Tuesday, 5 December 2017

Multiple Sclerosis

Overview

Multiple sclerosis (MS) is a chronic, sometimes disabling, disease of the central nervous system affecting approximately 400,000 people in the United States, according to the National Multiple Sclerosis Society. It affects two to three times as many women as men. MS develops more often in Caucasians than in other races. About 200 new cases of MS are diagnosed in the United States every week.
The cause of MS is still unknown, but most researchers think it results from an abnormal response by the body’s immune system. Some researchers believe this abnormal immune response could be caused by a virus, although it is unlikely that there is just one virus responsible for triggering the condition. Researchers do know that MS is not contagious. And while it is not an inherited disease, genetic susceptibility plays a role. There is a higher risk for MS in families where it has already occurred. Other possible causes include environmental triggers such as exposure to toxins and heavy metals, as well as low levels of vitamin D.
It is believed that MS is an autoimmune disease. In MS, the immune system—for reasons still not understood—attacks and destroys myelin and the oligodendrocytes(oligo, few; dendro, branches; cytes, cells) that produce it. Though the body usually sends in immune cells to fight off bacteria and viruses, in MS they misguidedly attack the body’s own healthy nervous system, thus the term autoimmune disease.Rheumatoid arthritis and lupus are other types of autoimmune diseases.
In multiple sclerosis, these misdirected immune cells (certain types of lymphocytes, T-cells and killer cells) attack and consume myelin, damaging the myelin sheath—the fatty insulation surrounding nerve cells in the brain and spinal cord. Myelin acts like the rubber insulation found in an electric cable and facilitates the smooth transmission of high-speed messages between the brain and the spinal cord and the rest of the body. As areas of myelin are affected, messages are not sent efficiently or they never reach their destination.
Eventually, there is a buildup of scar tissue (sclerosis) in multiple places where myelin has been lost; hence the disease’s name: multiple sclerosis. These plaques or scarred areas, which only are a fraction of an inch in diameter, can interfere with signal transmission. The underlying nerve also may be damaged, further worsening symptoms and reducing the degree of recovery. The disease can manifest itself in many ways. Sometimes the diseased areas cause no apparent symptoms, and sometimes they cause many; this is why the severity of problems varies greatly among people affected with MS.
Multiple sclerosis usually strikes in the form of attacks or exacerbations. This is when at least one symptom occurs, or worsens, for more than 24 hours. The symptom(s) can last for days, weeks, months or indefinitely.
The most common pattern of multiple sclerosis is relapsing-remitting MS. It is characterized by periods of exacerbation followed by periods of remission. The remissions occur because nervous system cells have ways of partially compensating for their loss of ability. There’s no way to know how long a remission will last after an attack—it could be a month or it could be several years. But disease activity usually continues at a low, often almost indiscernible level, and MS often worsens over time as the signal-transmitting portion of the cells—the axons—are damaged.
Most commonly, multiple sclerosis starts with a vague symptom that disappears completely within a few days or weeks. Temporary weakness, tingling or pain in a limb can be a first sign. Ataxia (general physical unsteadiness and problems with coordination), temporary blurring or double vision, memory disturbances and fatigueare also symptoms that can appear suddenly and then vanish for years after the first episode, or in some cases never reappear.
The symptoms of MS vary greatly, as does their severity, depending on the areas of the central nervous system that are affected. Most people suffer minor effects. The disease can, however, completely disable a person, preventing him or her from speaking and walking in the most extreme cases. The bodily functions that are commonly affected by MS are:

  • vision
  • coordination
  • strength
  • sensation
  • speech and swallowing
  • bladder and bowel control
  • sexuality
  • cognitive function (thinking, concentration and short-term memory)

A varying degree of dysfunction may occur within these general areas. For instance, one person may suffer blurred vision while another may suffer double vision. Or one person may suffer from tremors while another will experience clumsiness of a particular limb.
Specific symptoms associated with MS can include:
fatigue: a debilitating kind of general fatigue that is unpredictable and out of proportion to the activity; fatigue is one of the most common (and one of the most troubling) symptoms of MS.
cognitive function: short-term memory problems and difficulty concentrating and thinking, typically not severe enough to seriously interfere with daily functioning, although sometimes it does. Judgment and reasoning may also be affected.
visual disturbances: blurring of vision, double vision (diplopia), optic neuritis, involuntary rapid eye movement and (rarely) total loss of sight.
balance and coordination problems: loss of balance, tremor, unstable walking (ataxia), dizziness (vertigo), clumsiness of a limb and lack of coordination.
weakness: usually in the legs.
spasticity: altered muscle tone can produce spasms or muscle stiffness, which can affect mobility and walking.
altered sensation: tingling, numbness (paresthesia), a burning feeling in an area of the body or other indefinable sensations.
abnormal speech: slowing of speech, slurring of words and changes in rhythm of speech.
difficulty in swallowing (dysphagia).
bladder and bowel problems: the need to urinate frequently and/or urgently, incomplete emptying or emptying at inappropriate times, constipation and loss of bowel control.
sexuality and intimacy: impotence, diminished arousal and loss of sensation.
pain: facial pain and muscle pains.
sensitivity to heat: this often causes symptoms to get worse temporarily.
Though these are some of the symptoms commonly associated with MS, not all people with MS will experience all of them. Most will experience more than one symptom, however. There is no typical case of MS. Each is unique.
Today, life expectancy for those with MS is normal or close to normal.
Most people with MS begin experiencing symptoms between the ages of 20 and 50. But initial symptoms may be vague, may come and go with no pattern or may be attributed to other factors or conditions. For instance, a woman who experiences sudden bouts of vertigo once every few months may explain away the symptom by linking it to her menstrual cycle. Or, perhaps, someone who suddenly has a bit of blurry vision may blame too many hours at the office.

Diagnosis

Diagnosing MS involves several tests and a lot of discussions with several types of health care professionals. You can expect a complete physical examination, a discussion of your medical history and a review of your past and/or current symptoms.
You should pay attention to any symptom suggestive of MS. Early diagnosis of MS is important because a new generation of treatments introduced in the 1990s can reduce the frequency and severity of MS attacks. In fact, research has prompted health care professionals to change the diagnostic criteria to treat more cases of MS as early as possible.
At this point, there are no symptoms, physical findings or tests that alone can definitively show that a person has MS. Instead, physicians use several strategies, including a medical history, neurologic exam, tests such as visual evoked potentials (VEPs) and spinal taps and imaging tests such as magnetic resonance imaging (MRI), to make a diagnosis.
For a diagnosis of MS, a health care professional must:
Discover evidence of damage in at least two separate areas of the central nervous system (CNS), including the brain, spinal cord and optic nerves AND
Find evidence that the damages occurred at least one month apart AND
Be able to rule out all other possible diagnoses
In 2001, an international panel of experts convened to update the diagnostic criteria to include guidelines for using MRI, VEP and cerebrospinal fluid analysis to confirm an MS diagnosis faster. Health care professionals can use these tests to look for a second area of damage in a person who has experienced only one MS-like attack. These criteria were further revised in 2005 and again in 2010, termed the Revised McDonald Criteria, to speed up the diagnostic process even more.
The specific tests that help make an MS diagnosis include the following:
MRI: Health care professionals may use MRI to scan the brain for lesions indicating early evidence of damage, in addition to other tests. An MRI is painless and noninvasive. If you need one, a health care professional will have you lie on your back on a table. The table will be pushed into a tube-like structure and detailed pictures of your brain and, sometimes, spinal cord, will be taken. These images are able to show scarred areas of the brain.Bear in mind that a normal MRI does not ensure that a person does not have MS. About 5 percent of MS patients have normal MRIs, according to the National Multiple Sclerosis Society. However, it is important to note that the longer a person has a normal MRI, the more important it becomes to look for a diagnosis other than MS.
Visual evoked potential tests (VEPs): VEPs measure how quickly a person’s nervous system responds to certain stimulation. These tests offer evidence of neurological scarring along nerve pathways that may not show up during neurologic exams. Evoked potential tests are painless and noninvasive. A health care professional or technician will place small electrodes on your head to monitor your brain waves and your response to auditory, visual and/or sensory stimuli. The time it takes for your brain to receive and interpret messages is a clue to your condition.
Spinal tap: A spinal tap tests cerebrospinal fluid (fluid surrounding the brain and spinal cord) for substances that indicate strong immune activity in the central nervous system and helps rule out viral infections and other conditions that can cause neurological symptoms similar to those of MS. If you have this test, you will likely be given an injection of local anesthesia. Some people experience a transient headache and nausea after the test.
Blood tests: These may help rule out other potential causes of symptoms, such as Lyme disease, lupus and AIDS.
If you are diagnosed with MS, it will almost certainly be one of four patterns:
Relapsing-remitting MS: This is the most common pattern of the disease at the time of diagnosis, affecting 85 percent of patients at this stage. People with this pattern of MS experience clearly defined exacerbations or relapses, followed by partial or complete remissions (or recovery periods) where the disease stops progressing.
Secondary progressive MS: According to the National Multiple Sclerosis Society, before the introduction of disease-modifying drugs, about half of individuals with relapsing-remitting MS experienced a gradual worsening of symptoms with or without occasional flare-ups, minor remissions or plateaus within 10 years of initial diagnosis. This form of MS is called secondary progressive MS. At this point, the long-term data are not available to determine whether or not the changeover in diagnosis from relapsing-remitting to secondary progressive MS is delayed by treatment.
Primary progressive MS: This pattern of MS is characterized from the onset by a nearly continuous worsening of the disease, with no distinct relapses or remissions. There may be temporary plateaus with minor relief from symptoms but no long-lasting relief. About 10 percent of people with MS have primary progressive MS.
Progressive-relapsing MS: This form of the disease is relatively rare and takes a progressive course from the onset but also is characterized by obvious acute attacks, with or without recovery. In contrast to relapsing-remitting MS, the periods between relapses are characterized by continuing disease progression. About 5 percent of people with MS have progressive-relapsing MS.
MS varies so greatly in each individual that it is hard to predict the course the disease might take. However, some studies show that people who have few attacks in the first five years following a positive diagnosis of MS, long intervals between attacks, complete recoveries and attacks that are sensory only in nature generally have a less debilitating form of the disease.
On the other hand, people who have early symptoms that include tremors, lack of coordination or frequent attacks with incomplete recoveries generally have a more progressive form of MS. These early symptoms indicate that more myelin (the fatty insulation surrounding nerve cells in the brain and spinal cord) has been damaged.
Since MS generally strikes a woman during childbearing years, many women with the disease wonder if they should have a baby. Studies show that MS has no adverse effects on the course of pregnancy, labor or delivery; in fact, symptoms often stabilize during pregnancy. Although MS poses no significant risks to a fetus, physical limitations of the mother may make caring for a child more difficult. Also, women with MS who are considering having a child should discuss with their health care professionals which drugs to avoid during pregnancy and while breastfeeding. The disease-modifying drugs are not recommended during breastfeeding because it isn’t known if they are excreted in breast milk.

Treatment

There is no cure for MS, but some agents can modify the course of the disease, manage symptoms and treat exacerbations. These drugs include the following:
Fingolimod (Gilenya): Gilenya was FDA-approved in 2010 to help reduce frequency of attacks and to delay physical disability in people with relapsing forms of MS. It is a new class of medication called a sphingosine 1-phosphate receptor modulator, which is thought to reduce damage to nerve cells by trapping certain white blood cells within the lymph nodes, preventing them from entering the brain and spinal cord. Gilenya is given by mouth once a day. Gilenya is not recommended for people with preexisting heart conditions.
Teriflunomide (Aubagio): Aubagio became the second oral disease-modifying treatment for MS when it was FDA-approved in 2012. The once-a-day tablet may be prescribed to treat adults with relapsing forms of MS. Aubagio inhibits the function of immune cells that may contribute to MS. It can inhibit a key enzyme required by white blood cells (lymphocytes), reducing the proliferation of T and B immune cells active in MS and can also inhibit production of immune messenger chemicals by T cells. Common side effects include diarrhea, abnormal liver tests, nausea and hair loss. It is not recommended for pregnant women or people with liver problems.
Interferon beta-1b (Betaseron, Extavia): Interferon beta-1b, which was introduced in the 1990s, is prescribed to reduce the frequency of exacerbations of relapsing forms of MS, including secondary-progressive MS patients who continue to experience acute attacks or relapses. Betaseron and Extavia are also approved for patients who have experienced a first episode and who have an MRI result consistent with MS. Betaseron and Extavia are injected every other day under the skin. Common side effects include flu-like symptoms (which lessen over time) and reactions at the injection site. Rare side effects include elevated liver enzymes and depression.
Interferon beta-1a (Avonex, Rebif): Both Avonex and Rebif are approved by the U.S. Food and Drug Administration (FDA) for people with relapsing forms of MS to decrease the frequency of exacerbations and slow progression of disability. Avonex is injected once a week, usually in the large muscles of the thigh, upper arm or hip. Rebif is injected three times a week. The EVIDENCE trial, which compared Avonex and Rebif, found that patients treated with Rebif were more likely to be relapse-free at 24 and 48 weeks than those treated with Avonex. Side effects of both drugs include flu-like symptoms after injection, which lessen over time, and rarely, seizures, depression, mild anemia or liver problems.
Glatiramer acetate (Copaxone): Copaxone is FDA-approved to reduce the number of relapses in people with relapsing-remitting MS and for those who have experienced a first clinical episode and have MRI results that point to MS. While interferon beta-1a and interferon beta-1b work by dampening the immune system, glatiramer acetate works differently to influence the immune system and its cells. Copaxone is injected daily. Common side effects include injection site reactions, runny nose, tremor, unusual tiredness and weight gain. Rarer side effects include anxiety, chest tightness, shortness of breath and flushing.
Mitoxantrone (Novantrone): A cancer drug that is part of a group of medicines called antineoplastics, Novantrone helps in the treatment of MS by suppressing the activity of B cells, T cells and macrophages that are thought to attack the myelin sheath. Based on the results of a series of European studies done on Novantrone over 10 years, the FDA approved the drug for reducing neurologic disability and/or the frequency of relapses in people with secondary progressive MS, progressive-relapsing MS and worsening relapsing-remitting MS. Novantrone is taken by injection once every three months. Common side effects, which may go away as your body adjusts to the medication, include nausea, hair loss and menstrual irregularities. Rarer and potentially more serious side effects include fever or chills, lower back or side pain, stomach pain and heart problems (therefore, patients should be screened for heart disease before they start taking Novantrone).
Natalizumab (Tysabri): Tysabri was FDA approved in 2006 to help reduce the frequency of attacks in people with relapsing forms of MS. It should be used alone, not in combination with any other medications. The drug works by blocking potentially damaging immune cells from crossing into the brain and spinal cord. Tysabri is given intravenously once every four weeks. It is usually reserved for patients who have not responded well to other MS medications. Common side effects include headache, pain in your arms or legs, tiredness, joint pain, depression, diarrhea and pain in the stomach area. More serious side effects include increased risk of infection and increased risk of progressive multifocal leukoencephalopathy (PML), a viral infection of the brain that usually leads to death or severe disability.
Note: Talk to your health care provider if you experience side effects from one of the above-mentioned drugs. There may be strategies you can use to minimize the side effects; they may abate in a few months or you may be able to switch to one of the other drugs and avoid the side effects. If you stop taking the drug, it may seem like there are no consequences, but MS damage can occur steadily and silently for long periods before the next attack.
Steroids such as methylprednisolone often are prescribed to treat acute attacks of MS, whether the person is taking a disease-altering drug or not. These drugs speed the recovery from the acute attack but do not stop disease progression. Long-term use of steroids also has many side effects, including ulcers, weight gain, acne, cataracts, osteoporosis and diabetes.
Chemotherapies that suppress the immune system broadly and were originally designed to treat certain cancers are sometimes used for progressive MS. In addition to Novantrone, cyclophosphamide (Cytoxan) and azathioprine (Imuran) are used similarly but do not have approval from the FDA for treatment of MS.
A process in which the antibodies are filtered from a person’s blood called plasmapheresis may be successful, particularly when used in combination with immunosuppressants for short-term treatment of some progressive patients. However, its use is controversial.
For symptom management, health care professionals have an arsenal of medications. For example, baclofen (Lioresal) and tizanidine (Zanaflex) are antispasticity medications often prescribed to relieve muscle spasms, cramping and tightness of muscles in MS patients. Each has varying side effects in varying degrees. Your health care professional should be able to find one that provides comfort and relief for almost any symptom you have.
Although currently unapproved by the FDA for MS treatment, a growing number of health care providers now consider use of the botulinum toxin (Botox) as an effective short-term treatment option for certain types of MS-related problems, such as muscle stiffness and urinary problems, when first-line treatment is ineffective.
Nonmedical strategies for coping with MS
An MS diagnosis doesn’t have to stop your life, but you will have to learn—and practice—strategies for managing fatigue and dealing with other temporary or long-term disabilities. Physical and occupational therapists can help you develop strategies and select assistive devices to navigate the workplace and home environment.
Physical therapy usually focuses on walking (including using ambulatory aids correctly), balance and stability in standing, maintaining range of motion and functional strengthening. Occupational therapy focuses more on ways to accomplish specific everyday tasks at home and work, as well as managing your energy. Some programs include techniques to improve memory and concentration.
Check your health plan for coverage. Not all cover physical and occupational therapy.
Symptoms that affect your memory and concentration may be the most painful to talk about. But acknowledging these symptoms and discussing them with health care professionals and your family are the first steps toward getting them under control. The National Multiple Sclerosis Society can direct you toward support groups and publications that can help. Visit its website at www.nationalmssociety.org.
Things you can do at home to manage fatigue or limited mobility include:
Declutter your living areas.
Divide household tasks more equitably with family members.
Simplify tasks like cooking so they are less stressful. For example, cook more frozen vegetables or freeze individual servings of a meal, so you can give yourself time off from meal preparation.
Make tasks less fatiguing. For example, put a table and chair in the kitchen so you can sit while cutting or stirring.
Identify and abide by your priorities. If it’s important for you to continue working, take some shortcuts with household tasks, or eliminate some of them.
Cut back on tiring leisure activities, or make energy-conserving adaptations (such as planting a smaller garden).
Minimize or combine trips.
At work you may want to try the following:
Manage your workload to accommodate fatigue. For example, if you feel good in the morning but tire rapidly in the afternoon, do your most demanding work in the morning.
Ask your employer about flex time.
Consider multiple short breaks instead of an hour-long lunch. Perhaps a 30-minute lunch and two 15-minute breaks.
When you’re having trouble concentrating, close your office door or take your work to a quiet area, if possible.
“Journaling” can also be a helpful coping strategy. A written or recorded account can help you keep track of when symptoms occur, the management tools that work best for specific symptoms, your medication schedule and many other issues related to your condition. Recording your thoughts and feelings may also be helpful to you. However, it is important to not get carried away and obsess over each little feeling or sensation.
Exercise can be therapeutic and is at least as important for women with MS as for other women. If you have MS, the last thing you want is to develop other health problems—such as obesity, diabetes or heart disease.
People with MS, however, should not “go for the burn” during exercise because overheating can trigger symptoms and worsen fatigue. Some women with MS enjoy exercising in a cool pool, but others find that the bother of driving and changing twice is too fatiguing. A physical therapist can help you design an appropriate exercise program.

Prevention

No matter how much you exercise, how healthful your diet is or how well you take care of yourself, there is no way to prevent multiple sclerosis (MS). It affects people randomly. But it also is somewhat manageable. If detected early, medications may slow the progress of the disease and the severity of symptoms.
There is now preliminary evidence suggesting that higher vitamin D levels are associated with a decreased risk of MS. Research published in the Journal of the American Medical Association found that among white men and women, the risk of multiple sclerosis decreased by 41 percent with every increase of 20 ng/ml above 24 in vitamin D levels. And previous studies, including one done on women who took vitamin D supplements, also show a connection between higher vitamin D levels and lower risk of MS. Other research suggests that ultraviolet radiation from the sun (vitamin D is synthesized in the body as a result of ultraviolet radiation from the sun) may dampen the immune attack, and that people who live closer to the equator—and therefore, get more sun exposure—are less likely to get MS. This growing body of research on the link between vitamin D and risk for MS may help explain this phenomenon. The Food and Nutrition Board at the Institute of Medicine recommends 600 international units (IU) of vitamin D for people ages 1 to 70 and 800 IU for those over 70. Neurologists often recommend much higher levels, but 4,000 IU is considered the upper level intake without increasing health risks.

Facts to Know

Nearly 200 people in the United States are diagnosed with multiple sclerosis (MS) every week. There are 400,000 Americans with MS, according to the Multiple Sclerosis Society.
Most people with MS are diagnosed between the ages of 20 and 50.
Two to three times as many women as men develop MS.
The progress, severity and specific symptoms of MS in any one person cannot be predicted.
Symptoms of MS are unpredictable and vary greatly from person to person.
MS is not contagious or fatal. While quality of life is often changed for those diagnosed with MS, the disease does not significantly affect length of life.
Although there are no drugs to cure MS, treatments are available that can alter the course of the disease. Many symptoms can be treated and managed successfully.
Multiple sclerosis is Greek for “many scars” which aptly describes the manner in which the disease manifests itself—as scars or plaques on the brain.
Myelin is a substance made of fat and protein that helps speed messages through the central nervous system. Demyelination is the destruction of that substance. When myelin is destroyed, the messages from the brain to the rest of the body are slowed or destroyed. This results in impaired function and the symptoms of MS.
Genetics play a role in the development of MS, but the disease is not directly inherited. In other words, you have an increased chance of developing MS if a relative has the disease.

Key Q&A

What will happen to me if I am diagnosed with MS?Since this disease affects people so differently, it is impossible to predict. It is important to remember that most people with MS do not end up in a wheelchair, and life expectancy is normal or near normal. About 85 percent of people initially diagnosed with MS have relapsing-remitting MS, characterized by temporary attacks followed by periods of remission. About half those diagnosed with relapsing-remitting MS develop secondary progressive MS, in which there is a worsening of symptoms with or without occasional flare-ups and minor remissions. About 20 percent of those diagnosed will do well with no major treatments, but no one knows who they are up front. That can only be determined after many years of observation.
What are the symptoms?MS affects each person differently. Symptoms are a direct result of demyelination—the destruction of myelin, the substance made of fat and protein that helps speed messages through the central nervous system. When myelin is destroyed, the messages from the brain to the rest of the body are either slowed or destroyed. This results in impaired function and symptoms associated with MS, which can include difficulty walking, unusual fatigue, vision loss, strange tactile sensations like numbness or weakness, tremors, a lack of coordination, slurred speech, sudden paralysis and bladder dysfunction.
Complications that are a result of the primary symptoms are often called secondary symptoms—urinary tract infections due to bladder dysfunction, for example. Other secondary symptoms include poor postural alignment and trunk control, decreased bone density (increasing risk of fracture) and shallow, inefficient breathing. Paralysis can lead to the secondary symptom of pressure sores. While secondary symptoms can be treated, the goal is to prevent them by treating the primary symptoms.
There is a third classification of symptoms—the social and psychological effects. People with MS often become depressed. Psychologists, psychiatrists and social workers can help treat these symptoms.
It is important to remember that many MS symptoms can be effectively managed and complications avoided with regular care by a neurologist and other health professionals.
Is there any treatment for MS?There is no cure for MS, but there are medications that may reduce disease activity in relapsing MS. These include Avonex, Rebif, Betaseron and Extavia, all of which are injectable. In addition, the drug Copaxone is used for the relapsing-remitting form of MS and for those who have experienced a first clinical episode and have MRI results that point to MS, Tysabri is used for the treatment of relapsing forms of the disease in people who have not responded well to other therapies, and Gilenya is used to reduce frequency of relapses and to delay physical disability in people with relapsing MS. In people with progressive MS, Novantrone can be used to reduce disability and the frequency of relapses in patients with secondary-progressive, progressive-relapsing or worsening relapsing-remitting MS. However, the lifetime dose of Novantrone is limited due to cardiac toxicity.
Many aspects of MS can be effectively managed. For example, exacerbations can often be treated successfully with steroids. These drugs reduce inflammation at the site of new demyelination, allowing you to return to normal functioning more quickly than if they were not used. However, steroids have not been proven to have any long-term effect on the course of the disease and do have severe side effects. Also, physical and occupational therapy (rehabilitation) may help improve impaired functions. Counseling may have a positive effect on the psychological toll the disease takes on a person and her family.

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Menstrual Disorders

Overview

Some women get through their monthly periods easily with few or no concerns. Their periods come like clockwork, starting and stopping at nearly the same time every month, causing little more than a minor inconvenience.
However, other women experience a host of physical and/or emotional symptoms just before and during menstruation. From heavy bleeding and missed periods to unmanageable mood swings, these symptoms may disrupt a woman’s life in major ways.
Most menstrual cycle problems have straightforward explanations, and a range of treatment options exist to relieve your symptoms. If your periods feel overwhelming, discuss your symptoms with your health care professional. Once your symptoms are accurately diagnosed, he or she can help you choose the best treatment to make your menstrual cycle tolerable.
How the Menstrual Cycle Works
Your menstrual period is part of your menstrual cycle—a series of changes that occur to parts of your body (your ovaries, uterus, vagina and breasts) every 28 days, on average. Some normal menstrual cycles are a bit longer; some are shorter. The first day of your menstrual period is day one of your menstrual cycle. The average menstrual period lasts about five to seven days. A “normal” menstrual period for you may be different from what’s “normal” for someone else.
Types of Menstrual Disorders
If one or more of the symptoms you experience before or during your period causes a problem, you may have a menstrual cycle “disorder.” These include:
abnormal uterine bleeding (AUB), which may include heavy menstrual bleeding, no menstrual bleeding (amenorrhea) or bleeding between periods (irregular menstrual bleeding)
dysmenorrhea (painful menstrual periods)
premenstrual syndrome (PMS)
premenstrual dysphonic disorder (PMDD)
A brief discussion of menstrual disorders follows below.
Heavy menstrual bleeding
One in five women bleed so heavily during their periods that they have to put their normal lives on hold just to deal with the heavy blood flow.
Bleeding is considered heavy if it interferes with normal activities. Blood loss during a normal menstrual period is about 5 tablespoons, but if you have heavy menstrual bleeding, you may bleed as much as 10 to 25 times that amount each month. You may have to change a tampon or pad every hour, for example, instead of three or four times a day.
Heavy menstrual bleeding can be common at various stages of your life—during your teen years when you first begin to menstruate and in your late 40s or early 50s, as you get closer to menopause.
If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your health care professional right away. Any vaginal bleeding after menopause isn’t normal and should be evaluated immediately by a health care professional.
Heavy menstrual bleeding can be caused by:
hormonal imbalances
structural abnormalities in the uterus, such as polyps or fibroids
medical conditions
Many women with heavy menstrual bleeding can blame their condition on hormones. Your body may produce too much or not enough estrogen or progesterone—known as reproductive hormones—necessary to keep your menstrual cycle regular.
For example, many women with heavy menstrual bleeding don’t ovulate regularly.Ovulation, when one of the ovaries releases an egg, occurs around day 14 in a normal menstrual cycle. Changes in hormone levels help trigger ovulation.
Certain medical conditions can cause heavy menstrual bleeding. These include:
thyroid problems
blood clotting disorders such as Von Willebrand’s disease, a mild-to-moderate bleeding disorder
idiopathic thrombocytopenic purpura (ITP), a bleeding disorder characterized by too few platelets in the blood
liver or kidney disease
leukemia
medications, such as anticoagulant drugs such as Plavix (clopidogrel) or heparinand some synthetic hormones.
Other gynecologic conditions that may be responsible for heavy bleeding include:
complications from an IUD
fibroids
miscarriage
ectopic pregnancy, which occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes
Other causes of excessive bleeding include:
infections
precancerous conditions of the uterine lining cells
Amenorrhea
You may also have experienced the opposite problem of heavy menstrual bleeding—no menstrual periods at all. This condition, called amenorrhea, or the absence of menstruation, is normal before puberty, after menopause and during pregnancy. If you don’t have a monthly period and don’t fit into one of these categories, then you need to discuss your condition with your health care professional.
There are two kinds of amenorrhea: primary and secondary.
Primary amenorrhea is diagnosed if you turn 16 and haven’t menstruated. It’s usually caused by some problem in your endocrine system, which regulates your hormones. Sometimes this results from low body weight associated with eating disorders, excessive exercise or medications. This medical condition can be caused by a number of other things, such as a problem with your ovaries or an area of your brain called the hypothalamus or genetic abnormalities. Delayed maturing of your pituitary gland is the most common reason, but you should be checked for any other possible reasons.
Secondary amenorrheais diagnosed if you had regular periods, but they suddenly stop for three months or longer. It can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness.
Additionally, problems affecting the pituitary gland (such as elevated levels of the hormone prolactin) or thyroid (including hyperthyroidism or hypothyroidism) may cause secondary amenorrhea. This condition can also occur if you’ve had an ovariancyst or had your ovaries surgically removed.
Severe menstrual cramps (dysmenorrhea)
Most women have experienced menstrual cramps before or during their period at some point in their lives. For some, it’s part of the regular monthly routine. But if your cramps are especially painful and persistent, this is called dysmenorrhea, and you should consult your health care professional.
Pain from menstrual cramps is caused by uterine contractions, triggered by prostaglandins, hormone-like substances that are produced by the uterine lining cells and circulate in your bloodstream. If you have severe menstrual pain, you might also find you have some diarrhea or an occasional feeling of faintness where you suddenly become pale and sweaty. That’s because prostaglandins speed up contractions in your intestines, resulting in diarrhea, and lower your blood pressure by relaxing bloodvessels, leading to lightheadedness.
Premenstrual syndrome (PMS)
PMS is a term commonly used to describe a wide variety of physical and psychological symptoms associated with the menstrual cycle. About 30 to 40 percent of women experience symptoms severe enough to disrupt their lifestyles. PMS symptoms are more severe and disruptive than the typical mild premenstrual symptoms that as many as 75 percent of all women experience.
There are more than 150 documented symptoms of PMS, the most common of which is depression. Symptoms typically develop about five to seven days before your period and disappear once your period begins or soon after.
Physical symptoms associated with PMS include:
bloating
swollen, painful breasts
fatigue
constipation
headaches
clumsiness
Emotional symptoms associated with PMS include:
anger
anxiety or confusion
mood swings and tension
crying and depression
inability to concentrate
PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It’s not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.
PMS differs from other menstrual cycle symptoms because symptoms:
tend to increase in severity as the cycle progresses
are relieved when menstrual flow begins or shortly after
are present for at least three consecutive menstrual cycles
Symptoms of PMS may increase in severity following each pregnancy and may worsen with age until they stop at menopause. If you experience PMS, you may have an increased sensitivity to alcohol at specific times during your cycle. Women with this condition often have a sister or mother who also suffers from PMS, suggesting a genetic component exists for the disorder.
Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder is far more severe than the typical PMS. Women who experience PMDD (about 3 to 8 percent of all women) say it significantly interferes with their lives. Experts equate the difference between PMS and PMDD to the difference between a mild tension headache and a migraine.
The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women. Although some symptoms of PMDD and major depression overlap, they are different:
PMDD-related symptoms (both emotional and physical) are cyclical. When a woman starts her period, the symptoms subside within a few days.
Depression-related symptoms, however, are not associated with the menstrual cycle. Without treatment, depressive mood disorders can persist for weeks, months or years. If depression persists, you should consider seeking help from a trained therapist.

Diagnosis

To help diagnose menstrual disorders, you should schedule an appointment with your health care professional. To prepare, keep a record of the frequency and duration of your periods. Also jot down any additional symptoms, such as cramping, and be prepared to discuss health history. Here is how your health care professional will help you specifically diagnose abnormal uterine bleeding, dysmenorrhea, PMS and PMDD:
Heavy menstrual bleeding
To diagnose heavy menstrual bleeding—also called menorrhagia—your health care professional will conduct a full medical examination to see if your condition is related to an underlying medical problem. This could be structural, such as fibroids, or hormonal. The examination involves a series of tests. These may include:
Ultrasound. High-frequency sound waves are reflected off pelvic structures to provide an image. Your uterus may be filled with a saline solution to perform this procedure, called a sonohysterography. No anesthesia is necessary.
Endometrial biopsy. A scraping method is used to remove some tissue from the lining of your uterus. The tissue is analyzed under a microscope to identify any possible problem, including cancer.
Hysteroscopy. In this diagnostic procedure, your health care professional looks into your uterine cavity through a miniature telescope-like instrument called a hysteroscope. Local, or sometimes general, anesthesia is used, and the procedure can be performed in the hospital or in a doctor’s office.
Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used as a treatment for excessive bleeding and for bleeding that doesn’t respond to other treatments. It is performed on an outpatient basis under local anesthesia.
You can also expect blood tests to check your blood count for anemia and a urine test to see if you’re pregnant, as well as other laboratory tests.
The more information you can give your health care professional, the better. Take notes on the dates and length of your periods. You can do this by marking your calendar or appointment book. You might also be asked to keep a daily track record of your temperature to determine when you are ovulating. Ovulation kits, that use a morning urine sample, are available without a prescription and are easy to use.
During your initial evaluation with your health care professional, you should also discuss the following:
current medications
details about menstrual flow and cycle length
any gynecologic surgery or gynecologic disorders
sexual activity and history of sexually transmitted diseases
contraceptive use and history
family history of fibroids or other conditions associated with AUB
history of a breast discharge
blood clotting disorders—either your own or in family members.
PMS and PMDD
There are no specific diagnostic tests for PMS and PMDD. You’ll probably be asked to keep track of your symptoms and write them down. A premenstrual symptom checklist is one of the most common methods currently used to evaluate symptoms. With this tool, you can track the type and severity of symptoms to help identify a pattern.
Generally PMS and PMDD symptoms:
tend to increase in severity as the menstrual cycle progresses.
tend to be relieved when menstrual flow begins or soon afterward.
are present for at least three consecutive menstrual cycles.

Treatment

Treatments for menstrual disorders range from over-the-counter medications to surgery, with a variety of options in between. Your treatment options will depend on your diagnosis, its severity, which treatment you prefer, your health history and your health care professional’s recommendation.
Abnormal uterine bleeding
Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the abnormal bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to a light to normal flow.
Medication
Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.
Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives and contraceptive patches are highly effective in restoring regular bleeding, although they will not correct the reason you stopped bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.
They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone and marketed under the names YAZ, Yasmin, Ocella, Gianvi and Zarah, may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension. And Yaz is FDA-approved for the treatment of PMDD.
Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.
Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch, because it contains higher levels of estrogen.
Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don’t work as well as estrogen, they are effective for long-term management. Side effects include irregular menstrual bleeding, weight gain and, sometimes, mood changes.
The levonorgestrel intrauterine system (Mirena) is FDA-approved to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of birth control prevention. The Mirena system may be kept in place for up to five years. Over this time, it slowly releases a low dose of the progestin hormone levonorgestrel into the uterus. Mirena is also referred to as an intrauterine device, or IUD.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter and with a prescription and can help reduce menstrual bleeding and cramping. These medications include ibuprofen (Advil, Motrin) and naproxen (Aleve). Mefenamic acid (Ponstel) is a prescription-only NSAID. Common side effects include stomach upset, headaches, dizziness and drowsiness.
Tranexamic acid (Lysteda), although new to the United States, has been used successfully to decrease heavy menstrual bleeding in other countries for many years. These tablets are only taken on the days you expect to have heavy bleeding.
Surgery
Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.
There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.
Endometrial ablation. Endometrial ablation involves using heat, electricity, laser, freezing or other methods to destroy the lining of the uterus. These procedures are recommended only for women who have completed their families because they affect fertility. However, following treatment, you must use contraception. Although endometrial ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus. Overall, endometrial ablation procedures have a good success rate at reducing heavy bleeding, and some women stop having menstrual periods altogether.
Endometrial resection. During this surgical procedure, the surgeon uses an electrosurgical wire loop to remove the lining of the uterus.
Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used to diagnose abnormal uterine bleeding. It is performed on an outpatient basis under local anesthesia. This treatment is often only a temporary solution to the heavy bleeding.
Myomectomy. Fibroids are a common cause of heavy bleeding, and removal of fibroids with a procedure called myomectomy usually resolves the problem. Depending on the size, number and position of the fibroids, myomectomy may be performed with a hysteroscope, laparoscope or through a bikini abdominal incision.
Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a radical surgery that removes your uterus. Several factors make elective hysterectomy a serious consideration: It is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.Several types of hysterectomy are available. More information is available atwww.HealthyWomen.org.
Menstrual cramps
If you are experiencing severe menstrual cramps (called dysmenorrhea) regularly, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies.
Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn’t work as well. This will also help reduce heavy bleeding.
Oral contraceptive pills are also effective for menstrual cramps. If active pills are taken continuously for 90 to 120 days in a row, periods will only occur three to four times a year.
Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.
PMS and PMDD
To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don’t try to treat on your own; make sure you talk to your health care professional.
Dietary options for PMS include:
Cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse.
Increasing the calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium-fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
Increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans.
Exercise is another good way to relieve menstrual cycle symptoms. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five days a week. But even taking a 20- to 30-minute walk three times a week can:
Increase brain chemicals that give you more energy and improve mood.
Decrease stress and anxiety.
Improve deep sleep at night.
Other medical therapies your health care professional might suggest include:
Low doses of antidepressants such as paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and fluoxetine (Prozac). These are prescribed because they are effective in regulating the brain compound serotonin, which is related to PMS. Often these can be taken just during the times of expected symptoms.
GnRH agonists (Lupron), sometimes in combination with estrogen or estrogen-progestin hormone therapy, for short-term treatment (less than six months). This treatment is used for very severe symptoms since it has numerous side effects, including hot flashes, headaches and vaginal dryness.
Oral contraceptives that contain a progesterone called drospirenone may help reduce some mood-related PMS symptoms, such as irritability, anxiety, tearfulness and tension.
Diuretic medications, such as spironolactone (Aldactone) to help with water weight gain and bloating.
There’s evidence that some nutritional supplements such as calcium, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

Prevention

You cannot prevent abnormal uterine bleeding, but you can manage it once it develops.
Women who experience chronic ovulation problems—failure to ovulate—can regulate their bleeding by continuing to take oral contraceptives.
For other menstrual cycle-related problems, such as cramping or premenstrual syndrome, you can take steps to prevent or minimize your discomfort and pain as described in the Treatment section of this entry.
Additionally, changing your diet, exercising and adopting a regular sleep pattern can all help with PMS and PMDD symptoms. Specifically, try:
Changing your diet by reducing refined sugars, salt, nicotine, caffeine and alcohol, which can aggravate PMS symptoms
Exercising at least 20 to 30 minutes three times a week, ideally for at least 30 minutes, five days a week
Sleeping consistent hours and establishing a bedtime routine to help cue your body and mind for sleeping
Keeping a premenstrual symptom checklist to be prepared for highs and lows
For PMDD, antidepressants or anti-anxiety medications, particularly a type called selective serotonin reuptake inhibitors (SSRIs), can help prevent disruptive symptoms. It may not be necessary to take an SSRI every day; taking the medication only during your luteal phase (starting 14 days before your next period) may be sufficient.

Facts to Know

Abnormal uterine bleeding (AUB) includes menorrhagia (heavy menstrual bleeding), metrorrhagia (bleeding in between menses) and hypermenorrhea (menses too long). Abnormal uterine bleeding also includes amenorrhea or absence of menstrual periods.
Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
Sometimes abnormal bleeding is caused by hormonal problems. A significant number of women with excessive menstrual bleeding fall into this category. Hormonal imbalances occur when your body produces too much or not enough of certain hormones.
Aside from hormonal problems, there are many other causes of abnormal uterine bleeding. They include:• certain birth control methods, such as the copper-T intrauterine device (IUD) and birth control pills
• infection of the uterus or cervix
• uterine fibroids
• blood clotting problems
• some types of cancer, including uterine, cervical and vaginal
• chronic medical problems, such as hypo- and hyperthyroidism, liver disease, kidney disease and diabetes
Hysterectomy is the only treatment that completely guarantees heavy menstrual bleeding will end permanently. However, this is a radical surgery where your uterus is removed and you will no longer be able to have children.
Some premenopausal women don’t have periods at all. Called amenorrhea, or the absence of menstruation, this condition is normal before puberty, after menopause and during pregnancy. There are two kinds of amenorrhea: primary and secondary. Primary amenorrhea is diagnosed if you reach the age of 16 and haven’t yet begun to menstruate. Secondary amenorrhea is diagnosed if you’ve had regular periods, but they suddenly stop for more than three to six months.
Pain from menstrual cramps is caused by contractions of your uterus triggered by prostaglandins, hormone-like substances found in many types of tissue.
Both medication and surgery can be used to treat AUB. Typically, less invasive therapies should be considered first. Treatment depends on your age, desire to preserve fertility and the cause of the bleeding.
Premenstrual syndrome (PMS) is a term commonly used to describe a range of severe physical and psychological symptoms that some women experience about five to seven days prior to the start of their periods and end just after. To qualify as PMS symptoms, they must be associated with the menstrual cycle, become more severe as the menstrual cycle progresses and be present for at least three consecutive menstrual cycles.
Premenstrual dysphoric disorder (PMDD) is different from the more common PMS; it’s far more severe. Women who experience PMDD (about 3 to 8 percent of all women) say that it significantly interferes with their lives. The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women.

Key Q&A

How is abnormal uterine bleeding (AUB) defined? Is my condition serious enough to be considered AUB?Abnormal uterine bleeding refers to menstrual periods that are abnormally heavy, prolonged or both. The term may also refer to bleeding between periods or absent periods.
I used to have regular periods, and they’ve suddenly disappeared over the past few months. Is this something to be concerned about?This condition, called secondary amenorrhea, can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness. Also you may experience secondary amenorrhea because of problems affecting the pituitary, thyroid or adrenal gland. This condition can also occur if you’ve had ovarian cysts or have had your ovaries surgically removed. You should consult with a health care professional to determine what is causing you to skip periods.
Is there a certain age group of women who are more likely to have problems with AUB?Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, for a few years before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
Can AUB be a problem for me if I’ve already gone through menopause?If you are post-menopausal, any uterine bleeding is considered abnormal and should be evaluated by a health care professional as soon as possible.
Aside from excessive or lengthy bleeding, what other problems can be described as AUB?Other types of AUB could include:
absence of periods (no bleeding)
bleeding between regular periods
spotting
What are my treatment options for AUB?Generally, both medications and surgery are options. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural).
Is PMS (premenstrual syndrome) a problem I have to learn to live with every month or is there anything I can do to relieve my symptoms?PMS is not a disease but a collection of symptoms. Still, there are many things you can try to alleviate your pain, discomfort and emotional distress. They include dietary changes, exercise and medication options . Ask your health care professional for more information.

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Ocular Allergies

Overview

While most people associate allergies with runny noses, sinus congestion, hacking and sneezing, in fact allergies can affect various organs, including the eyes. Because the eyes are often a significant component of your allergies, they deserve specific attention and treatment.
Many who have ocular allergies experience itching as the primary source of discomfort, though some people have no itchiness but instead experience a burning sensation and “eye fatigue” that causes them to rub their eyes. Other common symptoms include redness, lid swelling, tearing, light sensitivity, “grittiness” and swollen eye. On the other hand, if you have dryness, stinging and the feeling that there is a foreign body in your eye, you likely have dry eye syndrome.
Beyond being annoying, ocular allergies may be disabling. Allergic symptoms typically occur when allergy sufferers are in situations that put them in close contact with allergens to which they are sensitive, such as mowing the lawn, spending time outdoors or playing with pets. Thus, it can affect your ability to engage in these activities, as well as your efficacy at work and school. Beyond activities, however, appearances may become a major quality of life factor. For allergy sufferers, red eyes and puffy eyelids can be bothersome because they give the appearance of fatigue or perhaps even illness or substance abuse.
Dry eye sufferers typically feel “tired eyes.” Their symptoms affect them most in computer work, reading or TV watching.
Eye allergies are anything but rare. In the United States, an estimated 20 percent of the population suffers from them, and the incidence appears to be on the rise. Some researchers believe that our increasingly clean, modern society—which no longer requires our bodies to fight off multiple childhood infections—has caused our immune systems to shift from an infection-fighting stance to more of an allergic stance. (Infection-fighting and allergies are opposites as far as the immune system is concerned). When the body’s immune system becomes sensitized and overreacts to substances such as seasonal pollens and pet allergens, an allergic reaction can occur whenever they come in contact with your eyes.
So while many people enjoy the spring and fall, millions of others frequently live in dread of those times when the trees, grass and weeds begin to pollinate. People who are sensitive to these allergens experience seasonal allergic conjunctivitis, the most common type of eye allergy. Conjunctivitis refers to a part of the eye called the conjunctiva that becomes inflamed when triggered by an allergen. All the signs and symptoms of allergy—itching, redness, tearing and inflammation—occur when someone who is sensitive is exposed to allergens such as pollens, molds, house dust mites, animals and insects.
The reason the eyes are so sensitive to these substances is that they, like the skin, are exposed, unprotected surfaces that are especially vulnerable to allergens and other irritants. Allergens cause cells in the eye, called “mast cells,” to release histamine and other substances or chemicals that cause blood vessels to dilate, mucous membranes to itch, and the eyes and eyelids to become inflamed. Tearing may also occur. Symptoms can range from mild eye annoyance to severe itching with major effects on the tissues inside the eyes. When the blood vessels expand, this allows for a greater flow of inflammatory and allergic molecules from the bloodstream into the eye, the site of the allergic reaction. This causes the redness and swelling of the eye. The itching is triggered by histamine binding to nerve cell receptors.
To avoid allergens, some patients have to stay indoors and lose time from school or work. Yet taking shelter is not always the answer. Some people must be outdoors for work or other daily activities. Additionally, some allergens reside indoors. Pet dander, dust mites and molds are common indoor allergens that can trigger symptoms for some people year round, causing perennial allergic conjunctivitis.
There are several more severe, although rare, forms of allergy, such as atopic keratoconjunctivitis (AK) and vernal keratoconjunctivitis (VK). These conditions may lead to corneal ulcers. However, the vast majority (80 to 90 percent) of eye allergies are caused by seasonal and perennial allergic conjunctivitis.
Ocular allergies may be further classified as either acute or chronic. An acute reaction occurs with intermittent exposure to an allergen, such as is often the case with seasonal allergic conjunctivitis, which may occur only at the height of pollen season. Chronic reactions occur with persistent exposure to allergens and are more likely to occur in perennial allergic conjunctivitis.

Diagnosis

To make the diagnosis, your eye care professional must identify the type of allergic condition you are experiencing. The eye care professional begins by asking you questions to create a thorough medical history for you and to rule out the possibilities of other eye problems. In particular, your doctor will ask you to describe your symptoms and when they occur most frequently. The main indication of ocular allergies is itching, often accompanied by redness, swelling of the conjunctiva (the transparent membrane covering the eyeball and undersurface of the eyelid), eyelid swelling, light sensitivity, “grittiness,” and sometimes tearing or mucus. Some people have no itchiness but experience a burning sensation and “eye fatigue” that causes them to rub their eyes.
The health care professional will examine your eyes thoroughly, looking for some of the classic signs of ocular allergy: fluid inside certain tissue layers in the eyes, more than normal visible redness of the blood vessels in the eyes, droopy or puffy eyelids and mucus discharge. In some people, congestion of the blood vessels in and around the eyes can cause dark circles to form around the eyes, called “allergic shiners.” Eyelid swelling is also a sign of seasonal allergic conjunctivitis that can have permanent effects on the skin surrounding the eye. The acute reaction can cause rapid swelling and gradual “deflation,” which, over time and repetition, can damage the collagen fibers and thin skin surrounding the eye, lending the appearance of drooping, wrinkly or sagging eyelids.
Many people also have itchy and runny noses. Some doctors may take a sample of your eyes’ tears for laboratory analysis to help identify what is causing your eyes to have an allergic response. It is important for the doctor to determine that you are indeed having an allergic reaction. Other eye problems can cause similar symptoms, including viral or bacterial conjunctivitis, dry eyes or a condition called blepharitis, which occurs when tiny oil glands located near the base of the eyelashes malfunction. If you do not respond to treatment, you should be treated by a specialist such as an allergist/immunologist or an ophthalmologist.
Although the seasonal and perennial allergic conjunctivitis discussed above are the most common types of eye allergies, there are also four other types, which, as mentioned above, are rare. While seasonal and perennial allergic conjunctivitis represent 80 to 90 percent of ocular allergy cases, the severe forms described here make up the remaining 10 to 20 percent.
Vernal keratoconjunctivitis usually occurs in adolescent boys, with symptoms first appearing between the ages of 3 and 20. It is typically a seasonally recurring disease, not typically present perennially. Often, children who suffer from eczema, asthma or sinus allergies will find themselves experiencing eye allergies as well. The symptoms are similar but more severe than those of allergic conjunctivitis, including intensely itchy eyes that burn and feel as if something has entered the eye to irritate it. Light sensitivity and blurred vision may be present. This condition is considered to be potentially vision threatening.
Atopic keratoconjunctivitis usually occurs in adults who are highly sensitive to allergens and is associated with asthma, rhinitis, skin rashes or food allergies. Patients usually have the same signs and symptoms as those with the more common types of eye allergies, except that these patients have perennial inflammation and are at risk for cataracts or conjunctival and corneal scarring. There is usually lid swelling, particularly on the lower lid, and the skin is scaly and wrinkled. Corneal ulcers may form.
Contact lens-associated papillary conjunctivitis, also called giant papillary conjunctivitis, or GPC, is a reaction to ill-fitting contact lenses, contact lens overuse or to their solutions. People who wear disposable or gas permeable lenses are less likely to develop this reaction. It is not a true allergy. Early symptoms include blurred vision from the accumulation of deposits on the contact lens surface, itching and mucus discharge from the eyes, especially following sleep. Over time, you may be unable to tolerate the lenses in your eyes.
Contact ocular allergy or toxic keratoconjunctivitis can result from a reaction to medications used in or around the eye, such as antibiotics and antivirals and other medications. It may also result from other types of substances, such as preservatives in some eyewashes and eyedrops, or from chemicals found in cosmetics and hair spray, when used excessively. Fluid in and around the eye is a typical sign, and the skin around the eyes and eyelids may show signs of an allergic reaction (redness, puffiness and/or vertical wrinkles). Symptoms improve when you stop using the product that is causing the problem.

Treatment

The treatment of ocular allergies is based largely on the degree to which symptoms interfere with quality of life. The more severe the symptoms, the more likely they are to interfere with everyday activities. The first step is to be evaluated by an allergist to identify the allergens causing your symptoms and to be educated by the allergist on how to avoid or remove the allergens that are creating the problem.
Some people find that applying cold compresses to the eyes is very soothing. That’s because the compresses cause vasoconstriction, or a reduction of inflammation in the eye’s blood vessels. Artificial tears, cooled by storing in a refrigerator, might produce similar results. It may also be necessary to avoid wearing contact lenses. Treating any associated eyelid problems, such as rashes or eczema, with lid scrubs and topical antibiotics may also help.
It may be necessary to get symptoms under control quickly by using a more aggressive approach. Following is a list of medications that are sometimes used.
Over-the-Counter Medications
Artificial tears are extremely safe and can be used at any age. The use of lubricants or saline washes helps to remove allergens from the eye’s surface to relieve mild symptoms. However, artificial tears contain no pharmacologically active ingredients to specifically combat the allergic reaction. Instead, these products mimic the soothing properties of natural tears and provide fast relief. If your eyes are especially sensitive, you might consider using preservative-free products, which may be helpful for patients complaining of both allergy and dry eye symptoms or “itchy, burny” eyes.
Over-the-counter eyedrops, which frequently contain decongestants and antihistamines, are used by many people for short-term relief of some symptoms. They also help to reduce redness by constricting conjunctival blood vessels. However, they may not relieve other symptoms. Another shortcoming is that some may only be used for short periods, no more than four times a day for no more than two to three days. Prolonged use may worsen your symptoms, causing more swelling and redness that persists even after you stop using the drops. Tachyphylaxis, or a rebound effect, sometimes occurs with the use of other decongestants as well, such as nasal sprays. Although initially they seem to relieve stuffiness, after a few days your nose feels stuffier than ever. It’s especially important to note that if you have heart disease, arteriosclerosis or narrow angle glaucoma, some eyedrops may pose a danger to your health. Nonsteroidal anti-inflammatory eyedrops may also work to relieve the itching associated with ocular allergies. You may need to use these drops four times a day, however, and they may cause burning or stinging when you first put them in your eyes. Your health care professional can tell if the solutions you are using might jeopardize your health or worsen your condition.
Over-the-counter oral antihistamines, available in both liquid and pill forms, can relieve itching slightly, but at the same time may cause dry eyes, worsening eye allergy symptoms. Side effects are sometimes very unpleasant and can include drowsiness, agitation, dizziness or poor coordination. These should not be used as primary therapy for ocular allergy. Direct, topically applied ophthalmic medication is a much better treatment. If you’re taking over-the-counter oral antihistamines for nasal symptoms, consider adding an eyedrop to adequately address eye ocular complaints. An eyedrop can aid in treatment of nasal symptoms as well.
Prescription Medications
Antihistamines are available in both oral and topical forms. Topical antihistamines come in the form of eyedrops and are sometimes preferred over oral forms because they are applied directly to the eye and act more rapidly. Eyedrops are less likely to cause side effects because they are not taken into the body systemically as oral medicines are. Antihistamines provide quick relief, though sometimes only for a few hours. Some of the oral prescriptions are formulated to be non-sedating and so do not cause the drowsiness of over-the-counter formulations, but they still can cause some drying effect on the eyes, contributing to or worsening symptoms of dry eyes. Some topical antihistamines need to be reapplied four times a day. They last about two hours, but shouldn’t be taken more than four times a day, so it could be difficult to get daylong coverage for your allergies if you’re relying solely on ophthalmic antihistamines.
Combination mast cell stabilizers and antihistamines are the most recently developed drugs available for topical ophthalmic treatment of allergic conjunctivitis. They combine the mechanisms of both an antihistamine and a mast cell stabilizer in a single drug. This allows for rapid blocking of the histamine receptors on nerves and blood vessels that are the cause of the itching and redness of allergy, as well as stabilizing the mast cells to prevent further release of substances/molecules that would induce further allergic reaction. Dosing is typically two times a day. Drugs in this class include olopatadine (Pataday, Patanol), azelastine (Optivar) and nedocromil (Alocril, Lastacaft).
Second-generation mast cell stabilizers work to prevent those cells from releasing the substances responsible for itching and, if chosen as allergy therapy, must be used regularly to prevent problems in people with seasonal allergic conjunctivitis. Mast cell stabilizers are not thought of as a fast-acting choice for allergic conjunctivitis. In fact, it usually takes two weeks, using them twice a day, before they reach their peak effectiveness. Additionally, they require regular, consistent dosing throughout the allergy season, not just when an acute attack occurs.
Corticosteroids tend to be prescribed carefully, using the minimum dose and mildest type of steroid for the shortest possible time. One topical corticosteroid, loteprednol etabonate (Alrex, Lotemax), is prescribed when a rapid response to treatment is necessary and other drugs have not worked. Corticosteroids should never be used for any length of time, as they have been linked to cataracts, glaucoma and superinfections of the eye’s surface.
Allergy shots, or immunotherapy, are sometimes used when other therapies do not help control your symptoms. These shots inject increasing amounts of the allergens that are affecting your eyes into your body to help curb your eyes’ reaction. The treatment usually takes several months to achieve maximum results.
Selecting the Proper Treatment
Your health care professional will recommend or prescribe the medication needed to treat the symptoms that are most troublesome to you. The most common and most effective medications used to treat ocular allergies are topical—that is, they are applied as eyedrops directly to the surface of the eye. Topical medications offer several advantages. They are noninvasive and deliver medication directly to your eyes where it can be speedily absorbed. This also reduces the risk of side effects within other parts of your body because the drug is not absorbed throughout your system the way an oral drug would be. The effect of a topical eyedrop depends on several factors, including the size of the drop, the size and condition of the eye and your willingness to consistently use it as directed.
Some medications are safe for children but others are not, so be sure to read the packaging information carefully before offering your children any type of medication. Medication available by prescription should, of course, be used only by the individual to whom it was prescribed and not shared with any others.
Your health care professional may recommend more than one medication for you. In that case, be sure to administer eyedrops or ointments at least five minutes apart to allow enough time for your eyes to absorb each medication and to prevent one drug from diluting the other. In addition, contact lens wearers should carefully follow instructions regarding medication instillation prior to lens insertion, typically a 15-minute wait between medication and lens insertion. If you are using a solution and an ointment, use the solution first, followed by the ointment, since an ointment can prevent the drops from entering the eye.

Prevention

The best way to prevent eye allergies is to avoid the source of the allergen. Once you and your eye care professional identify what substances are triggering your allergies, you can take steps to reduce contact with them. Take the following environmental control measures to minimize contact with pollens, molds and other substances.
Close windows and doors.
Avoid window or attic fans.
Reduce outdoor exposure to allergens by staying indoors when allergens are at their peak, usually in the morning.
Shampoo and shower following outdoor exposure to allergens.
Stay away from damp areas, such as a basement, that may harbor molds.
Avoid lawn mowing or raking leaves.
Minimize humidifier use to reduce the spread of molds.
Wash bedding in very hot water (at least 130 degrees F) frequently and dry in a hot dryer so that dust mites don’t proliferate. Use allergen-proof covers for pillows, mattresses and box springs.
Stay away from curtains or drapery that may harbor dust.
Remove stuffed toys from children’s reach.
Avoid furry animals.
Avoid irritants such as tobacco smoke, perfume, potpourri, chalk dust and markers.
You can take a number of additional measures. For example, try not to rub your eyes, even though they may itch horribly. Rubbing the eyes can worsen the allergic reaction. Your condition may clear up more quickly if you don’t rub.

Facts to Know

Twenty percent of people in the United States suffer the discomfort of eye allergies.
Steroids are sometimes used to treat eye allergies, but they carry a much greater risk of short- and long-term side effects than other therapies, including risks for glaucoma and cataracts. Steroid use should be reserved only for cases that do not respond to other treatment and for severe forms of allergy.
The most effective way to treat the eye is with eyedrops. If you’re taking a pill for nasal allergy symptoms, consider adding eyedrops to more effectively and specifically treat the ocular complaint.
Combination mast cell stabilizers and antihistamines, which combine mechanisms of both antihistaminic and mast cell stabilization in a single drug, are the most recently developed drugs for topical treatment of ocular allergies.
More and more people seem to be suffering from allergies these days. The exact reason why is unclear, but some researchers believe that our clean, modern society no longer requires us to fight off multiple childhood infections, thus causing our immune systems to take on a more of an allergic stance

Key Q&A

What are ocular allergies?Common things in the environment such as dust or pollen irritate some people’s eyes. These substances are called “allergens,” and they can cause symptoms such as itching and swelling in the eyes. This reaction is usually centered in a part of the eye called the conjunctiva, which becomes inflamed when triggered by a substance that a person is especially sensitive to. An ocular allergy can happen suddenly or some time after you come in contact with the allergen.
The most common form of ocular allergy is seasonal conjunctivitis. When a susceptible person is exposed to allergens from the environment, such as pollens in the fall and spring, they experience seasonal conjunctivitis. However, some people suffer year round from perennial allergies caused by other substances such as molds, house dust mites, animals and insects. They may have chronic allergies, which occur with persistent exposure to allergens, or acute attacks from intermittent exposure to these triggers.
Are there any other types of eye allergies besides seasonal and perennial?Yes, though these severe forms of ocular allergy are rare. Vernal keratoconjunctivitis usually occurs in adolescent boys who suffer from eczema, asthma or sinus allergies. Atopic keratoconjunctivitis usually occurs in adults who are highly sensitive to allergens associated with asthma, rhinitis, skin rashes or food allergies. Contact lens-associated papillary conjunctivitis appears to be an allergic reaction to contact lenses or their solutions. Contact ocular allergy or toxic keratoconjunctivitis can result from a reaction to medications used in the eye, such as antibiotics and antivirals.
What happens when allergens affect the eyes?When your eyes come in contact with something your body considers foreign—such as pollen, dust or pet dander—special cells in your eyes go on alert. These cells then release different kinds of chemical substances that can cause your eye allergy symptoms. This does not happen in all individuals, but only those who have been “sensitized” to these specific foreign substances.
Can cigarette smoke cause eye allergies?Although cigarette smoke, diesel exhaust and other environmental substances may cause your eyes to become inflamed and irritated, they do not trigger an allergic response. But they can make your allergy symptoms worse.
How do I know if I have eye allergies?Itching is the symptom that allergy sufferers complain about most. Other common reactions are redness and watery eyes. You may also have swelling, puffiness or throbbing. Some people find that their allergies make their eyes very sensitive to light. However, they only way to be certain that you are having an allergic response instead of some other type of eye problem is to visit your eye care professional for a diagnosis.
How can I prevent eye allergies?The best way to prevent eye allergies is to avoid the source of the allergen. Once you and your health care professional identify which substances are triggering your allergies, you can take steps to reduce contact with them.
The nonprescription medicines I am buying are not helping enough. What else can I do?Many new therapies are available to help relieve the symptoms of eye allergies and even to prevent them. Discuss the options with your eye care professional, who can tell you which medication is best for you.
What is the most common treatment for eye allergies?An effective allergy medication specifically aimed at halting ongoing symptoms and preventing future symptoms of allergy is best. Today, this would be the dual-action agents (antihistamine/mast cell stabilizers).
Topical antihistamines, usually in combination with decongestants, are another treatment option. They act quickly and effectively to block allergen receptors. However, they may need to be used up to four times a day.
Do allergy shots help eye allergies?Allergy shots, or immunotherapy, are sometimes used when other therapies do not help control your symptoms. However, they can take months to work and therefore are not typically the first choice for treatment.

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Metabolic Syndrome

Overview

Metabolic syndrome is not a disease, but a clustering or “constellation” of health markers. Although there are several definitions of what is required to be diagnosed with metabolic syndrome, in the United States most health care professionals use criteria from the National Heart, Lung, and Blood Institute (NHLBI) and the American Heart Association.
That definition says you must have at least three of the following five markers to be diagnosed with metabolic syndrome:
A waist measurement of more than 35 inches around (more than 40 inches in men).
A fasting blood glucose level of 100 mg/dL or higher; or you’re already taking medication because you have high blood glucose levels.
A triglyceride level at or above 150 mg/dL. Triglycerides are a form of fat in your blood.
An HDL cholesterol level (the “good” cholesterol) below 50 mg/dL (below 40 mg/dL in men); or you’re already taking medication to increase your HDL level.
A blood pressure at or above 130 mm Hg systolic (the top number) or 85 mm Hg diastolic (the bottom number); or you’re already taking medication to treat high blood pressure.
According to the American Heart Association, 47 million Americans have metabolic syndrome, although many may not know it. Metabolic syndrome is a concern because it is linked to several health conditions, particularly heart disease and diabetes. Although rates of metabolic syndrome are the same in men and women, women with a condition called polycystic ovary syndrome (PCOS) are up to 11 times more likely to have metabolic syndrome than those without PCOS.
Additionally, rates of metabolic syndrome increase with age, occurring in about 45 percent of those aged 60 to 69. Researchers have discovered the risk of metabolic syndrome in women begins to rise around perimenopause, which seems to be related to increases in testosterone at that time.
The reason so many Americans have metabolic syndrome is related to three things: weight, lack of exercise and genetics.
However, while you’re more likely to have metabolic syndrome if you’re overweight, not everyone who is overweight has it. And you can have it even if you are not overweight. Estimates are that about 22 percent of overweight and 60 percent ofobese people have metabolic syndrome, with the risk thought to be directly related to the amount of abdominal fat. Abdominal, or visceral, fat is defined by your waist circumference. Later, we’ll talk more about why this increases your risk for certain diseases.
You also have a higher risk of metabolic syndrome if you’re Hispanic or South Asian (from the Indian subcontinent), don’t get much or any exercise and follow a high-fat diet, particularly one high in fried foods, carbohydrates and so-called “empty calories” like soda. Conversely, following a diet high in whole grains and unsaturated fats, as well as mild-to-moderate alcohol consumption, can reduce your risk.
Metabolic syndrome can also be a side effect of antipsychotic medications, especially the drug clozapine (Clozaril).
Even as the incidence of metabolic syndrome is increasing in adults, it is also rising in adolescents. Today, about 9 percent of adolescents over the age of 12 fit the definition of metabolic syndrome. This includes 19 percent of Native Americans and 13 percent of Mexican-Americans. The more overweight teens are, the more likely they are to have metabolic syndrome. For instance, 39 to 50 percent of those considered obese for their age have metabolic syndrome.
Although you’re much more likely to have metabolic syndrome if you’re overweight or obese, you can have it even if you have a normal weight. The most important risk factor is the amount of fat around your abdomen, called visceral fat. This visceral fattends to accumulate more in women after menopause.
Visceral fat produces hormones and other chemicals that change the way certain systems in your body work. For instance, they increase the amount of inflammation in blood vessels, which can lead to a buildup of plaque on vessel walls. Eventually, pieces of plaque can break off and clog blood vessels, or blood clots can form and clog vessels, causing a heart attack.
Studies find that your risk of cardiovascular disease (CVD) doubles if you have metabolic syndrome, and you are more likely to die from CVD if you have metabolic syndrome. Additionally, you are significantly more likely to develop atherosclerosis, a buildup of plaque in your coronary arteries that contributes to heart disease, stroke and peripheral vascular disease (PVD).
Components of metabolic syndrome also lead to insulin resistance. Insulin is a hormone required to get cells to open up and let glucose in. Insulin resistance occurs when cells don’t have enough insulin receptors (the “lock” into which the “key” of insulin fits), or the insulin receptors don’t work properly. Maybe they’re not formed right or maybe they’re just stubborn and won’t let glucose into the cells. That’s why they’re called “resistant” to insulin. The result? Glucose builds up in your bloodstream. Eventually, this can turn into type 2 diabetes.
While metabolic syndrome is not a direct cause of diabetes, it is a strong predictor of the disease. If you have metabolic syndrome, your risk of developing diabetes is two and a half to four times greater than someone who does not have the condition. And the more risk factors you have for metabolic syndrome, the more likely you are to develop diabetes.
Researchers are also finding links between metabolic syndrome and nonalcoholic fatty liver disease (NAFLD), chronic kidney disease, dementia and obstructive sleep apnea.

Diagnosis

Metabolic syndrome is a very complicated condition to diagnose. The only visible symptom of metabolic syndrome is being overweight, but that is no guarantee that you’ll have the condition. And you can have metabolic syndrome even if you aren’t overweight.
There are at least six definitions for metabolic syndrome. The primary one used in the United States comes from the National Heart, Lung, and Blood Institute (NHLBI). The chart shows the differences among the definitions.
The WHO, for instance, requires evidence of insulin resistance or diabetes to make a diagnosis of metabolic syndrome, while the IDF requires a certain degree of abdominal obesity. The NHLBI, however, considers the five components equal in importance. The WHO’s definition is designed to identify people at greater risk for diabetes; while the NHLBI’s definition is designed to identify those with greater risk for cardiovascular disease (CVD).
In the United States , there’s general agreement among medical professionals to use the NHLBI definition, in part because it’s so difficult to test individuals for insulin resistance in the typical health care provider’s office.
The reality, however, is that any one of the five risk factors increases your risk of cardiovascular disease whether you have metabolic syndrome or not. So whether you have one or all five of the components, you and your health care professional need to work together to reduce that risk and any others you may have.
To diagnose metabolic syndrome, your health care professional should measure the five components involved in the condition: blood pressure, blood triglyceride level, HDL cholesterol level, waist circumference and fasting blood glucose level. You will need to fast for at least 12 hours before the blood tests.
If you have polycystic ovary syndrome, or PCOS, you should ask your health care professional to evaluate you for metabolic syndrome. This condition affects between 6.5 and 8 percent of women of childbearing age. Typical symptoms include irregular or absent menstruation, obesity and hair on the face and other parts of the body where women typically don’t have much hair, a condition called hirsutism. Women with PCOS also often have high levels of testosterone and often have trouble getting pregnant.
Some research finds that women with PCOS are up to 11 times more likely to have metabolic syndrome. What we don’t know is whether the components of metabolic syndrome cause the PCOS or vice versa. But women with PCOS tend to be overweight, have insulin resistance, have high levels of fasting blood glucose and, in fact, a much higher risk overall of cardiovascular disease and diabetes.

Treatment

The cornerstone of treatment for metabolic syndrome is simple: improving your diet, restricting calories, losing weight and/or maintaining a normal body weight and increasing levels of physical activity. Losing as little as 5 to 10 percent of your body weight can reduce blood pressure and insulin levels and decrease your risk for diabetes.
Don’t try a crash diet, however; they don’t work. Instead, the best approach is to reduce your total calories. You can cut out 500 calories a day, for instance, simply by skipping that Frappuccino and cutting out one large soda.
Cutting calories isn’t enough, however, if you’re after long-term weight loss. You also have to change the way you eat and view food. That means setting goals for weight loss, planning meals, reading labels, reducing portion sizes and avoiding eating binges. Measuring and cutting calories can be complicated, so you might try simpler techniques like setting aside 10 percent of your meal before you even start. You’ll eat less and not even notice the difference.
And you don’t have to lose a lot of weight; aim for 5 to 10 percent of your weight over six to 12 months. If you weigh 200 pounds, that’s a loss of 10 to 20 pounds, enough to change the way you look and feel and improve many of those metabolic markers.
Even if you’re not aiming to lose weight, you should change your diet. Studies find a diet high in saturated fat, simple sugars and cholesterol contributes to metabolic syndrome. Reducing the amount you eat while increasing the fruits, vegetables and whole grains in your diet is best.
Several specific dietary strategies are recommended for the treatment of metabolic syndrome, including the following:
The Mediterranean Diet, which is high in fruits, vegetables, nuts, whole grains and olive oil. In a study that compared the Mediterranean diet with a standard low-fat diet, participants who ate the Mediterranean experienced greater weight loss, lower blood pressure, lower markers of inflammation and improved insulin resistance and lipid profiles.
The D.A.S.H. diet, which includes a sodium intake of less than 2,400 mg per day and a higher dairy intake than the Mediterranean diet. When compared with a weight-reducing diet that emphasized healthy food choices, the D.A.S.H. diet resulted in greater improvements in fasting glucose, triglycerides and diastolic blood pressure, even after controlling for weight loss.
A low-glycemic diet, which includes foods with a low glycemic index and replaces refined grains with whole grains, fruits and vegetables and eliminates high-glycemic beverages. A low-glycemic diet appears to be particularly beneficial for people with metabolic syndrome; however, experts aren’t sure if it is the low glycemic index itself or the increase in high-fiber foods that produces the beneficial effects.
Now on to the second part of the equation: exercise. When you exercise, your cells become more receptive to insulin. Even if you don’t lose weight, regular exercise (a 30-minute walk a day) can make a huge difference in improving most, if not all, of the risk factors for metabolic syndrome.
Although lifestyle changes are the simplest and most effective way to improve all five risk factors associated with metabolic syndrome, in some instances your health care provider may also prescribe medication to treat the individual components of metabolic syndrome.
To improve insulin resistance, for instance, your health care professional may prescribe medications such as metformin (Glucophage), pioglitazone (Actos) and rosiglitazone (Avandia). In fact, studies find that metformin can help prevent diabetes in people with prediabetes.
If you have both high blood pressure and metabolic syndrome, make sure your health care professional knows you have the syndrome. Large doses of some commonly prescribed blood pressure drugs, such as diuretics and beta-blockers, can make insulin resistance worse. ACE inhibitors such as enalapril (Vasotec) and benazepril (Lotensin) and angiotensin receptor blockers like losartan (Cozaar) seem to work best in patients with diabetes.
While there aren’t many drugs that can raise HDL cholesterol, your health care professional may still prescribe a statin, particularly if your LDL cholesterol levels are high; statins can improve HDL cholesterol somewhat. Additionally, if your 10-year risk of heart disease is high, you may want to talk to your health care professional about aspirin therapy. You can learn more about your risk of heart disease atwww.nhlbi.nih.gov/guidelines/cholesterol/risk_tbl.htm.
Drugs may be prescribed in combination with a healthy diet to reduce high triglycerides. Prescription drugs include omega-3 fatty acids (Lovaza) and the fibrates gemfibrozil (Lopid) and clofibrate (Atromid-S). Talk to your health care provider about the risks and benefits of these drugs, based on your personal medical history.
Generally, your primary care physician—family practitioner or internist—will treat the components of metabolic syndrome, although you may also need to see an endocrinologist, a doctor who specializes in diseases like diabetes that are related to hormones.

Prevention

The best way to prevent metabolic syndrome is identical to the treatment for the condition: maintaining a healthy weight, incorporating at least 30 minutes of physical activity into your day and following a healthy diet high in fruits, vegetables and whole grains and low in sugar and fat. A good place to start is to have a conversation with your health care professional about weight management, weight-related health issues, your personal health risks and the health screenings you should be sure to have.

Facts to Know

Metabolic syndrome is not a disease, but a clustering or “constellation” of health markers.
To be diagnosed with metabolic syndrome, you must have three of the following:
Your waist measures more than 35 inches around (more than 40 inches in men).
Your fasting blood glucose is 100 mg/dL or higher; or you’re already taking medication because you have high blood glucose levels.
You have a triglyceride level at or above 150 mg/dL.
Your HDL cholesterol level (the “good” cholesterol) is at or below 50 mg/dL (at or below 40 mg/dL in men); or you’re already taking medication to increase your HDL level.
Your blood pressure is at or above 130 mm Hg systolic (the top number) or 85 mm Hg diastolic (the bottom number); or you’re already taking medication to treat high blood pressure.
About 47 million Americans have metabolic syndrome, although many may not know it, according to the American Heart Association.
Women with a condition called polycystic ovary syndrome (PCOS) are up to 11 times more likely to have metabolic syndrome than those without PCOS.
The risk of metabolic syndrome increases with age. Researchers have discovered the risk of metabolic syndrome in women begins to rise around perimenopause, which seems to be related to increases in testosterone.
Although you’re much more likely to have metabolic syndrome if you’re overweight or obese, you can have it even if you have a normal weight. The most important risk factor is the amount of fat around your abdomen, called visceral fat. This visceral fat tends to accumulate more in women.
Metabolic syndrome significantly increases your risk of developing heart disease and diabetes and has been linked to liver disease, chronic kidney disease, sleep apnea and dementia.
The only overt symptom of metabolic syndrome is being overweight.
The best way to treat metabolic syndrome is by losing weight and maintaining a healthy weight, becoming physically active and following a healthy diet. This is the only thing you can do that will improve all health markers for metabolic syndrome.
Your health care professional may prescribe medication to treat the individual components of metabolic syndrome, such as antihypertensives for high blood pressure and certain anti-diabetes drugs to improve insulin resistance.

Key Q&A

Do I really need to worry about metabolic syndrome?While metabolic syndrome itself isn’t a disease that will make you sick or kill you, it is a sign that you have a much higher risk of other diseases that will, such as heart disease and diabetes. Think of it as a warning sign that it’s time to get serious about things like diet and exercise.
My friend’s doctor says that metabolic syndrome is very controversial among medical professionals. Why?Health care professionals don’t always agree on everything, and metabolic syndrome is one of those things. Some health care professionals don’t see the value in identifying the syndrome in patients, because it isn’t itself a disease; others feel that not identifying it is irresponsible, because it is associated with other diseases, perhaps down the line. Whether or not your health care professional gives you a diagnosis of metabolic syndrome, it is important that you are aware of its components, since any one of the five components can increase your risk of heart disease and/or diabetes.
How will I know if I have metabolic syndrome?Ask your health care professional to do the following: Measure your blood pressure and your waist circumference, perform a fasting blood glucose test and test your triglyceride and HDL cholesterol levels. If you have any three of the following—a waist measurement more than 35 inches around; a fasting blood glucose test level of 100 mg/dL or higher; a triglyceride level at or above 150 mg/dL; an HDL cholesterol level (the “good” cholesterol) below 50 mg/dL; or a blood pressure at or above 130/85 mm Hg—then you have metabolic syndrome.
Why isn’t there a single medication to treat metabolic syndrome?Because the markers for metabolic syndrome are so diverse, it’s doubtful one medication could address them all. However, medications are available for several of the individual components, including high blood pressure, high triglycerides and low HDL.
Why are exercise and diet so important in treating metabolic syndrome?When you follow a healthy diet and increase your physical activity, nearly every component of metabolic syndrome improves, even if you don’t lose weight. Exercise makes your cells more receptive to insulin, the hormone that “unlocks” cells to allow glucose inside; thus your blood glucose levels drop. Exercise also increases HDL cholesterol and reduces triglycerides and can reduce blood pressure. Changing your diet from one high in fat and sugar to one high in vegetables and fruits, along with whole grains and lean protein, also changes levels of blood fats like triglycerides while reducing blood pressure. Finally, both these things—more exercise and a better diet—usually lead to weight loss, even if you’re not trying! And weight loss will improve every parameter of metabolic syndrome.
Why are women with PCOS so much more likely to have metabolic syndrome?We know that women with PCOS, or polycystic ovary syndrome, a hormone disorder that can lead to infertility and diabetes, are up to 11 times more likely to have metabolic syndrome. What we don’t know is whether the components of metabolic syndrome cause the PCOS or vice versa. But women with PCOS tend to be overweight, have insulin resistance, have high levels of fasting blood glucose and, in fact, have a much higher risk overall of cardiovascular disease. The condition affects 6.5 to 8 percent of women of childbearing age, and most have one or more of the classic features: irregular or absent menstruation, obesity and hair on the face and other parts of the body where women typically don’t have much hair.

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