Ask Your Doctor 195 (10.02.2017)

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1. I.L., Mangalore

* I am aged 53 years. I am still having periods every months sometime regular sometime every three months for the last one year. Can you please suggest is there any problem in the future? Is this due to any disease.

** While there is no set age when menopause occurs for every woman, the mid-40s to mid-50s is the traditional time for regular menopause to occur. Menopause that occurs before a woman is in her mid-40s is considered early or premature menopause. If a woman is 55 or above and still has not reached menopause, she is probably should be seen as being late. About one out of twenty women have late menopause (after age 55), so the stated conditions is not very rare.

• Late menopause is not uncommon among obese women, since fat can produce estrogen.
• Thyroid disorders can disrupt the timing of both menopause and menstruation in menopause, causing it to be early or late. Since the thyroid is responsible for regulating metabolism, when it malfunctions, it can have a number of effects on a woman’s reproductive system.
• If a woman has abnormally high levels of estrogen throughout her lifetime, she may experience menopause later in life. High estrogen levels can also bring about a condition called estrogen dominance, which comes with its own set of health risks, so it is important that this be discovered and treated.
• If a woman’s mother or grandmother also had late-onset menopause, she may as well.
• Multiple pregnancies can also be a cause of late menopause, although it is not to be assumed that a woman who has had multiple pregnancies will undergo menopause late. While it is still rare, women are giving birth in their early 50s more than ever before. This can delay menopause, as a woman’s body adjusts to the hormonal changes that happen during pregnancy. While it is rare for a woman over 50 to conceive and not miscarry, any pregnancy at all has an impact on the woman’s hormonal level.

Unlike early and premature menopause, late-onset menopause can actually have some major health benefits. Because menopause occurs with a decline in the production of estrogen and progesterone by a woman’s ovaries, it often signals such problems as osteoporosis and heart problems. When a woman’s ovaries produce these hormones longer, osteoporosis and heart problems seem to also be delayed. Because of this, women with late-onset menopause actually tend to live longer.

There is an increased risk of breast cancer, however, due to the lengthened amount of time a woman’s body is producing estrogen. Researchers have also pinpointed an increased risk for cervical neoplasia, the changes in cancer cells that can signal the onset of cervical cancer. Pap smears detect the presence of these cells and can catch them early enough to prevent progression into cancer. Regular mammograms and pap smears are especially important for women experiencing late-onset menopause.

Another substantial health risk is for ovarian cancer. This risk is particularly strong if the beginning of menstruation was relatively early, and if the body had no breaks from estrogen exposure through pregnancy and breastfeeding.

While any woman who is still experiencing a menstrual cycle in her late 50s and 60s should see a doctor, it is important to note that each woman’s reproductive system is different. Just as each young woman starts menstruating at a different age, menopause falls at a different age for each woman, as well. Noting the risk factors and staying on track with annual gynecological exams should help allay any concerns that may arise with late-onset menopause.

2. J.S., Udupi

*I am 29 years of age. I have a small kidney stone and also while doing ultrasound scan extra doctor have told me that I have a fibroid and cyst measuring up to 4x2 cms. I will be getting married this February. Will this fibroid will affect my pregnancy? Are there any medicines to cure fibroids?

** The small kidney stones normally are harmless; you require to drink lot of fluids even if you are not thirsty. You can have ultrasound scan once in a year or so to know the status of the stone. In most of the women of your age small firoids are found on the uterine wall outside or inside the muscular part. Rarely firoids can be inside the uterine cavity. Even the small fibroids can cause problems for fertility  if they are inside the uterine cavity. Small fibroids inside the musculature of the uterus (known as intramural fibroids) or on the surface of the uterus are normally harmless. You may consult an obstetrician doctor to know more about this. Fibroids can not be cured by any medicines.

3.A.D. Kundapura

*Aim 33 years of age. The sore throat and dry mouth keep repeating after very 12-15 days. It is happening only from past 2 months. I visited the regular clinic doctor and he provided me with antibiotics. Using the antibiotic cures the symptoms and no problem for next 10 days or so. Afterwards same issue with throat (uneasy while swallowing, dry and sore, and after a day or two mucus formation, cough and cold etc). I did try salt water gargle and it feels relief for few hour.

** Viral infections are the most common cause for sore throat that usually lasts for few days and subsides by its own. There are many other causes for repeated sore throat.

• Allergies. Allergies to pet dander, molds, dust and pollen can cause a sore throat. The problem may be complicated by postnasal drip, which can irritate and inflame the throat. The inflammation on the back of the nose can cause sorethroat while getting up from sleep in the morning.
• Dryness. Dry indoor air, especially when buildings are heated, can make  the throat feel rough and scratchy, particularly in the morning when one  wakes up. Breathing through  the mouth — often because of chronic nasal congestion — also can cause a dry, sore throat.
• Irritants. Outdoor air pollution can cause ongoing throat irritation. Indoor pollution — tobacco smoke or chemicals — also can cause a chronic sore throat. Chewing tobacco, drinking alcohol and eating spicy foods also can irritate your throat.
•  Gastroesophageal reflux disease (GERD). GERD is a digestive system disorder in which stomach acids or other contents of the stomach back up in the food pipe (esophagus). Other signs or symptoms may include heartburn, hoarseness, regurgitation of stomach contents and the sensation of a lump in  the  throat.

You may consult an ENT specialist for evaluation and reatment.

4. P.S., Bangalore

*My son is 4 years of age and he is suffering from severe cough and nose block very often. ENT doctor said he has enlarged adenoids and he is allergic too. After surgery can adenoids re grow? Surgery gives complete cure?

** The adenoids are a single clump of tissues in the back of the nose (nasopharynx).  In adults they are located on the back wall of the throat (pharynx). The tonsils are two clumps of tissue, on either side of the throat, embedded in a pocket at the side of the palate (roof of the mouth). Both these are frequently inflamed in children causing pain, fever and obstruction.  

There seems to be no adverse effect on the immune status or health of patients who have had the tonsils or adenoids removed.  There are a number of well-established and valid reasons for removal (called an adenoidectomy).  Some  children have more the one reason for the removal of adenoids and tonsils  The most common are  the blockage of the back of the nose  by the enlarged adenoids, chronic and recurrent infections of the  of the throat and recurrent sinus infections. It appears that the tonsils and adenoids were not "designed" to effectively handle the multitude of viral infections that occur in children in an urban population today. (They were probably designed to take care of the infection in an earlier era where the atmosphere was not filled with virulent organisms)  It is clear that in many cases, the tonsils and/or the adenoids become "dysfunctional" and are more of a liability than an asset. Once removed, they do not grow again and in many of the children the repeated uppe respiratoy infection becomes infrequent.

Surgery for the removal of adenoids is a minor surgery. You may follow the suggestion of your doctor if your child has frequent problem of adenoid infection.

5. O.D., Udupi

*I am 33 years, yet to be married. I feel I have improper erection during the day time. But during night time I feel there is no problem with it. I consulted an urologist once. He told me not to worry about it. Am I facing sexual problems? If yes is there any treatment for it?

**In men worries because of myths or improper information is one of the common causes of failure or inadequate erection. As you are already examined by an urologist who found nothing abnormal in you, you have to be confident that you are normal. You do not require any treatment.

6.S.C., Mangalore

*I am aged 25 years. The length of my sexual organ is 5 inches. Is there any treatment to increase the size?

** In marital sexual relationship the size of the penis matters very little. Marital sexual act is not a mechanical union. There are lots of feelings that are involved and the size of the organ hardly matters for proper physical union. There is one more interesting thing is that most penises are very much the same size when erect. The man whose non-erect organ is smallish will usually achieve about 100 per cent increase in length during sexual excitement, while the man whose non-erect penis is on the largish size will probably only manage about a 75 per cent increase. In round figures, this means that the great majority of men measure between 15cm (6") and 18cm (7") in the erect position, with the average figure being about 16.5cm (6 ½").

The size of the male organ can not be altered by any medications, local applications, exercises or even by plastic surgery. Men with small organ can perform as effectively as with the men having larger than average penis.

7. S.M., Udupi

*I am 30 years. Is there any medication to increase  the sperm count and motility?

** The production of sperm is a complex process and requires normal functioning of the testicles (testes) as well as the hypothalamus and pituitary glands — organs in the  brain that produce hormones that trigger sperm production. Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated outs. Problems with any of these systems can affect sperm production, sperm shape (morphology), movement (motility) or function.

Low sperm count can be caused by a number of health issues and medical treatments. Some of these include varicocele, infection, antibodies that attack the sperms, hormone imbalances etc.Sperm production or function can be affected by overexposure to certain environmental elements, including industrial chemicals, heavy metal exposure. Overheating the testicles is also one of the causes of low sperm count Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also might increase the temperature in the  scrotum and slightly reduce sperm production. Consuming anabolic steroids, alcohol abuse, tobacco smoking are some of the other causes. Severe or prolonged emotional stress, including stress about fertility, might interfere with hormones needed to produce sperm.

As there are multiple causes for sperm related problems, treatment from an expert like urologist is needed when the count and motility is affected.

8. J.S., Kuwait

*I am 24 years of age, married for 2 years now. My periods are very irregular for the past 4 months . What is the cause for this? Recently while urination during morning I also get burning pain.

** Having irregular periods is very common. The causes can range from something insignificant to something that requires treatment. During teenage the body's hormones can fluctuate and take some time until they find a balance. Therefore, it’s normal to have an irregular period during adolescence or, sometimes in your age.Hormonal irregularity is the commonest cause for irregular periods. There are host of other causesfor irregular periods like stress or emotional problem, excessive weight gain or weight loss, over execising. Burning while pasing urine may be related to urinary tract infection. You may consult a gynecologist for proper assessment and treatment for both the problems.

9. L.V., Mangalore

*I am 39 years, I have lot of bumps on my upper body. I have removed on hump from right arm bicep in Mangalore and diagnosed as fibrolymphoma. Is it dangerous ?.

** The small tumors or bumps that have developed under the skin are most likely to be neurofibromas and the condition is known as neurofibromatosis. The neurofibromatosis is the genetic disorders of the nervous system that primarily affect the development and growth of neural (nerve) cell tissues. These tumors may grow in many parts of the body. The tumors are slow growing and after attaining a particular size-varying from that of a grain to a peanut. The tumors are normally painless, unless they are at pressure bearing areas. Some tumors may grow in the nerve where it passes through a tight compartment such as carpal tunnel in the wrist. Such tumors may press on the nerve and may cause symptoms like weakness in the muscles supplied or numbness in the areas supplied by that nerve. Surgical removal of the tumors is done only when the tumor causes these symptoms. Asymptomatic tumors need not be removed and if the tumors are not progressing rapidly, the conservative approach of watchful waiting is recommended. Normally the tumor may not recur at the same site from where it is removed. However appearance of multiple tumors at other places is not dependent on surgery. There is no permanent cure for the problem.You may consult a neurosurgeon for further opinion.

10. J.F., Mumbai.

*I am 45 years of age. For the past two months I am getting pain during urination. The pain stops for two days or so and then starts again. Is there any kidney problem?

** Pain while passing urine is known as dysuria. Dysuria is a symptom of pain, discomfort, or burning when urinating. It is more common in women than in men. In men, it is more common in older men than younger men.The commonest cause of dysuirapain is  urinary tract infection. There can be other causes like stones in the urinary tract. Consult an urologist for proper evaluation.

11. J.R., Kuwait

*I am 48 years of age. My weight is 89 kg.I am facing cramps in the left leg if I attempt to bend while in sleep. My whole left lower limb feels numb if I start walking. It lasts for half an hour or so.

** It appears that the main nerve of your left lower limb may be getting compressed somewhewre in its course, most probably in the lower back. You may consult a neurologist initially who will be able to pinpoint the problem and refer to other specialists if needed.

12. C.A., KSA

*I am 63 years of age. I am suffering from pain on the left side of  the abdomen below the ribs. I consulted the doctor who gave medicine for gastritis and muscle pain. Sometimes itching pain inside the abdomen. I have been on medicines for more than a month, but is of no use. Is there any other problem in the abdomen?

** At your age persistent pain, not relived by normal medications has to be investigated further. You may consult a gastro-enterologist as early as possible.

 13. K.S.R. Bangalore

* I am 41 years of age. I am tested positive for Hepatitis B.I got rashes over neck and back. I want to know what are the signs and symptoms. What is the treatment?  Is it curable? How long I might live with this disease?

**You seem to be wrongly informed about Hepatitis B. It is not a dreaded disease even in all those who are infected by it. Only about ten percent of people get the complications of the disease. All those who are infected do not die of the disease; that is the difference from AIDS. The rashes you have developed may not be due to Hepatitis B. Consult a skin specialist for proper treatment. I hope you are convinced that for about 90% you may not develop the complications due to this infection.

Hepatitis B is caused by a highly contagious virus that infects the liver. The virus is found in the blood and body fluids of infected people and can spread through sexual contact, the sharing of needles or razors, from mother to infant during birth, and by living in a household with a chronically infected person. The hepatitis B virus (HBV) is hard and can live outside the body for several days.

In much of the developing world, (sub-Saharan Africa, most of Asia, and the Pacific), most people become infected with HBV during childhood, and 8% to 10% of people in the general population become chronically infected. Hepatitis B virus can cause chronic infection in which the patient never gets rid of the virus and many years later may develop cirrhosis of the liver or liver cancer. HBV is the most serious type of viral hepatitis and the only type causing chronic hepatitis for which a vaccine is available.

All who come in contact with HIV (AIDS virus) may not get infected, but chances of infection of hepatitis virus (HBV) are more. In this way it is more contagious. But real danger of these viral infections is the complications: Though HBV is more contagious than HIV; in all those who are infected by HIV almost all of them will get AIDS. Where as in hepatitis B it is around 8 to 10% of the infected people who will ultimately get the complications of the disease. Again a small number of them will get liver cancer. Compared to each other HIV is less contagious and more dangerous, HBV is more contagious but less dangerous.

Young children who become infected with HBV are most likely to develop chronic infection. About 90% of the infants infected during the first year of life and 30% to 50% of the children infected between 1 to 4 years of age develop chronic infection. The risk of death from HBV-related liver cancer or cirrhosis is approximately 25% for persons who become chronically infected during childhood.

How do people get infected?

Hepatitis B virus is transmitted by contact with blood or body fluids of an infected person in the same way as human immunodeficiency virus (HIV), the virus that causes AIDS. However, HBV is 50 to 100 times more infectious than HIV.

The main ways of getting infected with HBV are:

• Perinatal (from mother to baby at the birth)
• Child-to-child transmission
• Unsafe injections and transfusions
• Sexual contact

Worldwide, most infections occur from infected mother to child, from child to child contact in household settings, and from reuse of unsterilized needles and syringes. In many developing countries, almost all children become infected with the virus.

In many industrialized countries (e.g. Western Europe and North America), the pattern of transmission is different. In these countries, mother-to-infant and child-to-child transmission accounted for up to one third of chronic infections. However, the majority of infections in these countries are acquired during young adulthood by sexual activity, and injecting drug use. In addition, hepatitis B virus is the major infectious occupational hazard of health workers.

Hepatitis B virus does not spread by contaminated food or water, and cannot be spread casually in the workplace.

Hepatitis B is a "silent disease" that often affects many people without making them feels sick. If one gets sick from hepatitis B, the symptoms may be like the "flu." He/she may lose appetite, feel extremely tired, and have stomach cramps and vomit. If one are more seriously ill, the skin and eyes may turn yellow (jaundiced) and one may need hospitalization. There is no specific treatment for hepatitis B once it is contracted

Since 1991, WHO has called for all countries to add hepatitis B vaccine into their national immunization programmes. Many countries have included hepatitis B vaccine in their national programmes.

Who should get hepatitis B vaccine? : Hepatitis vaccination is mainly required for the children. Among the adults it is indicated for only those who are at risk of getting the disease. The vaccine has no role in the treatment of the disease or preventing the complication once the person is infected. It is indicated in selected group of adults such as:-

• Sexually active heterosexual  adults with more than one sex partner in the prior 6 months or a recently acquired sexually transmitted disease.
• People who have clotting factor disorders such as hemophilia.
• People whose jobs potentially expose them to human blood or body fluids. This includes most healthcare and some public safety workers, as well as some athletes, coaches and teachers.
• People living or having sexual contact with others who are chronically infected with hepatitis B virus. (If one of the spouse is infected, the non-infected  partner can take the vaccine)
• Adolescents who have not been immunized against hepatitis B.
• Children (under 7 years old) of immigrants and refugees from areas where HBV infection rates are high, and household contacts of adopted children, immigrants and refugees who have chronic HBV infection.
• Illicit injection drug users.
• International travelers to areas where HBV infection rates are high who will stay in these areas for more than 6 months and have close contact with local persons, who stay for shorter durations and may have sexual contact with local persons, or who perform medical procedures in these areas.
• Clients and staff of institutions for the developmentally disabled.
• Hemodialysis patients.
• Men who have sex with men.
• Long-term male prison inmates.

14.K.P, Dubai*I am in Dubai for the last 10 years. My age 34 years, I have married in 2015. I have education problem from my college days I had extra marital affair during that time. Normally I used to come out early in the first round but later I used to get complete satisfaction. I thought after marriage I would be alright but I am wrong. I am not getting full erection. I take erection pills (name given)and delay spray to enjoy my married life. What shall I do?

** The problem you are facing is termed as ‘erectile dysfunction’. Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this inability at some point in their lives, usually by age 40, and are not psychologically affected by it. Some men experience chronic, complete erectile dysfunction (impotence), and others achieve partial or brief erections. The erectile dysfunction can have a negative impact on self-esteem, quality of life and interpersonal relationships. It has many causes, most of which are treatable.

The causes of erectile dysfunction can generally be classified as either organic or psychological. Although the majority of men with erectile dysfunction are thought to have an organic factor, psychological aspects of anxiety, depression, self-confidence, and partner relationship are important contributing factors.  Consequently, many men have a combination of organic and psychological factors.

The organic causes and risk factors of erectile dysfunction include vascular disease, diabetes mellitus, hypertension (high blood pressure), certain medications, neurological disorders such as multiple sclerosis, chronic alcoholism, prolonged heavy smoking, pelvic trauma and spinal cord injury, pelvic surgery (such as non-nerve-sparing radical prostatectomy, cystectomy, or resection of rectum), Peyronie's disease (buildup of scar tissue in the penis), hormonal abnormalities, and other medical and surgical conditions.

Psychological causes of erectile dysfunction include performance anxiety, stress, depression, and marital conflict.

Although erectile dysfunction is often assumed to be a natural consequence of aging because its incidence increases with age, it is not inevitable. However, many conditions associated with aging—vascular disease, diabetes, cancer, and their treatments—may cause erectile dysfunction.

Erectile dysfunction can cause emotional strain between the couple. Many times, men will avoid sexual situations due to their emotional pain associated with erectile dysfunction, causing their partner to feel rejected or inadequate. Some couples consider seeking treatment for erectile dysfunction together, while other men prefer to seek treatment without their partner’s knowledge. A lack of communication is the primary barrier for seeking treatment, and can prolong the suffering.

As there is effective treatment for the problem, you may seek the help from an urologist.  He will do a thorough assessment to find organic causes and suggest proper treatment. If there are no organic causes and if required the help from a psychiatrist may be sought.

 15. R. B, Mangalore*I am 35 years of age. I am having piles problem. I took homeopathy medicine and the bleeding stopped but the extra growth  at the anal out let is there. I don’t have any problem but when I go to the toilet the extra growth is coming out. Is there any problem or do I have to get it operated?

** You are still having the problem of piles, only the bleeding has stopped. There is every possibility that the bleeding might recur. Piles, or hemorrhoids, are regions in the anal canal where the tissues containing blood vessels are swollen. The piles are common in all age groups from mid-teens onwards and particularly common in pregnant women.

Piles can be internal, inside the anus, or external, and be seen and felt on the outside of the anus. One can have internal and external piles at the same time. The internal piles are classified according to their position.

• First-degree piles are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the anus.
• Second-degree piles are larger and stick out (or prolapse) from the anus when one goes to the toilet, but return afterwards.
• Third-degree piles are similar, but hang out from the anus and only return inside when pushed back with a finger.
• Fourth-degree piles permanently hang down from the anus and you cannot push them back inside.

An external hemorrhoid (perianal haematoma) is a small lump that develops on the outside edge of the anus. They are less common than internal hemorrhoids.

The bleeding from the anus, itchiness around the anal area,  pain and discomfort after bowel movement, a slimy discharge of mucusand a feeling that the bowels have not completely emptied are the common symptoms of piles. There are conditions other than piles that can also cause bleeding from the anus.

The exact way piles form is controversial but it may be linked to excess pressure in the anus and lower rectum. (The rectum is at the end of the colon and is where faeces collect before they are expelled through the anus as a bowel movement.)

There is an increased risk of getting piles if one has to strain to empty the bowels when constipated; has chronic diarrhoea. The piles are common during pregnancy. The piles can run in families and are potentially hereditary, perhaps because of weak veins in the anal area. The incidence is high in those people with varicose veins^. Very rarely they can be due to cancer or growths in the pelvis or bowel, which may exert pressure in a similar way to a pregnancy^. The piles are not caused by sitting on cold hard surfaces, prolonged standing or sedentary work.

To encourage piles to clear up, it's important to avoid constipation. If you have regular bowel movements and avoid straining, stools will pass easily and will not put pressure on the blood vessels in the anal area. The piles will then eventually go away without treatment after about six weeks. Eating plenty of fiber-rich foods such as fruit, vegetables and wholegrain cereals (eg brown rice, whole meal bread), drinking plenty of fluids, especially water, should keep the bowel movements soft.

It may help to take a fiber supplement such as ispaghula husk or mild laxatives such as lactulose solution which soften bowel motions. The strong laxatives, such as the stimulant laxative senna are to be avoided on a routine basis unless the doctor advises because long-term use can be harmful.

If these self-help measures do not work, one may need to be treated by one of following procedures by doctors in the hospital.

Banding is a common treatment for second and third-degree piles. An elastic band is placed at the base of the pile so the blood supply to the pile is reduced. The pile then shrinks and drops off after a few days. The pile is passed with a stool and the bands fall off with time.

Sclerotherapy is another procedure in which an injection of a chemical solution known as a sclerosant (which usually has phenol in it) into the piles, which causes them to shrink. Cryosurgery is a surgical procedure that freezes the piles, causing them to shrink and drop off.

There are various surgical treatments like haemorrhoidectomy. There are a number of techniques. The most common involves placing a tight stitch or a staple around the base of the pile to control bleeding during the operation. Then, the surgeon will make a cut on the outer part of the pile and remove any excess tissue. The wound may be closed with dissolvable stitches. Most of the stitches will be inside the body and do not require removal.

 16. J.D’S, Udupi

*My mom is 62 year old/58 kgs. Recently she had full medical check and the findings are as following is revealed: The ultra-sound results showing liver in normal shape, size and echotexture. But there is evidence of hyperechoic focal lesion (haemangioma 22mm) in the right lobe. No duct dilatation and portal vein is normal in calibre. Please advise what needs to be done...otherwise she is a healthy person.Her fasting blood glucose level is 128 mg/dl and post pandial level is 130 mg/dl. Is this a cause of concern and does she needs to reduce intake of carbs and sugar?Her blood cholesterol level is 268mg/dl but blood pressure is normal. Does she need to start medication or what diet she has to start? 

** Except for marginal rise in the blood sugar level her other reports are not very significant. A small haemangioma in the liver does not require any intervention. She may reduce the intake of food containing sugar and repeat the blood test for glucose. If required a physician may be consulted. 

17. S.M., Mangalore*I am 20 weeks pregnant. I go for regular checkup every month here in clinic. A friend of mine told me to go for private for general checkup. I went and there the doctor advised me to take TT injection. First I refused to take. She said it was for safety of the child. Then I took the injection. Please inform me is there any harm for the child or any side effects. This is my first pregnancy.

** You have been properly advised to take tetanus injections. It is a requirement for all pregnant women to get immunized against tetanus to protect themselves and their newborn from the deadly disease tetanus. Maternal and neonatal tetanus (MNT) is a painful killer that kills thousands of women due to unsafe childbirth delivery practices. The true extent of the tetanus death toll is not known in many countries like India as many newborns and mothers die at home and neither the birth nor the death is reported. Tetanus bacteria are pervasive – they live in the soil, in animal dung and in feces – and can enter the infant at birth if the umbilical cord is cut with dirty instruments or if the incision is treated with contaminated dressings.

Once inside the body, the bacteria produce an extremely potent toxin, or poison, which attacks the nervous system causing spasms and tightening of muscles in the newborn’s jaw and neck and later, in the back and abdomen. The fatality rate is high – between 70 and 100 per cent. Maternal and neonatal tetanus (MNT) is easily preventable through immunization and hygienic birth practices. The World Health Organization (WHO) recommends two doses of tetanus toxoid (TT) for pregnant women during routine Ante Natal Care (ANC) and three TT doses to all women of childbearing age in high-risk areas. Three doses will protect the women for up to 15 years and will pass on their immunity to their newborns for the first few months of life. Such babies do not get the disease even if they are infected. \

18. G.P. UK* I am 30 years of age. I underwent hemithyroidectomy in Dubai. At 9 months postnatal. After surgery my doctor suggested to take thyroxin for 2 years post surgery. Five months later I came over to UK and my G.P suggested to stop thyroxin and do a blood test after 3 months which was borderline(TSH), she again suggested to repeat the tests after 3 months, which came out higher than before, she said I am heading towards under active thyroid. I would like to know whether or not to avoid certain food items (goitrogens) at this stage. My weight is also increasing, feel more hungry, could you advise more on this, and also since it has been diagnosed postnatally,I am bit worried that my daughter hasn't had her neonatal screening done at day 6(guthrie test),would it have any effect on her thyroid as well later on? She is 3 year old now.

** Rather than avoiding food items supposed to be goiterogenic, you require an early consultation with an endocrinologist. A rise in TSH is suggestive of low thyroid hormones; the other symptoms also suggest the same. Consult an endocrinologist (or at least a physician) to know whether you require taking thyroxin.The baby is normally affected by the thyroid abnormalities of the mother when it is still in the womb and the manifestations are revealed at birth. As your child is born normal it is unlikely for the child to have the thyroid problem. Most of the thyroid problems do not run in the families. 

19. A. M., Mangalore*

I am 32 years of age. I have some vaginal / urinal infection since long back.  I take the treatment from the gynecologist.  But it is recurring again and again.  I have done culture sensitivity tests/ scanning, urine sugar random/ fasting which all are normal.  Please let me know why this is occurring again and again?

** Vaginal yeast infections are among the most common infections of young women, and several other disorders cause very similar symptoms. Vulvo-vaginal yeast infections, usually caused by the fungus Candida albicans, affect up to 75 percent of all women at some point in their lives. There are several known risk factors for these infections, including high levels of estrogen. This is why young girls and postmenopausal women have fewer yeast infections than women of childbearing age. It has also been shown that birth control pills containing high levels of estrogen may increase the risk as well. Using vaginal sponges and intrauterine devices can also increase the risk of yeast infections.

The treatment of vaginal Candida infections is usually straightforward. Fluconazole an oral antifungal medicine, usually cures the infection with a single dose. This treatment has the benefit of convenience, but it does have rare side effects. Several vaginal preparations appear to be equally effective. Patients with especially severe infections sometimes require several days of oral therapy or several weeks of vaginal treatment with an antifungal cream.

Women with recurrent yeast infections should be evaluated for a few underlying conditions, including diabetes mellitus. Some of the vaginal discharge should be cultured (sent to a laboratory to grow any microbes present). This will confirm the diagnosis, as there are other infections and inflammatory disorders that can mimic yeast infections. If you are infected with another type of yeast, Candida glabrata, it is a difficult problem. This organism is far less susceptible to the usual treatments for yeast infections.

If you are infected with the usual Candida albicans, and if the strain is susceptible to fluconazole, you may simply need a longer course of treatment than usual. If the infection still recurs, several methods can prevent future problems. You may consult your doctor to get prescription for local applicants which might eradicate the organism from her gastrointestinal tract, where Candida often resides.

It has been shown that a male partner can be infected and can be a source of recurrent infection. When the partner is the source, the woman remains to be free of disease for some time between recurrences. In such a case he has to be evaluated and treated for it. Using barriers like condom till your husband is treated may help you to get rid off the problem.

20. D. M., Mangalore

*I am 29 years of age. For the past 5 years I have been suffering from severe allergic problems. It starts with small structure like pimple in the face and within two hours it spreads to whole body. I feel very hot all over the body. It covers to my whole body including the face, except the eyes. I tried my best to find out the cause for it, but I could not. Doctor told me that it comes from food. I am using the same food as I was using before. Even I tried with fasting still I get allergy. Whether I take some antiallergic medication or not it disappears after three days. For two days I have to abstain from work. It appears once in 25 to 30 days. I am working as an electronic technician.

**You seem to be having a problem known as urticaria. Urticaria refers to a group of disorders in which red patches and weals occur in the skin. The release of chemicals from certain cells in the skin causes small blood vessels to leak and results in tissue swelling. The weals can be a few millimeters or several centimeters in diameter, colored white or red, often surrounded by a red flare, and frequently itchy. Each weal may last a few minutes or several hours, and may change shape. Weals may be round, or form rings, a map-like pattern or giant patches.

The surface weals may be accompanied by deeper swelling of eyelids, lips, hands and elsewhere. The swelling is called angioedema. Angioedema may occur with or without urticarial weals

Generalized urticaria (hives) is often classified according to how long it has been present. As acute urticaria is of recent onset (hours, days or a few weeks) and chronic urticaria has persisted for several months or years.

Urticaria may not be present all the time. Some find it more noticeable at certain times of day, or when they are warm or emotionally upset.

Acute urticaria is sometimes due to allergy. Allergy depends on previous exposure to the material, and the development of an immune reaction to it. The cause of an allergy may be medicine, food such as tiny amounts of fish, eggs, nuts or chocolate, bee or wasp stings, skin contact with a potent allergen.

Most cases of urticaria are not due to allergy. Histamine and other vasoactive chemicals can be released into the skin for many reasons. Non-allergic causes of acute urticaria include viral or bacterial infection, certain food items.

Chronic urticaria is most often due to autoimmune disease (allergy to one's self), and may be associated with other autoimmune conditions.

Treatment to some extent depends on which type or types of urticaria one has.

 Oral antihistamines control wealing and itching for the majority of patients with urticaria. They do not affect the underlying cause of the rash. Antihistamines may need to be taken intermittently or continuously until the underlying tendency to urticaria disappears.

If the first antihistamine is not effective, consult one may need to increase the dose, or use a different drug. Sometimes a combination of antihistamines works better than a single type alone. Urticaria that fails to clear with antihistamines may be helped by oral steroids, immunosuppressive medications etc. There are certain general measures like:

• Do not take the medications the doctor has advised to avoid.
• Reduce the intake of acidic fruits.
• Find out if there is anything that aggravate the urticaria and try to avoid it.
• Avoid alcohol (it causes the surface blood vessels to dilate).