Know

The American Cancer Society estimates that in 2012, 72,590 women will die from lung cancer, compared to the 39,510 women who will die from breast cancer.
About 70 percent of smokers claim in surveys that they want to quit, and more than 50 percent of smokers report having tried to quit in the past year. However, the long-term success rate of a single unaided attempt to quit is low—only about 5 percent to 7 percent of smokers who attempt to quit are still not smoking one year later.
The health benefits of smoking far outweigh any risk of weight gain caused by quitting smoking. Research shows that the average weight gain after quitting smoking is six to eight pounds.
Quitting smoking saves money. A pack-a-day smoker, who pays $9 a pack, can expect to save more than $3,200 per year. At $11 a pack (the price in New York City), that amounts to a saving of $4,015! As the price of cigarettes continues to rise, so will the financial rewards of quitting.
Cigarette smoking causes lung and other cancers, emphysema and heart disease. An estimated 443,000 U.S. deaths each year are caused by cigarette smoking. But smoking also affects nearly every other organ system and disease in a negative way.
The Environmental Protection Agency has listed passive cigarette smoke (also known as secondhand smoke) as a carcinogen, and The American Lung Association reports that it causes close to 50,000 deaths per year.

Key Q&A

Am I addicted to nicotine?When addicted smokers try to quit, they go through a variable withdrawal period. If you experience symptoms such as anger, difficulty sleeping, cravings, mood swings, increased hunger, weight gain and difficulty concentrating when you stop nicotine, you are likely addicted.
Are there specific risks for women who smoke?Women who smoke experience all the same health risks as men do: lung and other cancers, coronary heart disease and stroke and severe lung diseases. In addition, they have other serious risks, including risks to their reproductive health. If you smoke while you are pregnant, you are putting yourself and your unborn child at increased risk for complications. Well-known risks of smoking during pregnancy are bleeding complications, prematurity and low birth-weight babies. Many studies have documented a link between smoking during pregnancy and sudden infant death syndrome (SIDS).
Why do I enjoy smoking so much?Nicotine’s effect on the central nervous system is what makes smoking pleasurable. Nicotine can induce relaxation and relieve anxiety or boredom and irritability. Nicotine also can improve your mood because of its effect on brain chemicals that regulate emotion and pleasure. Once smoking becomes a part of your everyday routine, the mere handling of a cigarette can become soothing.
I failed to quit smoking once. Does this mean I am doomed to smoke forever?It takes multiple attempts at quitting before many smokers become lifelong nonsmokers. You may be successful on your first try, but if you aren’t, don’t give up. Cigarettes hook smokers in three powerful interlocking ways, each of which needs to be addressed when you are trying to quit:
physical addiction
habit
emotional dependence
If you feel you need help to quit, talk to your health care professional about nicotine replacement therapies or buproprian (Zyban) or varenicline (Chantix)..
What is the first step in quitting smoking?A positive decision to quit is the foundation of a successful smoking cessation program. Try to avoid negative thoughts about how difficult it might be. Make a list of reasons to quit smoking and a list of reasons to continue smoking. Add to them daily. Develop strong personal reasons, in addition to your health and obligations to others. For example, think of all the time you waste taking cigarette breaks, rushing out to buy a pack, hunting for a light, etc.
Will I gain weight if I quit smoking?For many women, the fear of weight gain is a real concern and one that is used to rationalize continued smoking. The average amount of weight gained after quitting smoking is six to eight pounds, which not everyone is able to easily offset by changes in diet and exercise. However, women who smoke must weigh the many other benefits of quitting, especially health benefits, including cosmetic benefits, such as clean hair, teeth, fewer wrinkles and so on. The health benefits of quitting vastly outweigh health harm from any weight gain, experts say.
How long will it take for my health to improve after I quit smoking?Within 20 minutes of your last cigarette, your blood pressure and pulse rate drop and the body temperature in your hands and feet increase to normal levels. In 24 to 48 hours the carbon monoxide level in your blood drops to normal and oxygen carried in the blood increases. Your risk of heart attack decreases. In 48 hours your nose’s nerve endings start regenerating, and your senses of taste and smell are enhanced. You will breathe easier, although you may notice that you may continue to cough more for awhile. And you will be free from the mess, smell, inconvenience, expense and dependence of cigarette smoking.
My partner smokes and refuses to quit. How can I limit my exposure even though we live together?If you live with a smoker, ask him or her not to smoke inside your home. Discuss how his or her habit puts you at risk. If your partner is unwilling to go outside, suggest ways to limit the exposure of smoke for you. Maybe a room could be set aside for smoking—one that is seldom used by other members of the household. Some smokers protect others at home by smoking near an open window or when no one is around. It also helps to keep rooms well-ventilated and open windows.

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Stress

Overview

Stress can be your friend or your foe. When stress fuels the spark of personal achievement, it can work to your benefit by making you more perceptive and productive, acting as a motivator and even making you more creative. But when stress flames out of control—as it often does for many of us—it can take a terrible toll on your physical and emotional health, as well as your relationships.
While stress is not considered an illness, it can cause specific medical symptoms, sometimes serious enough to send you to the emergency room or your health care professional’s office. According to the American Psychological Association’s 2010 Stress in America survey, the majority of Americans report living with moderate or high levels of stress. And on average, those who report their health as fair or poor have more stress (an average stress rating of 6.2 on a 10-point scale) compared with those who rate their health as excellent or very good (an average stress rating of 4.9 on a 10-point scale).
In today’s fast-paced world, women are experiencing more stress at every stage of their lives than ever before. Juggling job pressures, family schedules, money issues, career and educational advancement and child and elder-care concerns are only a few of the common stressors confronting women.
Stressors are the external events, including pressures in people’s lives, such as divorce, marriage, children, work and money. The experience of stress, however, is related to how you respond to these stressors. One person’s stressor can be another person’s motivator.
You can learn to manage how you respond to stressors through relaxation, meditation, some forms of psychotherapy and exercise, among other methods. However, you can also work to reduce the stressors in your life, such as learning to say no to some commitments, simplifying your life or leaving a bad job or relationship. Sometimes techniques that are originally designed to simply reduce your stress response and improve coping (for example, meditation and psychotherapy) can lead you to choose to reduce the stressors in your life because you begin to see more clearly what needs to change.
Working mothers, regardless of whether they are married or single, face higher stress levels—both in the workplace and at home. The National Institute for Occupational Safety and Health (NIOSH), the US agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury, provides these statistics regarding stress in the workplace:
40 percent of workers reported their jobs were very or extremely stressful
25 percent view their jobs as the number one stressor in their lives
75 percent of employees believe that workers have more on-the-job stress than a generation ago
29 percent of workers felt quite a bit or extremely stressed at work
26 percent of workers said they were “often or very often burned out or stressed by their work.”
Stress has been linked with a variety of physical ailments from headache todepression to symptoms that mimic a heart attack. The balance between stressors and your ability to cope with them, however, can determine your mental health. When the stressors in your life match your coping abilities, you feel stimulated, engaged and appropriately challenged. Too many stressors in your life that overwhelm your attempts to cope can result in depression or anxiety.
Depression can feel like a pervasive sense of hopelessness, a feeling of wanting to give up, tearfulness or a sadness that does not seem to go away after a couple weeks. Anxiety can feel like a chronic state of feeling “keyed up” or “on edge.” Some people who are depressed or anxious have physical symptoms, such as changes in sleep or appetite (too much or too little).
Chronic depression and anxiety have been linked to other physical problems, such ascardiovascular disease, chronic pain, hypertension and diabetes. If you notice symptoms of depression or anxiety, it is important to get them treated. Your health care professional or mental health professional can help.
Regardless of your physical or mental symptoms, talk about the stress in your life with your health care professional. A thorough assessment by your health care team will help determine the cause of these symptoms. You may find that stress has triggered an illness, such as high blood pressure.
Stress and Your Body
Research indicates that women’s biological response to stress is to “tend and befriend”; this is, make sure the children are safe and then network with other women in stressful times. Men’s biological reaction to stress is to go into the “flight-or-fight” mode. Studies indicate that the hormone oxytocin, which has a calming effect, is released during stressful times in both men and women.
Estrogen may enhance oxytocin release, while testosterone may diminish it; this may be one reason that women seem to seek social support more often then men when under stress. However, women have also been socialized from an early age to look to their social group, particularly their female friends, for support when under stress, whereas men tend to engage in activities, such as exercise or even using substances, when under stress.
During stress, hormones including adrenaline and cortisol flood the body, resulting in:
an increased need for oxygen
increased heart rate and blood pressure
constricted blood vessels in the skin
tensed muscles
increased blood sugar levels
increased clotting ability of blood
spilling of stored fat from cells into the bloodstream
constriction of bowel and intestinal muscles
All this can strain your heart and artery linings. In fact, if you already have coronary heart disease, stress might lead to chest pain, called angina. Plus, the increased tendency for blood to clot during stress may lead to a clot in your coronary arteries, causing a heart attack.
Other physical dangers of stress include stomach problems as your bowel and intestinal muscles constrict and depression and anxiety. While stress doesn’t cause these mental illnesses, it can activate them in people who may already be prone to them.
Other physical dangers of stress include stomach problems, as your bowel and intestinal muscles constrict, as well as depression and anxiety. While stress doesn’t cause these mental illnesses, it can activate them in people who may already be prone to them.
Stress can also cause what has been termed “toxic weight gain.” Cortisol, a hormone released when you’re under stress, is an appetite trigger. That’s why so many women eat more—and less-than-healthy food—when under a lot of stress. Those extra calories are converted to fat deposits that gravitate to the waistline. These fat deposits, called visceral fat, are associated with life-threatening illnesses such as heart disease, diabetes, high blood pressure, stroke and cancer. Chronically high levels of cortisol may stimulate the fat cells inside the abdomen to fill with more fat. As you age, this expanding waistline can be life threatening.
Too much stress can also affect your immune system, weakening it and making you more susceptible to colds, coughs and infections.
Other symptoms of stress include muscular tension, headaches, gastrointestinalillnesses and sleeping more or less than normal.
Stress Triggers
It is important to distinguish between the acute stress response—when your heart beats faster and your breath comes faster as you get a rush of adrenalin—and the chronic stress response, in which you are continually under stress.
This chronic stress response is the one that causes the most problems as it literally wears out your body functions, leading to disease. That’s because our physical stress response was designed for emergency situations, such as fleeing an attacking animal, not for the everyday stressors we experience in modern society.
You may feel stressed in response to external or internal triggers, such as stressors in your life or your own way of relating to yourself. These include:
trauma or crises
small daily hassles
conflicts or unpleasant people
barriers that prevent you from reaching your goals
feeling little control over your life
excessive or impossible demands from others
noise
boring or lonely work
irrational ideas about how things should or must be; perceiving that life is not unfolding as you think it should
believing you are helpless or can’t handle a situation
drawing faulty conclusions like “they don’t like me” or “I’m inferior to them,” or having unreasonable fears of dire events such as “I’ll be mugged”
pushing yourself to excel and/or failing to achieve a desired goal
assigning fault for bad events, for example, placing blame on yourself or on others
realizing you may have been wrong but wanting to be right
overreacting to current stress as a result of intense stress years earlier, especially in childhood

Diagnosis

If you are suffering from stress, you may be experiencing a variety of symptoms that feel severe enough to prompt you to see a health care professional. These include:
headaches
frequent upset stomach, indigestion, gas pain, diarrhea or appetite changes
feeling as though you could cry
muscular tension
tightness in your chest and a feeling as though you can’t catch your breath
feeling nervous or sad
irritability and anger
having problems at work or in your normal relationships
sleep disturbance: either insomnia or hypersomnia (inability to sleep or sleeping too much)
apathy-lack of interest, motivation or energy
mental or physical fatigue
frequent illness
hives or skin rashes
tooth grinding
feeling faint or dizzy
ringing in the ears
disruptions in your menstrual cycle or unusually severe PMS or menopausal symptoms
There is no specific test to diagnose stress. Typically, your health care professional conducts a variety of tests (which may include a personal and family health history, blood and urine tests and other assessments) to rule out various medical conditions.
Because your symptoms may be similar to those of depression, your health care professional should also evaluate your mental state to determine if you may be suffering from a depressive or anxiety disorder. Symptoms associated with stress, anxiety and sleeplessness, for example, typically subside when the stress triggering them subsides. When these same symptoms are caused by depression or another mood disorder, however, they may not go away without medication or therapy.
If stress is identified as the culprit for your symptoms, you may want to ask your health care professional for stress management strategies and consider ways to control the stressors in your life-before your health is affected.

Treatment

Reducing or eliminating the things that cause stress and changing how you react to it are the safest and most effective ways to treat stress. No single method of stress management is always successful, so you might want to try a variety of approaches. It’s also important that you treat any medical symptoms stress exacerbates. However, keep in mind that treating the stress may not cure the medical problem.
Reducing stress can be difficult. Often, people succeed in relieving stress in the short term but return to old stress-producing habits. Plus, personal responsibilities don’t alwayslend themselves to stress-reducing tactics. The process of learning to control or redirect stress is lifelong, but working to master it will improve your lifelong health.
Cognitive-behavioral therapy, which helps you substitute desirable responses and behavior patterns for undesirable ones, is one proven way to reduce stress. It is very important that you learn cognitive-behavioral coping skills from a professional. They include:
Identifying sources of stress. You may want to keep a stress diary in which you record stressful occasions, incidents that triggered anger or anxiety or that caused a physical response like a sour stomach or headache. Jot down the time of day and the circumstances that led to these feelings, then try to identify the types of events or activities that caused them. See if you can alter or avoid these circumstances.
Restructuring priorities. Examine your priorities and goals to determine which stressful activities or situations you can get rid of. For instance, replace time-consuming chores that aren’t really necessary (like ironing) with more pleasurable or interesting activities.
Find ways to balance the stress inducers you can’t eliminate—like unpleasant working conditions, an unhappy family situation or a significant loss—by including stress-reducing activities in your day. Studies have shown that such activities can positively affect your immune system. Making time for recreation and stress reduction is as essential as paying bills or shopping for groceries.
Adjusting your responses to stress. Because you can’t simply wish some stresses away-you can’t just quit your job or walk out on your family, for example-you have to learn how to respond to stress to reduce its effects. These include:
Discussing your feelings. If you don’t discuss your feelings of anger or frustration, you may feel hopeless and depressed. Becoming aware of your feelings can help you assert yourself when it’s important. You can do this in a positive way, by writing a letter or calmly discussing your feelings with the other person. Asserting yourself in a negative way (yelling and behaving aggressively, for example) is only counterproductive. It’s also important that you learn to listen, empathize and respond to others with understanding. If you can’t talk to a trusted friend, try writing in a journal or composing a letter.
Keeping your perspective and looking for the positive. Think of the worst possible outcome to a situation that is stressing you and assess the likelihood of it occurring (usually small). Then, envision a positive outcome and develop a plan to achieve that outcome. It’s also helpful to remember past situations that initially seemed negative but ended well.
Using humor. Stress management experts often recommend that people keep a sense of humor during difficult situations. Laughing releases the tension of pent-up feelings and helps maintain your perspective on the situation.
In addition to cognitive-behavioral methods to approaching stress, learning a relaxation technique-the natural unwinding of the stress response-can also help. A stress management specialist can teach you some relaxation techniques, including:
Deep breathing. When you’re under stress, your breathing becomes shallow and rapid. Taking a deep breath is an effective technique for winding down. Inhale through your nose slowly and deeply to the count of 10, making sure your stomach and abdomen expand but your chest does not rise. Exhale through your nose, also to the count of 10. Concentrate fully on the breathing and counting. Repeat five to 10 times. The goal is to take three inhales and three exhales per minute, for a total of three deep breaths.
Relax your muscles. Sitting anywhere, even at your desk, relax your shoulders, let your arms drop to your side, rest your hands on top of your thighs, relax your legs, and don’t forget your jaw muscles, which often tense with stress. Close your eyes and breathe deeply. You can also do this lying in bed. Beginning with the top of your head and progressing downward, tense and then relax the muscles in your body one by one while maintaining a slow, deep breathing pattern.
Passive stretches. Allow gravity to help you relax and stretch your muscles. Relax your neck and let your head fall forward to the right. Then let it drop even more as you breathe slowly. Do the same with your shoulders, arms and back.
Visualization. Remember a relaxing time or place like a lakeside picnic or a beautiful beach scene. Close your eyes for a few minutes and picture it in your mind.
Meditation. The goal of meditation is to quiet your mind, to relax your thoughts and increase your awareness. Meditation can also reduce your heart rate, blood pressure, adrenaline levels and skin temperature. It involves concentrating on a simple image or sound while sitting in a comfortable position away from distractions. It can involve cultivating an open awareness or a more loving attitude toward yourself and others. Meditation can also help you become more aware of your priorities so you can make more productive choices in your life.
Electromyographic Biofeedback (EMG). During this totally painless process conducted in a health care professional’s office, you learn to reinforce your relaxation skills using methods such as those described earlier. Electromyograph biofeedback measures the electrical activation that signals muscles to contract. Electromyographic biofeedback training helps you relax overly contracted muscle groups to help reduce tension. As training continues, you learn to use the information from the instruments to discriminate between tension and relaxation. By repeating this process, you learn to associate the sound with the relaxed state and to achieve this state of relaxation by yourself without the machine.
Massage therapy. This approach slows the heart and relaxes the body. Rather than causing drowsiness, however, massage actually increases alertness
Your health care professional will probably discuss other issues with you, such as the necessity of:
Maintaining healthy habits. People who are coping with chronic stress often resort to unhealthy habits including high-fat and high-salt diets, tobacco use, alcohol abuse and a sedentary lifestyle.
Avoiding stimulants like tobacco (which contains nicotine) that make you feel calm in the short run, but actually rev up your nervous system. The addictive characteristics of some stimulants like nicotine can leave you anxious until your next fix.
Getting regular aerobic exercise. Even a brisk walk can reduce levels of stress hormones in your blood. At least 30 minutes a day (or two 15-minute sessions) most days of the week is best, but even three times a week offers benefits. In addition, as you get fitter, your body is better able to withstand stress and your mind to cope with stress and stay on an even, happier keel. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous. You should first discuss any exercise program with your health care professional.
Strengthening or establishing a support network. Even a pet can help reduce medical problems aggravated by stress. Studies of people who remain happy and healthy despite many life stresses conclude that most have very good social support networks.
Reducing stress at work. Try establishing a network of friends there, seeking out a sympathetic manager, or schedule daily pleasant activities and physical exercise during free time. For additional support, schedule an appointment with an Employee Assistance Program clinician, if your company offers that benefit. These programs provide professional counselors who can give you and your family confidential assessment and counseling.

Prevention

You can’t simply wish away stressful events from your life. The key is to handle the stress appropriately. The following may enhance your ability to manage stressful events in your life:
Eat a balanced, nutritious diet. General health and stress resistance can be enhanced by eating well and by avoiding alcohol, caffeine, tobacco and junk food.
Exercise regularly. Exercise promotes emotional well-being as well as physical fitness.
Schedule your time more effectively using a calendar and to-do lists, prioritizing activities and realizing you can’t do everything.
Learn how to say no to requests that add extra burdens and can wreak havoc on your day.
Insist on help with regular chores.
Balance work and play by planning time for hobbies and recreation—activities that relax your mind and temporarily take you away from your stresses. Even diversions like taking a warm shower, going to a movie or taking a walk can help.
Practice relaxation exercises every day, including visualization, deep muscle relaxation, meditation and deep breathing.
Rehearse for stressful events. Imagine yourself feeling calm and confident in an anticipated stressful situation. You will be able to relax more easily when the situation arises.
Let yourself laugh and cry. Laughter makes your muscles go limp and releases tension, so try to keep a sense of humor. Tears can help cleanse the body of substances that accumulate under stress.
Talk out troubles. It sometimes helps to talk with a friend, relative or spiritual leader. Another person can help you see a problem from a different point of view.
Help others. Because we concentrate on ourselves when we’re distressed, sometimes helping others is the perfect remedy for whatever is troubling us.
Learn acceptance when a difficult problem is out of your control, which is better than worrying and getting nowhere.
Develop and maintain a positive attitude. View changes as positive challenges, opportunities or blessings.
You don’t need to do all of these. Some may work for some people and others for other people. The key is to use the ones that work for you. Some of these become more effective with practice. If you are feeling especially overwhelmed, seek help. There is no need to suffer and there are trained people out there to help.

Facts to Know

According to the American Psychological Association’s 2010 Stress in America survey, the majority of Americans report living with moderate or high levels of stress. And on average, those who report their health as fair or poor have more stress in their lives (an average stress rating of 6.2 on a 10-point scale) compared with those who rate their health as excellent or very good (an average stress rating of 4.9 on a 10-point scale).
Working mothers, in particular, are among the people most likely to experience stress, particularly when they do not have a lot of support from others.
Stress takes a toll on your body. Stress can cause stress hormones such as adrenaline and cortisol to flood your system. These hormones cause your heart rate and blood pressure to rise, your muscles to tense, your blood sugar levels to increase and other physical symptoms.
The effects of stress may lead to actual medical illnesses, including heart problems, stomach problems and headaches.
While stress doesn’t cause mental illnesses like depressive disorders or anxiety disorders, it can lead to feelings of depression and anxiety. It can precipitate mental illnesses in people predisposed to them, particularly if left untreated.
Symptoms of stress include irritability, sleep disturbances, appetite changes, muscular tension, apathy, fatigue, headache and frequent illness.
Stress can be brought about by external factors such as conflicts in your relationships, job pressures and even traffic. In addition, internal factors-such as a desire for perfection, a feeling of helplessness, blaming yourself for things that are out of your control or intense worry-also cause stress.
The ways you react to stressful situations can be relearned. You can use cognitive-behavioral approaches in which you identify sources of stress and work to minimize them and adjust your responses to the stresses you can’t eliminate.
Relaxation techniques help dispel stress and can cause adrenaline and cortisol levels in your blood to decrease. These techniques include deep breathing, muscle relaxation, stretching, visualization, meditation and biofeedback.
A nutritious diet and regular exercise not only prepare your body to withstand the physical effects of stress, but strengthen your mind to cope with stress and stay on an even keel.
According to the National Institute for Occupational Safety and Health, the U.S. agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury, 40 percent of workers reported their job was very or extremely stressful.

Key Q&A

I feel so distressed that I have recurrent thoughts of suicide or death. Is this stress? What should I do?You should seek care or crisis intervention immediately. These types of thoughts are more indicative of a depressive disorder than stress, but your health care professional can assess your situation, give you a diagnosis and recommend treatment.
What causes stress?What causes a person to experience stress is different for different people; what may be one person’s stressor can be an exciting motivator to another person. However, this doesn’t mean one person is weak and the other is strong. That being said, some common causes of stress are changes in your life like marriage, divorce, a new job or the birth of a child; trauma or crises, like illnesses, death of a loved one, or a traumatic event like a burglary; excessive demands on you and your time; conflicts or unpleasant people; small daily hassles; barriers that prevent you from reaching your goals; feeling little control over your life; and boring or lonely work.
Sometimes when I feel stressed out, I feel a pain or tightness in my chest. What is this and what should I do?You need to seek care immediately to rule out heart disease or to begin treatment for any heart-related illness you might have. While you might not have a physical illness, you do need to have this symptom diagnosed. If you don’t have a serious illness-rather the stress in your life is causing this symptom-you need to address this issue so your health doesn’t deteriorate further.
Is stress an illness?

While stress is not itself considered an illness, it is a common cause of specific medical symptoms from high blood pressure to muscle aches and stomach ulcers. According to the American Psychological Association (APA), in 2010, 51 percent of people surveyed reported fatigue, 40 percent reported headaches, 49 percent reported lack of motivation or energy, and 56 percent reported irritability or anger as a result of stress.
Who’s most likely to suffer from stress?According to the APA, women report higher levels of stress than men, and women are less likely to think they are doing enough to manage the stress in their lives. On a 10-point scale, 28 percent of women report an average stress level of eight, nine or 10, versus 20 percent of men. In addition, those most likely to report frequent mental stress include younger adults, working mothers, divorced or widowed individuals, the unemployed and those with low incomes.
What are the effects of stress?Stress can cause symptoms of a variety of physical and mental illnesses and make you more susceptible to other illness. Some specific symptoms of stress include feeling anxious, depressed or irritable; stomach upset, diarrhea or appetite changes; muscular tension; headaches; mental or physical fatigue and apathy; sleep disturbances and frequent minor illnesses.
Can I avoid stress?You probably can’t completely avoid stressful situations, but you can alter your reaction to those situations, resulting in far fewer physical symptoms of stress and negative results. With enough “tools,” some stress may actually feel motivating.
Are there treatments for stress?While you can’t necessarily control the events that cause you stress, you can control how you manage the stress. Cognitive-behavioral methods, a form of psychological treatment that is used to help you substitute desirable responses and behavior patterns for undesirable ones, are the most effective ways to reduce stress. These methods include identifying sources of stress and then altering or avoiding these circumstances; restructuring your priorities and goals; and adjusting your responses to stress by discussing your feelings, keeping your perspective, looking for the positive and using humor. In addition, learning relaxation techniques-the natural unwinding of the stress response-can be helpful. Finally, working with someone to change your life in ways that reduce the external stressors is also helpful. Improving how you cope with stress as well as reducing stressors in your life go hand in hand. Mental health professionals can help you do both of these things.

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Urinary Tract Infections

Overview

Urinary tract infections result in eight to 10 million doctors’ office visits each year in the United States, and at least 50 percent of women will have at least one urinary tract infection at some point in their lives.
Luckily, most urinary tract infections are not serious and can be easily treated with antibiotic medications. The symptoms of a urinary tract infection can be stubborn and can persist after treatment. Sometimes an infection recurs a few weeks after treatment. Nearly 20 percent of women who have a urinary tract infection will have another, and 30 percent of those who have had two will have a third. About 80 percent of those who have had three will have a fourth. If left untreated, urinary tract infections can lead to other more complicated health problems so they should not be ignored.
How the Urinary Tract Works
Your urinary tract includes two kidneys, two ureters, the bladder and the urethra. Your kidneys remove waste and water from your blood to produce urine. Urine travels through muscular tubes, called the ureters, to the bladder. The bladder is a balloon-like organ composed of muscle, connective tissue and nerves that swells as it fills with urine. Urine is stored in the bladder until it is released from the body through another tube, called the urethra. Two muscle groups, the pelvic floor muscles and the urinary sphincters, control the activity of the urethra and bladder neck. These muscles must work together to hold urine in the bladder most of the time and allow the bladder to empty when appropriate.
Cause of Urinary Tract Infection: Bacteria
Most urinary tract infections are caused by a variety of bacteria, including Escherichia coli (E. coli), found in feces. Because the openings of the bowel, vagina and urethra are very close together, it’s easy for the bacteria to spread to the urethra and travel up the urinary tract into the bladder and sometimes up to the kidneys.
Untreated Urinary Tract Infections: Bladder & Kidney Infections
Infection occurs when the bacteria cling to the opening of the urethra and multiply, producing an infection of the urethra, called urethritis. The bacteria often spread up to the bladder, causing a bladder infection, called cystitis. Untreated, the infection can continue spreading up the urinary tract, causing infection in the kidneys, calledpyelonephritis. Pyelonephritis can also occur without a preceding bladder infection.
A kidney infection that is not treated can result in the bacteria entering the bloodstream (this is known as urosepsis), which can be a life-threatening infection requiring hospitalization and intravenous antibiotics.
The first sign of a bladder infection may be a strong urge to urinate or a painful burning sensation when you urinate. You may feel the urge to go frequently, with little urine eliminated each time. At times, the urge to urinate may be hard to control and you may have urinary leakage. You may also have soreness in your lower abdomen, in your back or in the sides of your body. Your urine may look cloudy or have a reddish tinge from blood. It may smell foul or strong. You also may feel tired, shaky and washed out.
If the infection has spread to the kidneys, you may have fever, chills, nausea, vomiting and back pain, in addition to the frequent urge to urinate and painful urination.
Common Causes of UTIs
Some women are more prone to urinary tract infections than others because the cells in their vaginal areas and in their urethras are more easily invaded by bacteria. Women with mothers or sisters who have recurring urinary tract infections also tend to be more susceptible. Your risk of urinary tract infection also is greater if you’re pastmenopause. Thinning of the tissues of the vagina, bladder and urethra, as well as change in the vaginal environment after menopause, may make these areas less resistant to bacteria and cause more frequent urinary tract infections.
Irritation or injury to the vagina or urethra caused by sexual intercourse, douching, tampons or feminine deodorants can give bacteria a chance to invade. Using adiaphragm can cause irritation and can interfere with the bladder’s ability to empty, giving bacteria a place to grow.
Any abnormality of the urinary tract that blocks the flow of urine, such as a kidney stone or significant prolapse of the uterus or vagina, also can lead to an infection or recurrent infections. Illnesses that affect the immune system, such as diabetes, AIDS and chronic kidney diseases, increase the risk of urinary tract infections. A weak bladder can also make it difficult to empty completely, allowing bacteria to grow. Lengthy use of an indwelling catheter, a soft tube inserted through the urethra into the bladder to drain urine, is a common source of urinary tract infections. Intermittentcatheterization (where a person empties the bladder several times a day but the catheter is removed immediately) actually is used to prevent recurrent infections in some patients.
Because the uterus sits directly on the bladder during pregnancy and can block the drainage of urine from the bladder, UTIs are more common in pregnant women. And when women develop urinary tract infections during pregnancy, the bacteria are more likely to affect the kidneys. Hormonal changes and repositioning of the urinary tract during pregnancy may make it easier for bacteria to invade the kidneys. Such infections in pregnant women can lead to urosepsis, kidney damage, high blood pressure and premature delivery of the baby. All pregnant women should have their urine tested periodically during pregnancy. Pregnant women with a history of frequent urinary tract infections should have their urine tested often.
Most antibiotic medications are safe to take during pregnancy, but your health care professional will consider the drug’s effectiveness, how far your pregnancy has progressed and the potential side effects on the fetus when determining which medication is right for you and how long you should take it.
Diagnosis
Your health care professional will determine whether you have a urinary tract infection based on your symptoms, a physical examination and the result of a laboratory test of your urine. You will be asked to urinate into a small cup. The urine will be examined under a microscope for bacteria and for a large amount of white blood cells, which fight infection. A urine culture may be done in which the bacteria in the urine are encouraged to grow. The bacteria can then be identified and may be tested to see which antibiotic best kills them.
If you are having recurrent symptoms of infections despite treatment, it is important that your urine be cultured before you are placed on antibiotics. Repeated treatment of presumed infections without urine culture should be avoided.
Some bacteria, such as chlamydia, can only be found with special urine cultures. A health care professional may suspect these infections when a woman has urinary tract infection symptoms, but a standard culture doesn’t grow the bacteria.
If you have recurring urinary tract infections, your health care professional may suggest other tests to look for obstructions or other problems that might trap urine in the tract and cause infection:
Intravenous pyelogram (IVP) is an X-ray exam of the urinary tract using a dye that is injected into a vein and then enters the kidneys, ureters and bladder. This test is not commonly used alone anymore.
A computed tomography scan (CT scan), also known as a CT urography, is a type of X-ray test used to capture images of different structures in the body. The CT scan is usually given with an intravenous dye similar to that used in an IVP (see above). The dye allows your doctor to better see your kidneys, ureters and bladder. Newer CT scanners use much less radiation.
Ultrasound uses sound waves to produce images of the urinary tract. No radiation is involved in this test.
Cystoscopy is a test using a thin telescope-like instrument that allows your health care professional to see inside the urethra and bladder and examine them for problems.

Treatment

Urinary tract infections are treated with medications that kill the bacteria causing the infection. Your health care professional will determine which medication to prescribe and how you should take it, based on your medical history and condition and the results of the urine tests. Many medications can have side effects, so talk to your health care professional about what to expect. Also, medications can interact with other prescriptions and over-the-counter drugs, so make sure you tell your health care professional what drugs you are taking.
The antibiotics most often used to treat urinary tract infection are pills typically taken for three days. More complicated infections are usually treated with seven to 10 days or more of antibiotics, depending on the bacteria causing the infection, the drug used and your medical history. The most frequently prescribed drugs include:
ciprofloxacin (Cipro)
levofloxacin (Levaquin)
nitrofurantoin (Macrobid, Furadantin)
norfloxacin (Noroxin)
fosfomycin (Monurol)
trimethoprim/sulfamethoxazole (Bactrim, Septra)
Note: Fluoroquinolones, which include the antibiotics ciprofloxacin, gatifloxacin, levofloxacin and norfloxacin, have been associated with an increased risk of tendonitis and tendon rupture. If you are prescribed one of these medications for a urinary tract infection, discuss this risk with your health care professional.
Urinary tract infections caused by microorganisms, such as chlamydia, may be treated with the antibiotics azithromycin, tetracycline or doxycycline.
Although your symptoms may be relieved in a day or two after starting the medication, you must take all the medication your health care professional prescribes. Otherwise, you run the risk of a recurrence. That is, some bacteria may survive and cause your infection to return or cause reinfection with a new or different organism.
To help ease your discomfort until the antibiotics kick in, you can take a prescription medication called phenazopyridine (Pyridium). A similar medication, called Uristat, is available over the counter. However, keep in mind that these medications only ease symptoms; they do not treat the infection. They also change the color of your urine, can interfere with laboratory testing and shouldn’t be taken for more than 48 hours unless told differently by your health care provider.
If you are menopausal, you may experience more frequent urinary tract infections because thinning of the tissues of the vagina and urethra following menopause may make these areas less resistant to bacteria. Hormone replacement (either systemic or vaginal) may help. Vaginal estrogen has fewer health risks than systemic estrogen (such as in birth control pill and patches) because only a small amount is absorbed into the bloodstream. Vaginal estrogen is available as a cream (Estrace), a tablet (Vagifem, Premarin) and a flexible plastic ring (Estring). Femring is another vaginal estrogen product, but it has higher doses of estrogen and is primarily recommended for hot flashes; women with a uterus who use Femring should take progestin to minimize their risk of uterine cancer.
Discuss these treatment options and the latest research about their risks and benefits with your health care professional, keeping your personal health history and needs in mind. If you decide to take hormone replacement therapy, you should take the lowest dose that helps for the shortest time possible. You and your doctor should also reevaluate every six months whether or not you should be taking hormones.
Severe kidney infections may require hospitalization and treatment with intravenous antibiotics, especially if nausea, vomiting and fever increase the risk of dehydration and prevent the ability to swallow pills. Kidney infections usually require two weeks of antibiotic therapy, although treatment may extend as long as six weeks (this extended course usually is prescribed for men whose infections are due to prostatitis, however).
In addition to taking your medication, your health care professional may recommend drinking plenty of fluid (the equivalent of six to eight 8-ounce glasses a day) to help flush the urinary tract and avoiding foods and beverages that can irritate the urinary tract, such as coffee and alcohol. A heating pad may help to temporarily relieve pain.
After you’ve completed your course of medication, your health care professional may suggest a follow-up urine test to make sure the infection is gone.

Prevention

There are several simple, do-it-yourself techniques that may prevent a urinary tract infection. Some may work some of the time or only in some women. But, because they carry no side effects, they certainly are worth trying to prevent the often painful and bothersome symptoms the infection can bring:
Drink plenty of fluid––the equivalent of six to eight 8-ounce glasses––every day to flush bacteria out of your urinary system. Water is the ideal fluid because it is readily available, inexpensive and noncaloric, but other beverages also count toward your fluid intake, including juices, milk and herbal teas. Even alcoholic beverages such as beer and wine and caffeinated beverages such as coffee and colas help replenish your fluids, but don’t rely heavily on them because they have diuretic properties. Additionally, alcohol and caffeine, as well as spicy foods, are among the substances that may irritate the bladder and, thus, should be avoided.
Make sure you’re getting vitamin C in your diet, either through diet or supplements. Vitamin C, or ascorbic acid, makes your urine acidic, which discourages the growth of bacteria. Drinking cranberry juice may also produce the same effect. Cranberry supplements are a more concentrated form of cranberry juice without the sugar content.
Urinate frequently and when you feel the urge; don’t hold it in. Keeping urine in your bladder for long periods gives bacteria a place to grow.
Avoid using feminine hygiene sprays and scented douches. They may irritate the urethra.
If you wear a pad for urinary leakage, you should change it often. Wet pads provide an environment for bacteria to grow.
If you suffer from urinary tract infections more than three times a year, your health care professional may suggest one of the following therapies to try to prevent another recurrence:
a low dosage of an antibiotic medication such as trimethoprim/sulfamethoxazole or nitrofurantoin, taken daily for six months or longer
a single dose of an antibiotic medication taken after sexual intercourse if it is determined that your UTIs are related to sex
a short, one- or two-day course of antibiotic medication taken when symptoms appear
Use of preventive medications that change the bladder environment, such as methanamine.
If you experience recurring UTIs, home urine tests, which involve dipping a test stick into a urine sample, may be helpful.
Some research suggests that a woman’s blood type may play a role in her risk of recurrent UTIs. Bacteria may be able to attach to cells in the urinary tract more easily in those with certain blood factors. Additional research will determine if such an association exists and whether it could be useful in identifying people at risk of developing recurrent UTIs.
Vaccines are being developed to help patients build up their own natural infection-fighting powers. Vaccines that are prepared using dead bacteria do not spread like an infection; instead, they prompt the body to produce antibodies that can later fight live organisms. Researchers are currently looking into vaccines that can be administered orally, by way of a vaginal suppository and through the nose.

Facts to Know

Urinary tract infections result in eight to 10 million doctors’ office visits each year in the United States, and at least 50 percent of women will have at least one urinary tract infection at some point in their lives.
Nearly 20 percent of women who have one urinary tract infection will have another, and 30 percent of those who have had two will have a third. About 80 percent of those who have had three will have a fourth. Four out of five such women get another infection within 18 months of the last one.
Some women are more prone to the infection than others. Women at higher risk include those who are past menopause, who have diabetes or who use a diaphragm. If your mother or sister had frequent urinary tract infections, you are more likely to have one. Recently, researchers found that women who use spermicides as contraception—particularly if they use them with diaphragms—are also at a greater risk for recurrent UTIs.
About 2 percent to 7 percent of pregnant women develop a urinary tract infection. Pregnant women are more likely to have UTIs and the infection is more likely to spread to the kidneys. UTIs during pregnancy need prompt attention by a health care professional to avoid a premature birth. Pregnant women may have no symptoms associated with an infection so regular urine tests are important.
One type of bacteria––Escherichia coli (E. coli), which lives in the digestive system and spreads to the urinary tract––causes most urinary tract infections.
Urinaryurgency, urge incontinence and pain with urination can be early symptoms of urinary tract infection. Urinary urgency is characterized by frequent overwhelming urges to urinate. Urgency incontinence is urine leakage resulting from not getting to a toilet in time.
Urinary tract infections usually are not serious and are easily treated by taking antibiotics. Kidney infection is the most common complication and can produce fever, chills, nausea, vomiting and back pain.
Although urinary tract infections do occur in men, women are at greater risk because of their anatomy. The female urethra is short, and the rectum, vagina and urethra are located closely together in women, making it easy to spread bacteria that live in the digestive tract to the urinary tract.
Women who have more than three urinary tract infections in a year may benefit from preventive antibiotic therapy. Such therapy may involve taking a low dose of medication every day for six months or longer, taking a single dose after having sex or taking a dose for one or two days when symptoms begin to appear. If you experience recurring UTIs, home urine tests, which involve dipping a test stick into a urine sample, may be helpful.
When being treated for a urinary tract infection, take all the antibiotic medication you have been given, even if your symptoms are gone before you finish your prescription. If you fail to complete the treatment, the infection may still be present, and your symptoms will return or another infection may arise in a short time.

Key Q&A

How do you get a urinary tract infection?The infection is most often caused by bacteria from the digestive tract being spread to the urethra and then traveling up the urinary tract to the bladder and sometimes the kidneys. It can also be caused by bacteria and microorganisms transmitted during sexual intercourse.
Isn’t it true that once you have a urinary tract infection, you’ll never have another one?No. In fact, once you have a urinary tract infection, you are more likely to have another. Nearly 20 percent of women who have a urinary tract infection will have another, and 30 percent of those who have had two will have a third. About 80 percent of those who have had three will have a fourth. Four out of five such women get another infection within 18 months of the last one.
How can I tell if I have a urinary tract infection?Symptoms of urinary tract infections may include frequent, urgent needs to urinate, but not making it to the toilet in time; a painful, burning sensation when urination occurs; cloudy or reddish-colored urine; urine that smells foul or strong; and soreness in the back, side or lower abdomen. If fever, chills, nausea, vomiting and/or back pain accompany the symptoms, you may have a kidney infection. See your health care professional promptly if you have any signs of a urinary tract infection.
My urinary tract infection seems to be gone. Do I still need to take the rest of my antibiotic medication?Yes, absolutely. Although your symptoms may disappear in one or two days after taking antibiotic medication, you must take all the medication to destroy the germs causing the infection. If you don’t, your symptoms may return, or you may have another urinary tract infection in a short time.
Will a urinary tract infection harm my baby or me when I’m pregnant?If the infection is caught and treated early, generally not. However, pregnant women are more likely to have a urinary tract infection spread to their kidneys, which can cause kidney damage, high blood pressure and increased risk of premature delivery. If you’re pregnant and suspect you have a urinary tract infection, see your health care professional right away.
Isn’t drinking cranberry juice to prevent urinary tract infection an old wives’ tale?Not necessarily. Cranberry juice and vitamin C make the urine more acidic, which makes it more difficult for bacteria that can cause urinary tract infections to grow. Cranberry juice also has another unique factor that helps prevent bacteria from adhering to the urinary tract walls.
Why do I keep getting urinary tract infections?Some women are more prone to urinary tract infections than others because the cells in their vaginal areas and in their urethras are more easily invaded by bacteria. Your risk of developing a urinary tract infection is also greater if you’re past menopause because changes in your tissues after menopause may make the area less resistant to bacteria.Irritation or injury to the vagina or urethra caused by sexual intercourse, douching, tampons or feminine deodorants can give bacteria a chance to invade. Using a diaphragm can cause irritation and can interfere with the bladder’s ability to empty, giving bacteria a place to grow.
Any abnormality of the urinary tract that blocks the flow of urine, such as a kidney stone, also can lead to an infection. Illnesses that affect the immune system also increase the risk of urinary tract infections.
Practicing good personal hygiene habits, including washing the areas around the bowel, vagina and urethra daily and wiping from front to back, can help prevent spreading bacteria to the urinary tract. Drinking plenty of water daily, urinating when you feel the need (rather than waiting) and urinating after sexual intercourse can help flush the system of bacteria.
Are there any medications that can prevent my recurring infections?If you have urinary tract infections three times a year or more, ask your health care professional about preventive antibiotic therapy. Taking a low dosage of antibiotics over an extended time or a single dose after sexual intercourse is often prescribed to head off infections. Or, you may take antibiotics for one or two days when you first notice signs of a urinary tract infection. Talk with your health care professional about which treatment may be best for you.

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Violence Against Women

Overview

Violence against women, also known as interpersonal violence, is a crime of power and control. It occurs in the context of many different types of relationships and takes many forms. It can happen within marriages, between siblings, roommates, dating couples and those in lesbian and gay relationships. Elderly members of a family can also be the objects of abuse by relatives.
In the majority of intimate partner violence incidents, men are the primary abusers. According to findings from the National Center for Injury Prevention and Control at the U.S. Centers for Disease Control and Prevention (CDC), about 1.5 million women and more than 800,000 men are raped or physically assaulted by an intimate partner every year. And the U.S. Department of Justice reported in 2000 that 25.5 percent of women and 7.9 percent of men reported being raped, physically assaulted and/or stalked by anintimate partner in their lifetimes.
According to the CDC’s National Center for Injury Prevention, almost 5.3 million intimate partner victimizations of women age 18 and over take place each year, and 3.2 million occur among men. These attacks result in approximately two million injuries and 1,300 deaths each year. In 2001, intimate-partner violence accounted for 20 percent of all nonfatal violent crime experienced by women. In addition, one study showed that almost all (93 percent) of the women who were murdered by their intimate partner had been treated for at least one injury at the hands of that same person. Generally, victims of repeated physical violence experience more serious consequences than victims of isolated incidents.
The abuser may use a number of tactics other than physical violence in order to maintain power and control over his or her victim. There are three categories of abuse:
Psychological abuse: Sometimes called mental violence, this type of abuse may include constant verbal abuse, harassment, stalking, excessive possessiveness, isolating the woman from friends and family, depriving her of physical and economic resources and destroying her personal property. The abuser may destroy objects or harm pets in front of the victim, and it may escalate to physical abuse. Psychological abuse can lead to psychological consequences for the victim, including depression, low self esteem, fear of intimacy, inability to trust men,anxiety, antisocial behavior and, in some cases, attempted suicide.
Physical abuse: Physical abuse may begin with grabbing, pinching or shoving and often escalates into more serious and more frequent attacks including kicking, punching, biting, throwing objects, holding down, driving recklessly, blocking exists and sexual assault. Physical attacks and aggressive behavior, although they may not be life threatening at first, are not trivial and should not be excused or ignored. This abuse becomes life threatening when the attacks include choking, breaking bones or the use of weapons.
Sexual abuse: Any time a woman is forced to take part in unwanted sexual activity, it is considered sexual violence. Physical abuse may be accompanied by, or culminate in, sexual violence, but there is a clear and distinct line between physical domestic violence and sexual abuse. Although some intimate partner abuse culminates in sexual abuse, the majority does not. And although perpetrators of sexual abuse sometimes physically harm their victims, it is unusual for sexual abuse perpetrators to be chronic intimate partner violence abusers.
Certain groups of women are at higher risk for becoming victims of abuse and violence. According to the National Center for Injury Prevention and Control, these include women who:
are single, separated or divorced (or planning a separation or divorce)
are between the ages of 17 and 28, especially under age 24
abuse alcohol or other drugs or whose partners do
have partners who are excessively jealous or possessive
have a history of prior physical abuse
have partners who are verbally abusive
have a history of childhood abuse
are unemployed or experiencing economic stress
have experienced prior injury from the same partner
have a low level of academic achievement
lack social networks and tend to be socially isolated
There are also various relationship risk factors for violence and abuse, including the following:
A male belief in strict traditional gender codes, such as the woman should stay at home and be submissive
Couples with educational, income or job status disparities
Male or female dominance in the relationship
Dating Violence
Another form of violence against women is dating violence (sometimes called “date rape”). In this form of violence, one person purposely causes physical or psychological harm to another person they are dating. Dating violence can manifest itself as physical abuse, sexual assault and/or psychological/emotional abuse.
A victim of dating violence might unknowingly be given alcohol or slipped “date rape” drugs like Rohypnol in her drink. Alcohol and date rape drugs can make you unable to resist assault. You experience a type of amnesia so you’re uncertain about what happened. This means you’re left to cope with not only the trauma of the sexual assault, but the uncertainty surrounding the specifics of the crime. Unfortunately, most cases of dating violence are not reported to the police.
Like other forms of violence against women, dating violence is a serious crime that occurs in both casual and serious relationships, as well as in both heterosexual and same-sex relationships.
The physical and psychological health consequences of intimate partner and dating violence are very serious. Affected women experience more reported chronic health problems than unaffected women, including:
Pain, gastrointestinal disorders and irritable bowel syndrome
Higher rates of sexually transmitted diseases, central nervous system disorders and cardiac problems, although no history of cardiac disease.
Gynecological disorders and unwanted pregnancies.
Headaches and back pain
Symptoms of post-traumatic stress disorder, including emotional detachment, flashbacks and sleep disturbances
In 2000, the U.S. Department of Justice reported on the extent, nature and consequences of intimate partner violence in the U.S. According to its findings, approximately 1.8 million women and one million men reported being raped and/or physically assaulted by an intimate partner in the past 12 months. These statistics do not take into account the occurrences of psychological abuse, which is harder to identify than physical or sexual abuse. Additionally, stalking by intimates is more prevalent than previously thought. According to CDC estimates, more than one million women and 371,000 men are stalked by an intimate partner every year.
An abuser can be anyone involved in a relationship with the victim: husbands, boyfriends, dating partners, same-sex partners and others. Many abusers were involved in or exposed to abusive relationships during their childhood. However, exposure to abuse is not a prerequisite for abusive behavior later in life.
The physical and psychological health consequences of intimate partner violence are very serious. Affected women have 60 percent more reported chronic health problems, including:
If you know someone who is involved in an abusive relationship, it may be difficult for you to understand why she doesn’t just leave. The answer as to why women stay in violent relationships is complex.
Part of the reason is that domestic violence often occurs as a pattern of behavior known as the “cycle of violence.” The cycle involves three phases:
Phase 1: Tension builds. The abuser may threaten or push and shove the victim. The victim often reacts by working harder to keep the abuser calm. During this phase, the victim may believe that she can prevent a violent incident, but she is walking on eggshells. Her efforts typically fail.
Phase 2: Violence occurs. The abuser may hit, beat, sexually abuse or use weapons against his partner. Women’s lives are most often in danger during phase two.
Phase 3: The “Honeymoon” Phase. The abuser apologizes to the victim and promises he won’t harm her again. He may also blame his actions on her behavior. Often the partner accepts the abuser’s apologies and forgives his behavior. The tension-building phase begins again, renewing the “cycle of violence.”
If you or someone you know is trapped in this cycle of violence, talk to someone at the National Domestic Violence Hotline. Dial toll-free: 1-800-799-SAFE (7233) or TDD 1-800-787-3224 24 hours a day, 365 days a year in English, Spanish and other languages. If you think you are being stalked, call the Stalking Hotline at the National Center for Victims of Crime at 1-800-FYI-CALL (394-2255).
There are also many external barriers to women leaving a violent relationship. Reasons why women stay include:
Lack of resources. Many women have children to support, yet they are not employed outside the home. Often the car, house, bank accounts and credit cards are in the abuser’s name.
Institutional responses. Clergy and secular counsel are often trained to save the marriage at all costs, despite the fact that abuse is occurring. Police officers often treat women not as victims of violent crime, but rather as participants in a domestic dispute. However, in most jurisdictions police can file charges against the perpetrator if women are afraid to. Prosecutors are sometimes reluctant to take legal action against abusers and when they do, the courts rarely levy heavy sentences. Restraining orders often do little to prevent an abuser from returning and repeating the assault. However, many women do not believe they will get support if they leave.
Traditional ideology. MMany women do not believe divorce is an alternative to an abusive marriage. When children are involved, they may believe that an abusive father is better than no father at all. Also, women often feel responsible for the failure of their marriage. Because abused women may become isolated from family and friends by a jealous abuser, they may feel they have no one to turn to. Many times women will rationalize their partner’s abusive behavior, blaming it on drugs, alcohol, stress or other factors. During non-violent “honeymoon” phases within the cycle of violence, the abuser may convince his victim that he is truly sorry and will not hurt her again. She may believe that her abuser is “basically a good person.”
Losing children. This is an enormous fear for women with children. They believe that in leaving they will lose their children.
Reaching out to a woman who is in an abusive relationship can be difficult. Here are some things you can say to her:
I’m afraid for your safety
I’m afraid for the safety of your children
It will only get worse
You deserve better than this
Let’s figure out a safety plan for you
Reflect and recall the pattern of events (to stop the cycle of violence)

Diagnosis

Prevailing myths about intimate-partner violence often encourage denial about abusive situations and prevent women from getting the help they need. Remember: Domestic violence can happen in any type of relationship, income level, environment or culture. Common myths associated with domestic and intimate partner violence include:
Myth: Family violence is rare. Truth: Although statistics on family violence are not precise, it’s clear that millions of children, women and even men are abused physically by family members and their closest relations or partners.
Myth: Family violence is confined to the lower classes. Truth: Reports from police records, victim services and academic studies show domestic violence exists in every socioeconomic group, regardless of race or culture.
Myth: Alcohol and drug abuse are the real causes of violence in the home. Truth: Because many male batterers also abuse alcohol and other drugs, it’s easy to conclude that these substances may cause domestic violence. Substance abuse increases the risk for and lethality of the violence. But for some men, battering begins when they come off of drugs and other substances. Substance use and abuse are not excuses for a batterer’s behavior or for his failure to take responsibility for his behavior, however. In addition, successful completion of a drug treatment program does not guarantee an end to battering. Domestic violence and substance abuse are two different problems that both require treatment.
Myth: Battered wives like being hit, otherwise they would leave…Truth: The most common response to battering—”Why doesn’t she just leave?”—ignores the economic and social realities facing many women. Shelters are often full; and family, friends and the workplace are frequently less than supportive. Faced with rent and utility deposits, day care, health insurance and other basic expenses, the woman may feel that she cannot support herself and her children. Moreover, in some instances, the woman may be increasing the chance of physical harm, death or losing her children if she leaves an abusive partner.
Are you in an abusive or potentially abusive relationship? Here are some questions to ask yourself about how you are being treated by your partner and how you treat your partner.
Does your partner:
Embarrass or make fun of you in front of your friends or family?
Put down your accomplishments or goals?
Criticize you for little things?
Constantly accuse you of being unfaithful?
Control your use of needed medicines?
Make you feel like you are unable to make decisions?
Use intimidation or threats to gain compliance?
Tell you that you are nothing without him or her?
Control how you spend money?
Treat you roughly—grab, push, pinch, shove or hit you?
Call you several times a night or show up to make sure you are where you said you would be?
Use drugs or alcohol as an excuse for saying hurtful things or abusing you?
Blame you for how he or she feels or acts?
Pressure you sexually for things you aren’t ready for?
Make you feel like there “is no way out” of the relationship?
Destroy your property or things you care about?
Prevent you from doing the things you want, like spending time with your friends or family?
Try to keep you from leaving after a fight or leave you somewhere after a fight to “teach you a lesson?”
Do you:
Sometimes feel scared of how your partner will act?
Constantly make excuses to other people for your partner’s behavior?
Believe that you can help your partner change if only you changed something about yourself?
Try not to do anything that would cause conflict or make your partner angry?
Feel like no matter what you do, your partner is never happy with you?
Always do what your partner wants you to do instead of what you want?
Stay with your partner because you are afraid of what your partner would do if you broke up?
If you answered yes to any of these questions, you may be in an abusive or potentially abusive relationship. If you do not seek help, the abuse will continue.
Ultimately, you can take the first step toward getting help by confiding in your health care professional. If you find yourself in a health care professional’s office, an emergency room or clinic for treatment as a result of abuse, take the opportunity to talk to the health care professional about why you’re there. Today, many health care professionals are trained to notice signs and symptoms of abuse, and they know how to help you. It might be up to you, however, to bring up the topic.
Prevention
Emotional and verbal abuse, attempts to isolate and threats and intimidation within a relationship may be an indication that physical abuse is to follow. Even if these behaviors are not accompanied by physical abuse, they must not be minimized or ignored.
If you are dating, learn how to minimize your risk of becoming a victim of dating violence before you find yourself in an uncomfortable or threatening situation.
If you are already in an abusive relationship, take the following actions to prevent the violence from escalating:
Share your situation with someone you can trust. Tell a family member or friend what’s going on.
Prepare NOW for your escape. Make plans for what you will do if you are attacked again.
Locate a safe place for you and your children to go—a friend’s house or a shelter. A crisis hotline or your local police can help you find a shelter.
Have a back-up plan in mind just in case your first plan doesn’t work.
Build a survival kit including a spare set of keys, clothes, birth certificates, passports, divorce/custody/separation agreements, protection orders, prescriptions, bank cards and money. Ask someone you trust to keep these items for you.
Contact your local family court or domestic violence court for information about getting a civil protection order.
Try not to let the abuser trap you in a kitchen with potential weapons or in small places like a bathroom.
If you are injured, go to a hospital or health care professional’s office, tell the health care professional who treats you what happened and make sure he or she writes it in your medical records.
Try to open a savings account in your own name. Ask someone you trust to keep the account statements, and have the statements sent directly to that person. Keep some emergency cash in a safe place near an escape exit.
Know your rights. Contact the shelter or women’s center in your area to find out about your legal rights and what resources are available in the community.

Facts to Know

Help is available by calling the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or TDD 1-800-787-3224. You can reach the National Sexual Assault Hotline at 1-800-656-4673. And the Stalking Hotline number is 1-800-FYI-CALL (394-2255).
Women living with female intimate partners experience less intimate-partner violence than women living with male intimate partners. However, men living with male intimate partners experience more intimate-partner violence than do men who live with female intimate partners.
Unmarried couples are at greater risk of intimate partner violence than married couples.
According to the U.S. Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control, women who experience intimate partner violence are more likely to have been unemployed in the past and are more likely to be receiving public assistance. Ironically, however, women with an education level higher than their partners’ are also more likely to become victims of intimate partner violence.
Women are primarily raped and/or physically assaulted by intimate partners and are more likely than men to be injured during an assault. Approximately 1,300 women are murdered every year by an intimate partner, according to the U.S. Department of Justice.
The CDC reports that people with disabilities are four to 10 times more likely to become victims of abuse than people without disabilities, and that women with disabilities report a greater number of perpetrators of physical violence, emotional abuse or sexual abuse—and for longer periods of abuse—than women without disabilities.
A batterer may be pleasant and charming between periods of violence, and is often seen as a “nice person” to outsiders. Some behavioral warning signs of a potential batterer include extreme jealousy, possessiveness, a bad temper, unpredictability, cruelty to animals and verbal abusiveness.
Women and men who were physically assaulted as children by adult caretakers are significantly more likely to report being victimized by their current partner. One-third of women who are physically abused by a husband or boyfriend grew up in a household where their mothers were similarly abused. About one in five were abused themselves as children or teenagers. Children who witness violence at home or who are abused themselves are more likely to abuse their own children when they become parents
Information from the U.S. Department of Justice shows that violence perpetrated against women by intimate partners is rarely prosecuted.
It is important to realize that a woman who begins to talk about her situation is reaching out for help and making an effort to involve someone in her situation. Family and friends should be supportive of her attempts to escape her abuser, since there are often financial and psychological barriers standing in her way.

Key Q&A

If things are so bad, why doesn’t she just leave her abuser?Shelters often are full, and family, friends and the workplace are frequently less than fully supportive of a woman fleeing an abusive relationship. Faced with rent and utility deposits, day care, health insurance and other basic expenses, she may feel that she cannot support herself and her children. In some instances, the woman may be increasing the chance of physical harm or even death if she leaves an abusive partner.
What can I do to convince my friend that she needs to leave her abusive partner?Explain to her that you are afraid for her safety and the safety of her children. Assure her that the abuse will likely continue to escalate and will definitely not go away. Tell her that she deserves better than this and offer to help her devise a plan for escape.
What if she will not or does not want to leave?Encourage her to investigate local resources for counseling and temporary shelter, or other social services she or her family may need. Sometimes abusers can be persuaded, or court-ordered, to enroll in anger-management programs for intensive therapy aimed at rechanneling rage. Additionally, the woman needs continued support—it may take a victim months or even years before she feels safe enough to leave.
Is it still considered abuse even if he doesn’t physically harm her?Yes. Psychological abuse, sometimes called mental violence, may include constant verbal abuse, harassment, excessive possessiveness, isolating the woman from friends and family, deprivation of physical and economic resources and destruction of personal property in her presence. The abuser may destroy objects or harm pets in front of the woman. Psychological abuse often escalates to restraining, pushing, slapping and/ or pinching.
If I can get my partner to stop drinking so much, will that help calm his abusive behavior?Probably not. Although abuse is often blamed on alcohol and drug use, abusers rarely stop their abusive behavior even after completion of a drug or alcohol treatment program. Abusive behavior and substance abuse are two separate issues that both require treatment.
How can I prepare for the day when I finally leave for good?Begin now to build a survival kit containing a spare set of keys, clothes, birth certificates, passports, divorce/custody/separation agreements, protection orders, prescriptions, bank cards and money. Ask someone you trust to keep these items for you. If you are concerned about leaving important items and money with someone, get a safety deposit box.
How can I leave my husband when he always seems so sorry after he hits me?Your husband’s apologies may seem sincere for the moment, but they are part of the cycle of violence. After a violent incident, most abusers apologize and promise to stop hurting their victims. But soon after the “honeymoon” is over, violent tension begins to build again and will inevitably result in more abuse.
Am I doing something to provoke my husband’s rage?Like other abusers, your husband would like for you to believe that his violent behavior is your fault. It is not. And by the same token, there is nothing you can do or say to prevent the abuse from continuing, except to leave. Its important to understand that one reason the abuser attacks you is because he sees you as vulnerable, not because he has a tendency to attack all women.
Can sexual abuse occur between husband and wife?Yes. Sexual abuse is any type of unwanted sexual activity. Sexual abuse can occur within a marriage or between lovers. Physical abuse may accompany or culminate in, sexual violence. However, a few states still don’t allow women to charge their husbands with a sexual crime. Sexual abuse can include the abusers’ insistence on total control of the woman’s sexual life, including the type of contraception she is “allowed” to use, or the insistence that she cannot use any contraception. Today, more contraception choices are available to women and may be used without detection. Every woman should also know about and have access to emergency contraception, the so-called “morning-after” pill that can prevent a pregnancy from occurring after unprotected sex

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Vulvodynia

Overview

Vulvodynia (“vul-vo-din-ee-a”) is chronicpain or discomfort of the vulva (the area surrounding the outside of the vagina) that lasts for three months or longer without any evidence of other skin or gynecological causes. Vulvodynia is usually characterized by burning, stinging, irritation or rawness of the area. The most common complaint is a burning sensation.
Vulva Anatomy
Labia—the folds just outside the vaginal opening
Vestibule—the portion of skin at the vaginal opening that contains the opening of the urethra, vagina and lubricating glands
Perineum—the area between the vaginal opening and the anus
Some women experience discomfort of the entire vulva area (generalized pain). Others have localized pain, which affects a specific part of the vulva, such as the vestibule or clitoris. Symptoms may be constant or come and go. The pain may be provoked by sexual and/or nonsexual contact (e.g., inserting a tampon, during a pelvic exam, wearing tight-fitting pants), unprovoked (spontaneous), or mixed (provoked and unprovoked).
The two types of vulvodynia are:
Generalized vulvodynia—refers to generalized, unprovoked vulvar pain.
Vulvar vestibulitis—is characterized by pain experienced when pressure is applied to the area surrounding the vaginal opening. In this case, the recurrent vulvar pain may be triggered by sexual activity, tampon insertion or gynecological exams, or when wearing tight-fitting pants or even when sitting.
It is estimated that up to 16 percent of women—roughly 13 million—will suffer with chronic vulvar pain at some point in their lives. Still, vulvodynia remains poorly understood and is often misdiagnosed.
Many women suffer with unexplained vulvar pain for months—even years—before a correct diagnosis is made and an appropriate treatment plan is determined. A Harvard study funded by the National Institutes of Health found that 60 percent of women who suffer from the condition consult at least three health care professionals in seeking a diagnosis, and 40 percent of those still remained undiagnosed. The study emphasizes how important it is for women to be persistent in seeking an accurate diagnosis so they can receive appropriate treatment.
While vulvodynia affects women of all age groups, the onset of symptoms is most common among women between the ages of 18 and 25. This risk drops significantly in those 35 years and older. Although vulvodynia was once thought to affect mainly Caucasian women, recent studies have shown that Hispanic and African American women are equally likely to develop the condition.
Causes and Risk Factors
There is no simple answer to the question, “What causes vulvodynia?” We do know that it is not caused by infection, the human papillomavirus (HPV) or other sexually transmitted diseases, cancer or neurologic disorders. It can only be diagnosed after other causes of vulvar pain, such as yeast infections, have been ruled out.
Early difficulty or pain when using tampons appears to predict those at high risk for future vulvodynia.
Research shows the following may contribute to vulvodynia:
pelvic nerve damage or irritation
spasms or weakness of the muscles that support the pelvic organs
abnormal response of cells in the vulva to environmental factors, such as infection or injury
allergies to certain detergents or soaps
altered hormone receptor expression in the vulvar tissue
genetic factors, including susceptibility to inflammation
recurrent yeast infections
previous laser treatments or surgery external to the vagina
Impact on Quality of Life
Vulvodynia can cause significant physical, sexual and psychological distress. Women who suffer with vulvodynia report difficulties exercising, being intimate and taking part in other daily activities. Even sitting for long periods of time can trigger vulvar pain episodes in some women.
According to an NIH-funded study done at Robert Wood Johnson Medical School and reported by the National Vulvodynia Association:
Seventy-five percent of women with vulvodynia feel “out of control” of their bodies.
Sixty percent say the condition interferes with their enjoyment of life.
Almost two out of three (60 percent) cannot have sexual intercourse because of the pain. The sheer anticipation of vulvar pain can heighten anxiety and lead many women to avoid sexual intercourse. Refraining from sex not only affects a woman’s self-image, but it may also result in spasms of the muscles around the vagina (vaginismus), making it even more difficult to be intimate with her partner.
In addition, some women with vulvodynia may be burdened by other health problems, including interstitial cystitis, fibromyalgia, irritable bowel syndrome, chronic fatiguesyndrome, temporomandibular joint and muscle disorders and endometriosis.
Lack of awareness about this condition, coupled with the stigma frequently associated with genital disorders, makes diagnosis and treatment more challenging. As a result, many women are left not knowing why they have such severe, often debilitating vulvar pain, which can strain a couple’s sexual relationship. Some women report being told the pain is “all in your head” by health care providers, who are often unaware that vulvodynia is a common medical problem in women with long-term vulvar pain.
If untreated, chronic pain can lead to:
low self-esteem
anxiety
depression
reduced quality of life
And the severity of the pain can worsen when women with this condition are stressed, depressed or anxious.

Diagnosis

Vulvodynia is poorly understood and, as with many pain conditions, it can be difficult to diagnose. Vulvodynia is diagnosed when other causes of vulvar pain, such as infections, skin problems or neurologic disorders, are evaluated and ruled out.
Women with vulvodynia often report having one or more of the following symptoms in the vulvar area:
burning (most common symptom)
stinging
rawness
aching
throbbing
stabbing
soreness
To make a diagnosis, your health care professional will begin by reviewing your medical history. He or she will ask you specific questions about your symptoms, treatments you may have already tried, your menstrual cycle, feminine hygiene, sexual history, previous medical problems or surgeries, as well as any medications you use (including over-the-counter medicines). You should also discuss any difficulties you have using tampons or having sexual intercourse. Your health care provider will then do a pelvic exam and carefully inspect your vulva. He or she may order blood tests and/or take a sample of discharge from your vagina to check for yeast or other infections that could be causing your symptoms.
A cotton swab test is often used to map vulvar pain. For this evaluation, your doctor will use a moist, cotton-tipped swab to place pressure on various parts of the vulva to identify the location and intensity of your pain. You will be asked to rate the extent of the pain at each site; for example, how would you describe the pain on a scale of 0 to 10 (no pain to extreme pain)? Your health care professional may use a diagram to visually note where you feel discomfort, as well as the degree and nature of the pain, such as burning, throbbing or stabbing.
Your doctor may use a large magnifying instrument (called a colposcope) to take a closer look at the vulvar skin. While there may be redness and inflammation, vulvar skin usually appears normal despite the occurrence of pain.
Describing Your Pain
Be sure to clearly describe your pain, including its:
onset (When did the pain begin, and did it start gradually or all of a sudden?)
location (Where do you feel pain? Is it isolated to a certain part of the vulva?)
frequency/duration (When do you feel pain? Is it constant or does it come and go? How long have you had vulvar pain?)
nature/type (Is it aching, burning, stabbing?)
severity (On a scale of 0 to 10, 10 being the worst pain you can imagine, how bad has your pain been?)
Explain how chronic vulvar pain impacts your daily life. Are there certain activities you avoid, such as exercise, use of tampons or sex? You may want to keep a pain diary with detailed information about your pain—when it occurs and for how long, things that make it better or worse and any other symptoms. This can provide important clues and will help your health care professional make a diagnosis.

Treatment

There are treatments available to provide symptom relief. These may include a combination of advice on vulvar skin care, oral and/or topical medications, physical therapy and biofeedback training, dietary modifications, counseling and, in some cases, surgery. Adjunct therapies, such as acupuncture, massage therapy and cognitive behavioral therapy, are also being explored.
The main goals of treatment are to manage your pain, improve your quality of life (e.g., restore a healthy sex life and reduce anxiety), and prevent the recurrence of symptoms. The chronic nature and complexity of vulvodynia often require multiple treatment strategies. Finding the right treatment or combination of therapies may take some time, especially because each woman’s symptoms and response to treatment are different. Your health care provider will recommend a treatment approach based on your condition(s), level of pain and preferences.
Available Treatment Options
The following section provides a snapshot of available treatments that have been beneficial in reducing pain symptoms (listed in no particular order):
Medications. Oral and/or topical medications, including topical anesthetics (lidocaine ointment), opioid pain killers (for temporary relief), estrogen, anticonvulsants, certain types of antidepressants and nerve blocks, may be prescribed for chronic pain.
Topical anesthetic ointments provide quick pain relief and comfort and may be used overnight or applied 15 to 30 minutes before sexual activity. Low doses of tricyclic antidepressants may be recommended to treat vulvodynia because of their pain-blocking properties, particularly amitriptyline (Elavil), desipramine (Norpramin) and nortriptyline (Pamelor). For many women, the tricyclic antidepressants are the initial treatment prescribed. Gabapentin and pregabalin are often considered as additional agents. A newer class of antidepressants, known as SSNRIs (Effexor, Cymbalta), have also demonstrated benefit with fewer side effects for some women than the tricyclic antidepressants. Like the older tricyclic class of antidepressants, these medications can also help relieve symptoms of depression.
Ask your health care professional about various medications and their common side effects. When using certain medications, keep in mind it can take up to six to eight weeks for symptoms to improve, and that you will not necessarily achieve complete relief.
Basic vulvar care. Some common suggestions for vulvar care include:
wearing cotton-only underwear
avoiding tight-fitting pants and pantyhose
using unscented cotton pads and tampons
keeping harsh soaps and shampoos away from the vulva area and not using douches
applying plain petroleum (Vaseline) after cleansing to hold moisture in the skin
using plenty of water-soluble lubrication during sexual intercourse
patting the area dry after rinsing and urination
Diet Modifications. Talk with your provider about the pros and cons of eliminating certain types of foods from your diet, such as those high in oxalates or sugar. To test for food sensitivity and to determine which foods, if any, are affecting you, eliminate one food or food group at a time. Use a food diary to record your results—you might begin to notice an association between your symptoms and certain foods you wouldn’t have otherwise suspected.
Biofeedback training. Biofeedback, which helps you enter a relaxed state to reduce pain, can help decrease vulvar pain by teaching you how to control specific body responses. To help cope with vulvodynia, you can use biofeedback to relax your pelvic muscles, which may contract in anticipation of pain, thus causing chronic pain. Try to find a biofeedback specialist with experience treating vulvodynia.
Physical therapy. Some women may have associated spasms or weakness of the pelvic floor muscles. To determine what may be causing your vulvar pain, a physical therapist may evaluate your pelvic floor muscles, joints and nerves in the pelvic area. Treatments may include exercises, education, biofeedback and manual therapies, such as massage. Ultrasound, hot/cold and electrical stimulation may also provide some relief. Finding a physical therapist with experience treating vulvar pain will be helpful.
Relaxation and breathing techniques. Learning to recognize when you are tensing your pelvic floor muscles due to stress and then learning specific relaxation techniques to reduce stress and anxiety can help alleviate pain.
Counseling. Vulvodynia can limit daily activities and diminish quality of life. It is not uncommon for women who suffer with chronic vulvar pain to experience depression and feelings of low self-worth. Some women find that psychological counseling helps them develop coping strategies and deal with sexual intimacy issues; for many, it is a valuable part of their overall treatment plans.
Neurostimulation and Spinal Infusion Pump. If other treatment forms haven’t helped and your pain is severe, your health care professional may have you consult with a professional skilled in neurostimulation or in the use of a spinal infusion pump. With neurostimulation, an electronic device delivers low-voltage electrical stimulation to a targeted nerve or the spinal cord in an attempt to substitute a tingling sensation for pain. A spinal infusion pump is an implanted device that constantly administers a small dose of medication to the spinal cord and nerve roots to help dull pain.
Surgery. Women with severe vulvodynia localized in the vestibule who have failed to find relief with other remedies, may consider vestibulectomy, a surgical procedure that removes the painful tissue of the vulvar vestibule. This surgery is usually reserved only for women with vulvar vestibulitis who have not responded to more conservative therapies and understand that, despite the surgery, the pain may not resolve afterward.

Prevention

Because we don’t know what causes vulvar pain, we really don’t know how to prevent it. But there are some things you can do to help minimize your pain. As always, talk with your health care provider about what’s best for you.
Check your environment and follow basic vulvar skin care. If your vulvar pain symptoms come and go, think about what that area is exposed to. Do you use a lubricant during intercourse? Have you switched laundry detergents? Are symptoms worse when you wear a certain kind of underwear or use a certain brand of sanitary pad? Try changing one thing at a time and see if it helps.
Don’t miss your annual exam. Routine pelvic exams—once a year for women age 18 and older—are very important to ensure early intervention for problems, including chronic pelvic and vulvar pain. Annual gynecologic appointments may include breast exams, Pap tests and other important preventive screenings, such as cholesterol screening and thyroid tests. These visits give you the opportunity to discuss any gynecological concerns or symptoms with your provider.
If you experience vulvar pain, don’t wait. Make an appointment to discuss your symptoms with your health care professional.
Diet. There is some evidence that vulvar pain, though not necessarily vulvodynia, is associated with oxalates and other highly acidic foods, such as soda, wine, energy drinks, juice, tart candies, citrus fruits and foods containing vinegar, and foods high in sugar, such as candy, cakes, cookies, pies, ice cream and sugary drinks. Avoiding these foods may help improve your symptoms.

Facts to Know

Vulvodynia is chronic pain or discomfort of the vulva (the area surrounding the vaginal opening) that lasts for three months or longer in the absence of other skin or gynecological disorders.
Women who suffer with vulvodynia report burning, stinging, irritation and rawness in the area. For some, this pain affects the whole vulva, for others it is localized to one area. Pain may be constant or episodic, often when triggered by tampon insertion, sexual activity or exercise, especially bicycling.
One study found that roughly three out of five women consulted three or more doctors in seeking an accurate diagnosis.
It is estimated that up to 16 percent of women—roughly 13 million—will suffer with chronic vulvar pain at some point in their lives.
There is no known cause of vulvodynia. However, we do know it is not caused by an active infection, including sexually transmitted diseases; skin disorders; cancer; or neurologic or psychological disorders.
Diagnosis often includes a cotton swab test in which the doctor places pressure on different parts of the vulva area to locate the pain and its relative intensity.
As with other chronic pain conditions, the unrelenting nature of vulvodynia, its negative impact on a woman’s quality of life and ability to perform daily activities and the challenges encountered in its diagnosis and treatment, may lead to depression, anxiety, fatigue and low self-image, especially related to a woman’s sexuality.
The goal of treatment is to manage pain, restore normal activities, improve quality of life and prevent recurrence of symptoms.
Treatment may include a combination of advice on vulvar tissue care, oral and/or topical medications, nerve blocks, physical therapy, biofeedback, dietary modifications, counseling and, in some cases, surgery. Many therapies recommended to promote general health may also be recommended with traditional medical approaches for people in chronic pain. These therapies include acupuncture, massage therapy, relaxation techniques, biofeedback and cognitive behavioral therapy.
The aim of ongoing research is to determine the causes of vulvodynia and to find more effective ways to identify and treat chronic vulvar pain.

Key Q&A

What is vulvodynia?Vulvodynia is chronic pain or discomfort of the vulva, the area surrounding the vaginal opening. It is diagnosed when pain lasts for three months or longer without any evidence of other skin or gynecological disorders that might cause the pain. Up to 16 percent of women—roughly 13 million—will suffer with chronic vulvar pain at some point in their lives.
Do we know what causes it? Is it due to an infection?We don’t know what causes vulvodynia, although it is likely due to multiple factors. Some factors that may contribute are pelvic nerve damage, spasms or weakness of pelvic muscles and genetic components such as susceptibility to inflammation. We do know that vulvodynia is not caused by active infection, the human papillomavirus (HPV) or other sexually transmitted diseases or cancer.
What are the symptoms of vulvodynia?Women with vulvodynia often report having one or more of the following symptoms around the vulva:
burning
stinging
rawness
aching
throbbing
stabbing
soreness
Burning sensations are most common; however, the type and severity of symptoms are highly individual. More than half of women who suffer with chronic vulvar pain have other health problems, including interstitial cystitis, fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and recurring yeast infections.
What triggers the pain?Some women experience constant, generalized pain of the whole vulva area. Others have localized pain specific to one part of the vulva that may come and go. Vulvar pain may be triggered by sexual activity, tampon insertion or gynecological exams, or simply by wearing tight-fitting pants or sitting. Take note of what things make your pain better or worse and share this information with your health care professional, so he or she has a better sense of the location and intensity of your pain and how it impacts your overall and sexual health.
How is it diagnosed?Vulvodynia is a “diagnosis of exclusion.” That is, it is established after other potential causes of vulvar pain have been ruled out, including such things as yeast or bacterial infections. Most women see multiple health care providers before a correct diagnosis is made.To diagnose vulvodynia, your doctor will first take a complete medical history, including the duration and intensity of the pain, sexual health, treatments already tried and previous medical problems and pelvic/abdominal surgeries. A pelvic exam will follow. A cotton swab test that applies pressure to various parts of the vulva is often used, especially for women whose pain is provoked by pressure on the vulva. You will be asked to rate the extent of the pain at each site so your provider can map your pain.It’s important to talk openly with your health care professional about any difficulties you have exercising, using tampons or having sexual intercourse, so he or she knows how the pain impacts your daily life.
What are the treatments for vulvodynia?There is no cure for vulvodynia, but there are a variety of medications and nondrug therapies. Medications may include antidepressants, local anesthetics and nerve blocks, changes to your diet, counseling and, in select cases, surgery. You might also want to ask about acupuncture, massage therapy, relaxation techniques, biofeedback and cognitive behavioral therapy, which often are recommended as treatments for other conditions causing chronic pain. No single approach works for all women. It often takes time to find a treatment or combination of therapies that will adequately alleviate the pain.
What should I tell my partner?Many women find it difficult, if not impossible, to engage in vaginal penetration due to the severity of what is sometimes described as “knife-like pain.” Since this condition significantly affects your sexual relationship, it’s important to educate your partner about this condition and how it affects you, both physically and psychologically. Be honest and open about how you feel, the steps you are taking to alleviate the pain and ways your partner can support you. You may feel embarrassed to broach the subject, but it’s important for your peace of mind and for your significant other to feel involved in the process. Counseling with a sexual therapist is often helpful for couples dealing with vulvodynia.

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Stroke

Overview

A stroke—also referred to as a brain attack—occurs when a part of the brain is injured by a disturbance to its blood supply.
There are two types of stroke. An ischemic stroke, or cerebral infarction, occurs when the flow of blood through an artery supplying part of the brain is suddenly interrupted, usually by a clot. A hemorrhagic stroke, or intracerebral orsubarachnoid hemorrhage, occurs when a blood vessel in the brain bursts, releasing blood into the substance of the brain or into the spaces surrounding the brain.
The term “brain attack” is becoming increasingly common to describe this condition. A person suffering a loss of blood flow to the heart is said to be having a heart attack, so a person with a loss of blood flow to the brain or sudden bleeding in the brain is having a “brain attack.” Deprived of oxygen, nerve cells (neurons) in the affected area of the brain can’t function and die within minutes. And when nerve cells can’t function, the part of the body controlled by these cells can’t function either. Although the healing process can help some patients improve after a stroke, some devastating effects of stroke are often permanent; unlike other cells in the body, dead brain cells aren’t replaced.
Strokes affect different people in different ways, depending on the type of stroke, the area of the brain affected and the extent of the brain injury. Brain injury from a stroke can affect speech and language, motor activity (muscles and strength), cognitive ability, behavior, memory and emotions. Paralysis or weakness on one side of the body is common. Stroke is the leading cause of serious adult disability.
More women than men suffer strokes. In 2006, women accounted for about 60 percent of stroke deaths. And of the 6.4 million stroke victims who are alive today, 2.5 million are males and 3.9 million are females. Of every 10 deaths from stroke, six occur in women and four in men. This is because the average life expectancy for women is greater than for men, and the highest rates for stroke are in the oldest age groups.
Stroke is often deadly: the condition killed more than 137,000 Americans in 2006, accounting for one in 17 deaths. Stroke ranks third after heart disease and cancer as a major cause of death in the United States.
The most important risk factors for stroke are hypertension, heart disease, diabetesand cigarette smoking. Other factors that increase your risk of having a stroke include heavy alcohol consumption, high cholesterol levels, migraines (especially with aura), illicit drug use and genetic or congenital conditions (particularly vascular abnormalities).
Atrial fibrillation, a heart rhythm disturbance that causes the small chambers of the heart to beat irregularly allowing blood clots to form, is another risk factor. It is particularly common in elderly people; it increases markedly in people after age 65, and it affects about 9.8 percent of women and 12.2 percent of men 65 and older. It may also occur in younger women, particularly in association with hyperthyroidism or Graves’ disease. However, you can have a stroke at any age. More than a quarter of stroke victims are under 65.
Stroke risks may be common in some families, particularly those in which family members have had heart attacks before age 50. These families have a tendency for premature atherosclerosis, or “hardening of the arteries,” and may share a genetic predisposition for high blood pressure, elevated cholesterol or diabetes, all of which are risk factors for stroke. Of course, shared lifestyle habits of poor diet, lack of exercise and tendency to smoke or drink may also be a factor in a family history of stroke.
African Americans are more likely to have strokes than Caucasians, but after age 55 the risk of death from stroke is the same for Caucasians as for African Americans. Researchers note that African Americans have higher rates of stroke risk factors, including high blood pressure, cigarette smoking, diabetes and sickle cell anemia. It is not clear whether the increased risk of stroke in minority populations is related to increased prevalence of these risk factors or to other factors. Hispanic Americans and Native Americans also have an increased risk of stroke, which may also relate to their higher rates of stroke risk factors, including diabetes and hypertension.
Some risk factors for stroke apply only to women, including pregnancy, childbirth (especially the postpartum period) and menopause. These risk factors are tied to hormonal fluctuations, changes in blood volume, tendency to form blood clots and other physical changes that affect a woman in different stages of life.
Some studies have shown an increased risk of stroke in pregnancy, particularly in pregnant women who suffer complications such as preeclampsia and postpartum hemorrhage. The period immediately after delivery (the postpartum period) is the period of highest stroke risk. During this time, there is an increasing tendency to form blood clots, which can lead to clots in the veins of the brain. This can cause headaches, seizures, brain swelling, bleeding in the brain and loss of function.
A 2005 study published in the journal Obstetrics and Gynecology found that women with pregnancy complications were nearly 75 percent more likely to suffer a stroke in the 13.5 years following their pregnancies than women with no pregnancy complications. However, since the risk of stroke in women of childbearing age is very small to begin with, a moderate increase in risk during pregnancy is still a relatively small risk.
Migraine, particularly when it is associated with aura (loss or change in vision preceding the headache), is also more common in women than men, and it has been associated with an increased risk of stroke. Because the increased risk is small, however, very few women with migraine will ever suffer strokes. The combination of migraine, smoking and oral contraceptive use can act together to increase the risk further, however.
Having already had a stroke puts you at higher risk for another one. Recurrent stroke is frequent: about 25 percent of people who recover from a first stroke will have another one within five years. The risk of severe disability or death from stroke increases with each stroke recurrence, and the risk of recurrence is greatest soon after a stroke. According to the National Institutes of Health, about three percent of stroke patients will have another stroke within 30 days of their first one, and one-third of recurrent strokes take place within two years of the first stroke. The underlying cause of the stroke influences the risk of recurrence.
A transient ischemic attack (TIA), sometimes called a ministroke, also is a risk factor for stroke. A TIA starts just like a stroke, lasts several minutes and then symptoms disappear. You should still contact your doctor immediately because there is no way of telling if the episode will be a TIA or a full-blown stroke. And, even if it is a TIA, you may be able to prevent a more serious stroke.
An additional risk factor applies only to people subject to hemorrhagic stroke. A person with an abnormality of the brain blood vessels, such as an aneurysm orarteriovenous malformation (AVM), is at increased risk for hemorrhagic stroke. Aneurysms are weakened blood vessels that balloon out on the blood vessel wall, while AVMs are a tangle of defective blood vessels and capillaries in the brain. Both have areas of thin walls and are more likely to rupture.
Types of Stroke
Stroke is actually a collective term for many subtypes of brain injuries:
Ischemic strokes are caused by blood clots. There are two types of ischemic stroke:
Embolic stroke means a blood clot forms somewhere in the body (either in the heart or in one of the arteries in the chest or neck that supply the brain) and travels through the bloodstream to your brain.
Thrombotic stroke means the blood flow ceases because of a blockage of one or more of the arteries supplying blood to the brain or within the brain itself.
Hemorrhagic results when a blood vessel bursts in the brain. Two types of hemorrhagic stroke include:
Intracerebral hemorrhage occurs when vessels bleed within the brain itself.
Subarachnoid hemorrhage is usually caused by the rupture of an aneurysm or a malformation of blood vessels on or near the thin, delicate membrane surrounding the brain.
Clotting is a necessary function; it stops bleeding and allows repair of damaged areas of arteries or veins. However, when arteries are damaged by atherosclerosis (“hardening of the arteries”), the lining of the artery is injured and cholesterol components seep into the wall of the blood vessel.
This sets up an inflammatory response within the vessel wall and ultimately forms aplaque. Plaque rupture attracts blood-clotting factors that can interfere with blood flow to the brain. A thrombotic stroke or cerebral thrombosis is caused by thrombosis, the formation of a blood clot on top of an atherosclerotic plaque, which grows large enough to block blood flow. Atherosclerotic plaques can start to develop in young adulthood but may take several decades to produce stroke symptoms. Atherosclerosis progression is accelerated by conditions such as hypertension, diabetes, smoking and hypercholesterolemia.
A clot can also form in another part of the body, such as the heart, and travel through blood vessels and become wedged in a brain artery. This free-roaming clot is called an embolus. A stroke caused by an embolus is called an embolic stroke.
A transient ischemic attack (TIA) starts just like a stroke but goes away after several minutes with no lasting damage. Recent evidence suggests that many patients with TIA actually do have small strokes: as many as one-third of those whose symptoms last less than an hour. You can’t ignore it. Even if it is a TIA, take heed: it can be a warning that you are at risk for a more serious stroke.
According to the American Heart Association, more than one-third of Americans who have a TIA will have an acute stroke sometime in the future. However, TIAs are a better prediction of if a stroke will happen than when; a stroke may occur days, weeks or months after a TIA. In about half of cases, the stroke takes place within a year of the TIA. Thus, the occurrence of a TIA should be taken very seriously, and you should seek medical attention immediately to prevent a disabling stroke.
Hemorrhagic stroke accounts for about 13 percent of all strokes and is more frequent among the young and people with high blood pressure. One common cause is a bleeding aneurysm (weak or thin spot on an artery wall). Over time, these weak spots stretch or balloon out under high pressure. The thin walls of these ballooning aneurysms can rupture and spill blood into the space surrounding brain cells.
Hemorrhage also can occur when arterial walls break open. Plaque-encrusted artery walls eventually lose their elasticity and become brittle, thin and prone to cracking. High blood pressure increases the risk that a brittle wall will give.
When an artery in the brain bursts, blood spews into the surrounding tissue. Brain cells generally don’t come into direct contact with blood; the contact upsets the delicate chemical balance neurons require to function. For people with hemorrhagic strokes, treatment is aimed at alleviating pressure on the brain and minimizing damage.
As the terms “brain attack” and “stroke” suggest, strokes strike suddenly. Symptoms include numbness or weakness of the face, arm or leg, especially on one side of the body; confusion; difficulty speaking or understanding speech; trouble seeing out of one or both eyes; dizziness, or loss of balance or coordination; or sudden, uncharacteristic, severe headache, which is most characteristic of bleeding. Since the symptoms appear suddenly and there is usually more than one, you can often distinguish stroke from other causes of dizziness or headache.
Brain cells die when they no longer receive oxygen and nutrients from the blood, but they also are damaged by sudden bleeding into or around the brain. When blood flow to the brain is interrupted, some brain cells die immediately, while others remain at risk for dying. That’s why immediate treatment is critical.
If you experience the sudden onset of the worst headache in your life or a sudden onset of neurological symptoms, call 911 and get to a hospital immediately . Do not waste precious time by calling your health care professional and do not call a family member. These actions have been shown to cause unnecessary delays in treatment. The best action is to call 911. The most effective therapies must be administered fast—typically within three hours of when the stroke started.
Although some health care professionals suggest taking aspirin at the onset of a heart attack, this recommendation hinges on the type of stroke you suffer, and it isn’t a remedy you should take into your own hands. Don’t take aspirin in a stroke situation without advice from a health care professional.

Diagnosis

Being aware of a stroke’s warning symptoms is the first step in diagnosis and management. Symptoms vary depending on the area of the brain that is involved, but they are still relatively easy to identify.
Primary symptoms include:
sudden, painless numbness or weakness, usually on one side of the body
sudden confusion or trouble speaking or understanding speech
sudden trouble seeing out of one or both eyes
sudden trouble walking
dizziness or loss of balance or coordination
sudden severe headache with no known cause
Notice the one oft-repeated word: sudden. When you’re having a stroke, time is critical. Recognizing a stroke quickly means you get help sooner and may be able to minimize the amount of damage the stroke will cause.
You may experience other, less-common symptoms, including sudden nausea, fever and vomiting. Sometimes, a stroke is accompanied by fainting, convulsions or coma. Stroke symptoms do not cause pain in the limbs, but hemorrhagic strokes are typically associated with sudden, severe, uncharacteristic headache.
If you’re having a stroke, you should get to the hospital as soon as possible. Once you get there, health care professionals will obtain basic vital information such as blood pressure and heart rate and will begin a neurological examination. One standardized way of reporting the neurological problems and the severity of a stroke is the standardized National Institutes of Health (NIH) Stroke Scale, developed by the National Institute of Neurological Disorders and Stroke (NINDS). Health care professionals use the NIH Stroke Scale to measure a patient’s neurological deficits by asking the patient to answer questions and to perform several physical and mental tests.
Health care professionals also use a variety of imaging devices to evaluate stroke patients. The most widely used imaging procedure is the computed tomographic (CT) scan. It creates a series of cross-sectional images of the head and brain. Since it works quickly and is generally available 24 hours a day at most hospitals, the CT scan is usually one of the first tests given to patients suspected of having a stroke. It can rule out a hemorrhage and reveal if a tumor or other problem is causing the symptoms.
If a stroke is caused by hemorrhage, a CT can show evidence of bleeding into the brain immediately after stroke symptoms appear. This is important, since a stroke caused by a hemorrhage must be treated differently than one caused by a blood clot. For instance, the only proven acute stroke therapy for ischemic stroke is thrombolytic therapy, or the use of medications to dissolve or break up blood clots. This therapycannot be used until the doctor diagnoses you with an ischemic stroke. Otherwise, the treatment could make a hemorrhagic stroke worse by increasing bleeding.
Your doctor may also order a magnetic resonance image (MRI) , which uses magnetic fields to detect subtle changes in brain tissue content. The benefit of MRI over CT imaging is that MRI is better able to detect small areas of dead cells soon after the stroke begins.
Other tests include angiography, ultrasound and magnetic resonance angiography (MRA), all of which can detect blockage of brain arteries.
Risk Factors
Determining if you have any of the risk factors associated with stroke can help your health care professional estimate your likelihood of having one over many years.
The most important risk factors for stroke are high blood pressure, heart disease, diabetes and cigarette smoking. Others include heavy alcohol consumption, high cholesterol levels, illicit drug use and genetic conditions, particularly those involving the blood vessels. Significant trauma to the head or neck can cause a rip to form in the wall of the artery, called a dissection, increasing the risk of stroke, while bacterial and viral infections are also associated with stroke.
One potential risk factor for stroke is chiropractic manipulation. A study published in a 2003 issue of Neurology suggested that people who undergo chiropractic neck and spine adjustments may have a higher risk of stroke as a result of tiny tears in their arteries. The study found that patients under 60 who had strokes or ministrokes from tears in their neck arteries were more likely to have visited a practitioner who manipulated their neck within the past 30 days compared with people who had strokes from other causes.
The authors warned that a significant increase in neck pain following spinal manipulation warrants immediate medical evaluation. This was a retrospective study, however, in which patients were asked to remember events that occurred months or even years before. Very few people who go for chiropractic manipulation experience strokes.
Although there may not be a single genetic factor associated with stroke, genes do play a large role in hypertension, heart disease, diabetes and vascular malformations. (Of course, genes may not be the ultimate culprits. Increased risk for stroke within a family might be due to a common lifestyle issues such as lack of exercise or poor eating habits.)

Treatment

The type of treatment you receive depends on the type of stroke you suffered and how long it has been since the stroke started. The three phases of treatment for stroke are: prevention, therapy immediately after stroke, and post-stroke rehabilitation. Therapies for stroke include medications, surgery and rehabilitation.
The most popular classes of drugs used to prevent or treat stroke are antithrombotics (antiplatelet agents and anticoagulants) and thrombolytics.
Thrombolytic agents (clot-busters) are used to treat an ongoing, acute ischemic stroke caused by an artery blockage. These drugs act by dissolving the blood clot blocking blood flow to the brain, thus restoring, or reperfusing, the brain’s blood flow. The only FDA-approved thrombolytic for the treatment of stroke is recombinant tissue plasminogen activator (tPA), a genetically engineered form of a thrombolytic substance made by the body.
TPA can be effective if given intravenously within three hours of the start of the stroke but can only be given after confirming the stroke is ischemic, not hemorrhagic, typically with a CT scan. A major clinical stroke trial (ECASS- III ) recently found that tPA can be effective even when given up to 4½ hours after ischemic stroke in carefully selected patients. More specifically, in 3,570 patients who received either tPA or a placebo, the chances of a good outcome at three-months was more than double for those who received tPA within 90 minutes of a stroke, 68 percent higher in those who received tPA between 90 minutes to three hours and 28 percent higher in those treated with tPA between three and 4½ hours. As a result, in 2009, the American Stroke Association revised its recommendations and now says tPA can be given up to 4½ hours after stroke symptoms in some patients.
Strokes caused by bleeding—hemorrhagic strokes—cannot be treated with tPA because the drug would make the bleeding worse and could be fatal.
Another treatment for people with acute ischemic stroke involves the use of a special corkscrew-type device to pull out a blood clot from the blood vessel in the brain where the blockage exists. The device is delivered by a catheter, or narrow tube, carefully threaded through the femoral artery in the groin up through the body to the brain. This type of highly specialized procedure can only be performed at certain medical centers and by those experienced in its use, and it must be performed within eight hours of the onset of the stroke. Other similar devices that can be used to flush the clot out of the brain blood vessel have also been approved recently. Doctors may choose to use a combination of these devices in some situations.
Another approach is the delivery of thrombolytic drugs like tPA or urokinase directly to the site of the blockage using a similar catheter. Clinical trials find it’s effective when used up to six hours after stroke. Many centers are using this procedure, although it requires experienced physicians and backup systems in case of complications.
Antiplatelet drugs prevent clotting by decreasing the activity of platelets (blood cells that help blood clot). These drugs reduce the risk of blood clots, thus reducing the risk of ischemic stroke. Health care professionals typically prescribe antiplatelet drugs after a stroke to prevent another one.
The most widely known and used antiplatelet drug is aspirin. Other antiplatelet drugs include clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine) and Aggrenox, a combination of dipyridamole and aspirin.
Anticoagulants reduce stroke risk by reducing the ability of the blood to clot. The most commonly used anticoagulants include warfarin (Coumadin) and heparin.
Researchers have conducted numerous studies to find out whether anticoagulants or antiplatelet drugs are better at preventing strokes. Several trials in patients with chronic atrial fibrillation, a common heart condition in which the heart rhythm is abnormal, find warfarin is best. But warfarin carries a risk of bleeding that requires careful monitoring of blood levels with regular blood tests. Aspirin is also a modestly effective therapy in atrial fibrillation.
For most people who have had a stroke but who don’t have atrial fibrillation, there’s no evidence that warfarin or other anticoagulants are any better than aspirin. This was clearly demonstrated in two government-sponsored studies, the Warfarin Aspirin Recurrent Stroke Study (WARSS) and the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial, as well as in the European/Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT).
At this point, the American Heart Association says people with atrial fibrillation at high risk for stroke should probably be treated with warfarin instead of aspirin unless there are reasons not to do so. In people under age 75 and at low risk for stroke, aspirin is the standard treatment.
Neuroprotective agents are being developed to protect the brain from secondary injury caused by stroke. If given quickly enough after a stroke, these drugs may help minimize the damage that results from brain cells being deprived of oxygen. Although no neuroprotectants are currently approved for use in stroke, many are being studied. There are several classes of neuroprotectants that show promise for future therapy, including antioxidants, glutamate antagonists, statins and anti-inflammatory agents.
Surgery
Surgery can be used in some situations to prevent stroke, to treat acute stroke or to repair blood vessel damage or malformations in and around the brain from a stroke. There are two main types of surgery for stroke prevention and treatment: carotid endarterectomy to prevent ischemic stroke, and surgery to remove or repair blood vessel malformations or aneurysms to prevent hemorrhagic stroke.
Carotid endarterectomy ( CEA ) is a surgical procedure in which a health care professional removes fatty deposits (plaque) from the inside of one of the carotid arteries. These arteries are located in the neck and provide the main supply of blood to the brain. This treatment aims at treating underlying atherosclerosis, characterized by the buildup of plaque on the inside of large arteries.
More recently, health care professionals have begun to use a procedure called carotid artery stenting, a procedure that involves the insertion of an expanding metal scaffold (stent) into the neck artery after it has been widened with balloon dilation, to reduce carotid artery blockages. This procedure is usually reserved for patients who have had a TIA or stroke but can’t undergo surgery. Some cardiologists are also exploring the use of drug-eluting stents for use in stroke prevention. While stenting has certain advantages, it is not risk-free; both bare-metal and drug-eluting stents carry some risk. Studies evaluating the proper role of stenting in stroke prevention are ongoing.
One useful surgical procedure for treatment of brain aneurysms that could lead to a hemorrhagic stroke is “clipping.” Clipping involves clamping off the aneurysm from the blood vessel, reducing the chance it will burst and bleed.
Another therapy is the detachable coil technique for the treatment of high-risk aneurysms. Small platinum coils are inserted through an artery in the groin and threaded through the arteries to the site of the aneurysm. The coils are carefully packed into the aneurysm, causing a blood clot to form inside the aneurysm, thus strengthening the artery walls of the aneurysm and reducing the risk of rupture. The coiling procedure may be enough to treat the aneurysm, but if it isn’t, the surgeon can clip the aneurysm and clamp it closed, reducing the risk of hemorrhage and death.
Treatment after a Stroke
The disability resulting from strokes is devastating to the stroke victim and family, but the good news is that therapies are available to help rehabilitate post-stroke patients with any of the following:
speech problems
motor activity, coordination and weakness issues
vision problems
hearing problems
cognitive problems
behavioral problems
memory problems
emotional problems
paralysis or weakness
Physical therapy (PT) is the cornerstone of any rehabilitation process and should be started as soon as possible. A physical therapist uses training, exercises and physical manipulation to restore movement, balance and coordination. Through PT, the stroke patient works to relearn simple motor activities such as walking, sitting, standing, lying down and switching from one movement to another.
Occupational therapy (OT) focuses on creating independence in stroke victims. It involves exercise and training to help a stroke patient relearn everyday activities such as eating, drinking, swallowing, dressing, bathing, cooking, reading, writing and using the toilet.
Recent studies found that specific types of physical therapy, such as constraint-induced movement therapy ( CIMT ), can improve outcomes even when started months or more after stroke. In CIMT , the stroke patient’s strong hand is put in a sling to prevent its use, and the patient undergoes intensive therapy during which they are forced to use the weak hand. In the Extremity Constraint Induced Therapy Evaluation (EXCITE) randomized trial, patients undergoing this treatment had better outcomes and used the weak hand more than patients who received more standard therapy regimens. Since the study, CIMT has become increasingly popular. The researcher who developed CIMT and conducted the EXCITE trial recently did a follow-up study on patients who had had a stroke an average of 4.5 years before receiving CIMT . The patients showed “large to very large” improvements in the use of their affected arms, illustrating that CIMT may work to improve the lives of stroke survivors years after they’ve suffered a stroke. CIMT remains controversial, however, because it is a very intensive type of rehabilitative therapy that may not be suitable for all patients, and it remains unclear whether the benefits are due to the intensity of the therapy or the specific program involved.
Speech and language problems arise when brain damage occurs in the language centers of the brain, located on the left side of the brain. But this doesn’t mean a stroke patient will never have a command of language again. Thanks to the brain’s ability to learn and change (called brain plasticity), other areas of the brain can learn to take over some lost functions.
Speech therapy can help a stroke victim relearn language and speaking skills or learn other forms of communication. Such therapy is also needed if the stroke victim has problems understanding speech or written words or has problems forming words.
With time and patience, a person who has had a stroke may be able to regain some, perhaps all, language and speaking abilities. Generally, the majority of recovery takes place within the first six months after the stroke, but it all depends on how quickly rehabilitation begins and the extent of brain damage.
New advances in imaging and rehabilitation find that the brain can compensate for function lost as a result of stroke. For example, a stroke patient who is unable to recognize faces may gradually come to recognize faces again, even though the part of the brain originally programmed to perform that function is still dead. The plasticity of the brain and its ability to “rewire” connections between brain cells means one part of the brain can change function and take up the function of a disabled part.
Stroke patients may also need psychological or psychiatric help. Depression, anxiety, frustration and anger are common post-stroke occurrences. Talk therapy, sometimes in conjunction with the appropriate medication, often helps alleviate some of the mental and emotional problems arising from the stroke. Sometimes it is also beneficial for family members to seek counseling.

Prevention

Many—perhaps most—strokes can be prevented. Therapies to prevent a first or recurrent stroke are based on treating your underlying risk factors for stroke or on preventing the widespread formation of blood clots that can cause ischemic stroke in anyone, regardless of risk factors.
Some people simply have a higher risk for stroke than others. Factors such as age, gender, race/ethnicity and family history of stroke can’t be changed. But you can control other risk factors, such as high blood pressure or cigarette smoking.
The most significant risk factors for stroke are high blood pressure, heart disease, diabetes and smoking. Others include heavy alcohol consumption, high blood cholesterol, illicit drug use and genetic or congenital conditions, particularly problems with blood vessels. If you have more than one risk factor, you have “amplification of risk.” This means that the multiple risk factors compound their destructive effects and create an overall risk greater than simply adding the individual risks together.
Atrial fibrillation, a heart rhythm disturbance that causes the small chambers of the heart to beat irregularly and allows blood clots to form, is another risk factor for stroke. With this condition, your doctor will likely prescribe a medication like warfarin (Coumadin) which “thins” the blood to prevent clots.
Cigarette smoking is one of the greatest risk factors for stroke. Smoking almost doubles your risk for ischemic stroke, independent of other risk factors. It is also responsible for more strokes in young adults than older adults. Smoking increases the risk of stroke by promoting atherosclerosis, a condition in which arteries harden after years of buildup of plaque, cholesterol and other debris in the bloodstream. Narrowed arteries can’t effectively deliver blood to the brain, raising the risk of stroke. Smoking also increases levels of blood-clotting factors and weakens blood vessels, so if a stroke occurs, the damage may be worse.
Your relative risk of stroke drops immediately after you stop smoking, and it may take only a few years for a former smoker’s risk to drop to the level of someone who never smoked. One of the most important things you can do to prevent stroke is to stop smoking.
Your risk of stroke also goes up if you take oral contraceptives and smoke. Talk with your health care professional to weigh the pros and cons of oral contraceptives as compared to other forms of birth control.
High alcohol consumption (more than two drinks per day) may reduce the number of blood platelets, interfering with blood clotting and thickness and increasing the risk of a hemorrhagic stroke. It is clear that heavy drinking or binge drinking can lead to a rebound effect after the alcohol leaves your body and your blood thickness and platelet levels skyrocket, increasing the risk for ischemic stroke.
If you drink, do so in moderation. This means no more than one drink per day for women, and no more than two drinks per day for men. One drink equals 12 ounces of beer, four ounces of wine, or one and a half ounces of 80-proof liquor.
If you are a nondrinker, this is not a recommendation to start using alcohol. And certainly, if you are pregnant or have another health condition that could make alcohol use harmful, you should not drink.
The use of illicit drugs, such as cocaine, crack cocaine and amphetamines, can cause stroke. Cocaine can aggravate other risk factors, such as hypertension, heart disease and vascular disease, triggering a stroke. It decreases blood flow to the brain, causes blood vessels to tighten and prevents blood vessels from relaxing, leading to narrowing of the arteries. It also affects the heart, causing arrhythmias and rapid heart rates that can lead to blood clots.
Marijuana is sometimes identified as a risk because it reduces blood pressure and may interact with other risk factors, such as hypertension and cigarette smoking, to cause rapidly fluctuating blood pressure levels, damaging blood vessels. Other drugs of abuse, such as heroin and anabolic steroids—and even some over-the-counter diet aids—may increase stroke risk. Many of these drugs are vasoconstrictors, meaning that they may cause blood vessels to constrict and blood pressure to rise.
Diet may also be a factor. One study finds that eating five to six servings of fruits and vegetables a day can reduce the risk of ischemic stroke by a third compared to eating fewer vegetables and fruits. The American Heart Association recommends a healthy, balanced diet rich in fruits, vegetables, whole grains, and low-fat or fat-free dairy products.
So, here’s what you can do to reduce your risk of stroke:
Stop smoking.
Check your blood pressure regularly; if it is high, work with your health care professional to keep it under control. A normal blood pressure reading is less than 120/80.
Restrict salt intake to reduce your blood pressure if you have high blood pressure.
Find out if you have atrial fibrillation, or an irregular beating of the heart. This is a risk for blood clots. If you do have atrial fibrillation, your health care professional may prescribe a blood-thinning medication to prevent clots, depending on any other risk factors.
Drink alcohol in moderation. Moderate drinking is defined as no more than one drink per day for women and no more than two for men. (A standard drink is one 12-ounce bottle of beer or wine cooler, one 4-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) This is intended to measure the amount consumed on a single day and does not represent an average over several days. In other words, if you don’t drink all week and then drink seven drinks on Saturday, it’s not the same as having one drink a day. More than a drink in a single day is considered heavy drinking in women.
Have your cholesterol checked. Healthy cholesterol guidelines for individuals without heart disease are:
total cholesterol levels less than 200 mg/dL
HDL (high density lipoprotein) levels 50 mg/dL or higher for women; 40 mg/dL or higher for men.
LDL (low-density lipoprotein)
People who are at a low risk for heart disease: levels less than 160 mg/dL
People who are at an intermediate risk for heart disease: levels less than 130 mg/dL
People who are at a high risk for heart disease: levels less than 100 mg/dL
People who are at a very high risk for heart disease: levels less than 70 mg/dL
Triglycerides (another type of lipid) less than 150 mg/dL
For more information on blood cholesterol.
If you have high blood cholesterol, discuss treatment options with your health care professional.
If you have already had a stroke, ask your doctor whether you should be on a statin medicine. While these medications are generally used to lower cholesterol, there is strong evidence that they reduce the risk of stroke.
If you have diabetes, work with your health care professional to control the disease.
Exercise regularly.
Treat any circulation problems.

Facts to Know

Stroke, or brain attack, is the leading cause of serious disability in adults. Millions of Americans are living with the effects of stroke. About 10 percent recover completely; 25 percent recover with mild impairments; 40 percent are moderately to severely impaired, requiring special care; and the remainder require care in a nursing home or long-term care facility.
You can have a stroke at any age; it strikes all age groups. More than 25 percent of stroke victims are under 65.
Even though a stroke can occur at any age, the older you get, the greater your risk. For every decade after age 55, your risk of stroke increases 10 percent; two-thirds of all strokes occur in people over 65 years old.
In 2004, 40 percent of those who died from stroke were men, and 60 percent were women.
Race is a factor in stroke risk with blacks at greater risk than whites. In white women, the incidence of TIA and stroke is nearly 5 percent in women ages 55 to 64 and nearly 10 percent for ages 65 to 74. In black women, the incidence is 10 percent for ages 55 to 64 and 15 percent for ages 65 to 74. In white men, the incidence is about 6 percent for ages 55 to 64 and 12 percent for ages 65 to 74, and in black men the incidence is 13 percent for ages 55 to 64 and 16 percent for ages 65 to 74.
There are two forms of stroke: ischemic (blockage of a blood vessel supplying the brain) and hemorrhagic (bleeding into or around the brain).
People in the southeastern United States have the highest stroke mortality rate in the country. Researchers have dubbed this area the “stroke belt.” The buckle of the stroke belt—coastal North Carolina, South Carolina and Georgia—has a mortality rate higher than other parts of the belt and up to two times the stroke mortality rate than that of the United States overall. The increased risk could be due to geographic or environmental factors or to regional differences in lifestyle, including higher rates of cigarette smoking and a regional preference for salty, high-fat foods.
The most important risk factors for stroke are hypertension, heart disease, diabetes and cigarette smoking. Other risks include heavy alcohol consumption, high blood-cholesterol levels, illicit drug use and genetic or congenital conditions (particularly vascular abnormalities). Having more than one risk factor amplifies risk.
If you have the sudden onset of the worst headache of your life or the sudden onset of neurological symptoms, call 911 to get to a hospital immediately. A stroke must be diagnosed as either ischemic or hemorrhagic to determine the appropriate treatment, and some of those treatments have to be given within just several hours of the stroke’s onset. Time is of the essence.
Pregnancy may increase the risk of stroke, particularly in pregnant women who experience complications, such as preeclampsia or postpartum hemorrhage. Severe headaches or visual changes after delivery can be a warning sign of blood clots in the brain’s venous drainage system and should be reported to your doctor immediately.
Women with pregnancy complications may also be at longer term risk of stroke. A 2005 study published in the journal Obstetrics and Gynecology found that women with pregnancy complications were nearly 75 percent more likely to suffer a stroke in the 13.5 years following their pregnancies than women with no pregnancy complications.
Dietary changes may reduce your risk. Reducing salt and fat intake can reduce your chances of developing high blood pressure and hardening of the arteries. There is also some evidence that boosting your intake of B vitamins may help reduce risk of stroke.

Key Q&A

What is a stroke?A stroke or “brain attack” is caused by inadequate blood flow to the brain. It occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks, interrupting blood flow to an area of the brain.
How can I prevent a stroke?You can’t always prevent a stroke, but many could be prevented by heeding stroke’s warning signs and treating its underlying risk factors, including high blood pressure, cigarette smoking, diabetes, high blood cholesterol and heart disease.
What is most likely to put me at risk?Hypertension is the most important risk factor for stroke, increasing risk up to six times.
What’s a “ministroke”?A transient ischemic attack (TIA), also known as a ministroke, is a brief episode of stroke symptoms caused by temporary interruptions of blood flow to the brain. A TIA starts just like a stroke but then resolves, leaving no noticeable symptoms or deficits. The average duration of a TIA is a few minutes, and most go away within an hour. Unlike actual strokes, TIAs do not kill brain cells, and therefore do not result in permanent neurological impairment. However, they can be important warning signs of an impending stroke. According to the American Heart Association, more than a third of people who have had a TIA will go on to have a stroke, and in half of those cases, the stroke will occur within a year of the TIA. Thus, the occurrence of a TIA should be taken very seriously, and medical attention should be sought immediately to prevent a disabling stroke.
If it doesn’t kill me, I’ll get over a stroke, right?Not always. Stroke is the leading cause of serious adult disability. About 10 percent recover completely; 25 percent recover with mild impairments; 40 percent are moderately to severely impaired, requiring special care; and the remainder require care in a nursing home or long-term care facility.
What’s the most common type of stroke?Ischemic strokes account for about 87 percent of all strokes. In these strokes, blood clots block an artery, depriving brain cells of oxygen.
What are the psychological effects of a stroke?Depression, anxiety, frustration and anger are common post-stroke disabilities. Talk therapy, sometimes in conjunction with appropriate medication, can help alleviate some of the mental and emotional problems arising from the stroke. There is evidence that antidepressant medications given after stroke can prevent the development of depression in some patients. Sometimes it is also beneficial for family members to seek counseling.
Are women at greater risk for a stroke?In 2006, women accounted for 60.2 percent of stroke deaths. And of every10 deaths from stroke, four occur in men and six occur in women. This is because the average life expectancy for women is greater than for men, and the highest rates for stroke are in the oldest age groups . Moreover, pregnancy, childbirth (particularly the postpartum period) and menopause are added risk factors.
What are the symptoms of a stroke?Primary symptoms include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing out of one or both eyes; sudden trouble walking, dizziness or loss of balance or coordination; or sudden severe headache with no known cause.
What should I do if I think I might be having a stroke?Call 911 to get to a hospital immediately. Thrombolytic agents, or clot busters, are effective at treating ischemic strokes (the most common kind), but they must be administered within three hours of the onset of a stroke. They can only be given, however, after your health care professional has confirmed that the stroke is ischemic, not hemorrhagic. Hence, time is of the essence.
Do I have atrial fibrillation, and what can I do to test my pulse for the development of this condition?Atrial fibrillation is a heart rhythm disturbance that causes the small chambers of the heart to beat irregularly, allowing blood clots to form. About 15 percent of strokes occur in people with atrial fibrillation. It is particularly common in older people; three to five percent of people over 65 have the condition. It may also occur in younger women, particularly in association with hyperthyroidism or Graves’ disease. Your health care professional can tell you whether or not you have atrial fibrillation just by checking your pulse. By learning to check for it yourself, you can periodically monitor yourself to rule out this important cause of stroke. It is important to recognize atrial fibrillation because strokes can be prevented by using a blood thinning medication to prevent clots from forming in the heart.

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