Dealing With Schizophrenics

Q: My brother is schizophrenic and suffers from delusions, hallucinations and hearing voices. He can become quite difficult to calm down when he has them. What is the right thing to do when he has one of these episodes? — Janet, Batu Caves.

Dr. Yen Teck Hoe :

Most families reported that a crisis or psychotic episode — that is, a severe break with reality — occurred a few months to a year after they began to notice unusual behaviour. Some said, however, that the crisis occurred with little or no warning.

During a crisis episode, your relative will exhibit some or all of the following symptoms : hallucinations, delusions, thought disorder, and disturbances in behaviour and emotions. No amount of preparation can fully protect you from the shock and dread you will feel when your relative enters this stage of schizophrenia.

Understand also that your relative may be as terrified as you are by what is happening : 'voices' may be giving life-threatening commands or delusions like 'snakes crawling on the window'.

You must get medical help for your relative as quickly as possible, and this could mean hospitalisation. If your relative has been receiving medical help, phone the doctor or psychiatrist immediately. Ask which hospital you should go to and for advice about what to do.

Try to remain calm, speak slowly and clearly in a normal voice. Too much emotion on your part can upset your relative further. Allow your relative to have personal 'space'. Do not stand over him or her or get too close.

Do not shout. If your relative appears not to be listening to you, it may be because other 'voices' are louder. Do not criticise. Your relative cannot be reasoned with at this point. Avoid continuous eye contact. Do not block the doorway.

It is far better, if possible, to have your relative go to the hospital voluntarily. Some have found that presenting their relative with a choice seem to work. 'Will you go to the hospital with me, or would you prefer that John take you?'

Such an approach may serve to reduce the person's feeling of helplessness. Offering choice, no matter how small, provides some sense of being in control of the horrible situation in which they find themselves in.

If your relative becomes violent during the psychotic episode threatening to harm him or herself, to hurt you, or to damage property, you must do whatever is necessary to protect yourself and others (including the ill person) from physical harm. Under extreme circumstances, it may be advisable to secure your relative in a room while you phone or go for help.


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Pesky Presbyopia

DO you often hold printed pages like this one at arm's length in order to read them clearly? Or do you routinely slip on a pair of non-prescription reading glasses, the sort you can pick up off a pharmacy rack, so you can read your Sunday morning papers?

Either way, if you are over 45, such habits most likely mean you are subject to a pesky aspect of ageing called presbyopia.

Oh My, Another -opia?

You might be familiar with the terms myopia (short-sightedness), and hyperopia (long-sightedness), but not presbyopia.

Short-sightedness is a condition where you have clear vision when viewing something close up, but blurry vision when viewing something far away. Long-sightedness is the opposite - clear vision when viewing things far away, blurry vision close up.

Presbyopia, on the other hand, is a condition where your 'near vision' i.e. your clear vision when viewing something close up gradually declines. Left alone, it can make near tasks like reading fine print or sewing difficult or impossible.

While near- and far-sightedness are caused by physical imperfections in the eye that are usually inherited (too much or too little curvature in the cornea, eyeballs that are too long or short), presbyopia develops as the lens of the eye ages and hardens.

In a normal eye, the cornea and lens focus light precisely onto the retina (the innermost, light-sensitive layer of the eye.) To do this, the lens needs to be flexible - when you look at something nearby, a ring of muscles around the lens contracts and your lens fattens, bringing the near object into focus; when you look at something far away, the muscle ring relaxes and your lens flattens, bringing the far object into focus.

The retina then sends coded signals to the brain, via the optic nerve, for interpretation. It is as if the retina asks the brain 'What am I reading?' and the brain answers 'Oh my, another -opia,' faster than you can blink.


In a presbyopic eye, the retina asks the same question, but the brain sees a blur because the lens can no longer bring the words into focus. So the presbyopic person compensates by moving the page further away from him (to the closest point he can focus on) or magnifying the image with visual aids like reading glasses or a magnifying glass.

Correcting presbyopia is a simple matter of seeing an optometrist and finding a pair of spectacles or contact lenses that works for you. Uncorrected presbyopia can lead to unecessary eyestrain or headaches after doing close work and the loss of near vision. Unfortunately, uncorrected presbyopia is all too common.

One Person in Six Has Presbyopia

A recent study on the prevalence of uncorrected presbyopia around the world, published in the Archives of Ophthalmology estimated 1.04 billion people suffered from the condition as of 2005.

There were a billion presbyopes in 2005, and in 2020 there will be a billion and a half. And that is because the population of the world is aging.

The average age of onset of presbyopia is 45. In temperate countries where UV light exposure is lower, it is later – about 48 in Finland. In countries nearer the equator, like Malaysia, where UV light exposure is higher, it can be as early as 30.

By 65, the condition is almost universal. As people live longer and longer, they can expect to live with the condition for longer and longer too (Malaysia's life expectance is now 74 - 71 for men, 76 for women).

A girl born today in Sydney, Australia has a 50% chance of living to 100. If a woman have lost the ability to read naturally by the age of 45, she have 55 years without the ability to read naturally.

Reading is not the half of it. According to the Global Impairment report, 517 million presbyopes either have no spectacles or have inadequate spectacles to correct their condition. As a result, 4 out of 5 of them are unable to perform necessary near tasks, resulting in lost income for individuals and lost productivity for countries.

Unsurprisingly, the majority of these vision impaired presbyopes come from the developing world where access to adequate eye healthcare is limited or unaffordable, or both. Fortunately, that is not the case here, so do not take those services for granted - take advantage of them instead.

Spectacles and Contact Lenses

An optometrist should say to someone who is presbyopic : 'You can have spectacles - reading glasses or multifocals; you can have one contact lens for near vision, one for distance vision (one monovision lens in each eye); or you can have multifocal contact lenses.

These days, we can get freedom from old-type spectacles; we can get more opportunities to be more active in our lifestyles, and presbyopic contact lenses are part of that revolution.

They are becoming more successful because they are more reproducible, have better oxygen permeability, and are better designed.

Seeing an Optometrist

Failure to see an optometrist regularly for something unthreatening like presbyopia may result in other, more threatening eye problems being missed e.g. glaucoma (leading cause of blindness worldwide), age-related macular degeneration (AMD, leading cause of blindness in elderly Americans), or diabetic retinopathy.

For adults, it is recommended a visit :

* Once every five years, or
* Once every two years if you have a family history of glaucoma, diabetes, hypertension, AMD, or a personal history of eye injury

Additionally :

* Have a 'baseline' check when you turn 40
* Up your frequency to every one to two years after age 60-65

Children should visit an optometrist :

* At least once when they enter primary school
* At least once when they enter secondary school

What Else Can You Do?

You can not prevent presbyopia, but you can hold it off for longer by protecting your eyes and vision :

# Use the right glasses, read in good light.

# Eat fruits, leafy greens, and other antioxidant-rich foods. Antioxidants help slow the oxidative stress of ageing in the eye.

# Say 'no' to UV light. Wear spectacles and contact lenses that have full UVA and UVB blockage (look for the World Council of Optometry seal of acceptance for UV blockers/absorbers.)

· Wear protective eyewear when your eyes are at risk e.g. when playing sports, mowing the lawn, or using toxic substances (look for 'ANSI Z87.1', a US standard of effectiveness in protecting against injury, on the lens or frame.)


More info on PREBYOSPIA here.

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Sleepwalking (Somnambulism)

by Dr. Milton Lum

Sleepwalking (somnambulism) is not uncommon among children and is a reason for a medical consultation. The children find themselves in a state of transition from one sleep cycle to the next, i.e. from non-rapid eye movement (NREM) to wakefulness.

During this transition state, there is a high arousal threshold, mental confusion and unclear perception.

It usually occurs in the first or second sleep cycle during the deeper stages of NREM sleep.

When the child awakens there is no recollection of the sleepwalking. It is sometimes associated with nonsensical talking. The child's eyes are often open with a characteristic 'looking right through you' appearance.

More Often in Children

As somnambulism occurs more often in children, there are suggestions that it is indicative of immaturity of the central nervous system.

It is estimated to occur in about 15% of children aged between 4 and 12. Somnambulism can sometimes start in their teens but is usually resolved by the late teenage years. How­­ever, it also occurs in adults.

Some children may hit objects while sleep­walking and injure themselves occasionally. The effects in adolescents and adults may be of more concern as there have been reports of behaviors like driving a car, cooking and eating, with consequent injuries.

Causes

There are several causes of sleepwalking. It is more common in identical twins and is 10 times more likely to occur if a first degree relative also sleepwalks.

In adults, the frequen­cy of sleepwalking increases during menstruation and pregnancy. Sleepwalking may be triggered by disordered sleep schedules, sleep deprivation, fever, stress and excessive alcohol consumption.

Certain medicines can cause sleepwalking. They include sleeping pills (hypnotics), allergy pills (antihistamines), antidepressants, some antibiotics (fluoroquinolone) and calming pills (tranquilisers).

Sleepwalking is associated with medical conditions like fever, nocturnal asthma or fits, abnormal heart rhythms (arrhythmias), regurgitation of food from the stomach into the oesophagus (reflux), psychiatric conditions (panic attacks and post-traumatic stress) and when there is temporary stoppage of breathing during sleep (obstructive sleep apnoea).

Somnambulism episodes vary and can range from walking quietly around a room to disturbed running. The patients may later tell of attempts to run away from dangerous situations. They have a typical clumsy, staring and dazed appearance with their eyes opened as they walk about.

When questioned, their responses are slow or absent with simple or non-sensical words uttered. There is no recollection of the event if the person returns to bed without awakening. Older children are more likely to be awakened at the end of the episode of somnambulism.

Night Terrors

Somnambulism has to be distinguished from night terrors (or sleep terrors) which are similar to somnambulism in that they occur in the first or second sleep cycle during the deeper stages of NREM sleep.

However, night terrors present with sudden screams associa­ted with a panic-like appearance. The eyes are opened wide, there is sweating and increased heart and respiratory rates. This may be follow­ed by movements such as running around the room.

By itself, night terrors are not dangerous but injuries to the child or others may result if the child is violent. Night terrors may occur for many consecutive weeks, stop completely and then recur later. They usually cease when the child reaches adolescence but may occasionally persist until the child is mature.

A similar condition is confusional arousals. They occur in the first or second sleep cycle during the deeper stages of NREM sleep. There are short episodes, lasting about 10 minutes or so, of disorientation, inconsolable crying and thrashing movements in bed.

The child typically does not remember the event. The condition is common in younger children. Attempts to awaken the child frequently prolong the episode.

However, if the child is awakened, the episode typically ceases. Unlike night terrors, there are no changes like sweating and increased heart and respiratory rates.

Diagnosis and Management

No treatment is needed in most instances of somnambulism because it is rarely an indication of a medical or psychiatric problem.

Somnambulism usually disappears in most children at puberty although it sometimes persist into adulthood. A medical consultation is advisable if it occurs frequently, if there is injury or if the behaviour is violent.

The doctor will carry out a physical examination to exclude any medical causes. Some­times, a specialist referral may be made for an assessment to determine whether a psychia­tric condition is the cause.

Reassurance is all that is needed in most instances. Several general measures can be taken by someone affected by somnambulism which includes getting sufficient sleep and avoiding any precipitating factors like visual, tactile or auditory stimuli just before bedtime.

To reduce the likelihood of injury, remove obstacles and sharp objects from the bedroom and avoid bunk beds. Lock windows and doors of the bedroom. It may be useful to have an alarm placed on the window or door.

Any underlying medical condition such as fever, nocturnal asthma or fits, cardiac arrhyth­mias, obstructive sleep apnoea, gastro-oeso­pha­geal reflux, panic attacks or post-trau­matic stress, would be treated appropriately.

Medicines are prescribed if there is a likelihood of injury, excessive sleepiness during the day, significant disruption of family life, and general measures have been unhelpful.

The medicines that have been reported to be useful are the benzodiazepines, tricyclic antidepressants and serotonin reuptake inhibitors. Low-dose clonazepam before going to bed for 3 to 6 weeks have also been reported to be usually effective. The medicines can be stopped after 3 to 6 weeks without recurrence of symptoms.

Other treatment like relaxation techniques and anticipatory awakenings have been reported to be useful.

These techniques are usually carried out by a psychologist. Antici­patory awakenings involve waking up the affected child about 15 minutes prior to the usual time the somnambulism occurs and keeping the child awake throughout the time the episode usually occur.

Somnambulism can be prevented by avoiding sleep deprivation, avoiding stress and avoiding alcohol consumption.


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Infant Diarrhoea

In essence, diarrhoea is not a disease. It is a symptom of an infection or illness. Infant diarrhoea is usually caused by infectious agents such as bacteria (shigella or Escherichia coli), viruses (rotavirus), and parasites. If these organisms enter your baby's body, his normal bodily functions may be affected. Diarrhoea is a reaction to these infections. It is usually acute, lasting not more than two days.

Is Your Baby Having Diarrhoea?

Your baby is having diarrhoea when there is a significant increase in the fluidity, frequency, and volume of his bowel movements compared to his usual bowel pattern.

Keep in mind that the frequency of your baby's bowel movement may be affected by his diet, and may not be an indication of diarrhoea, especially if you have changed his diet recently.

Breastfed babies usually have more frequent bowel movements than formula-fed babies. However, please be aware if your baby's stools appear very loose and watery as they are an indication that your baby may be having diarrhoea. In any case, consult your doctor immediately for clarification.

What Are The Dangers of Infant Diarrhoea?

Diarrhoea can sometimes be accompanied by vomiting, fever, loss of appetite, stomach pain/cramp, or a bloated stomach. If vomiting accompanies diarrhoea, your baby may experience rapid fluid loss.

This can lead to dehydration. Dehydration occurs when the body loses water faster than it can replace. It is accompanied by mineral loss and electrolyte imbalance.

Dehydration in infants is very dangerous and may be life-threatening if it is not countered quickly. Severe health problems may arise if your child is dehydrated.

Signs to Watch Out For

* Dry mouth
* Extreme thirst
* Sunken soft spot on top of baby’s head
* Dry, cool skin
* Sunken eyes
* Absence of tears when crying.

Consult your doctor if diarrhoea in your baby persists for more than 48 hours or if you notice any of the above symptoms.

Do not give medication to stop diarrhoea in your baby unless it is prescribed by the doctor. If your baby is experiencing mild to moderate dehydration, you can give him oral rehydration solutions (ORS) in small and frequent amounts to replace loss of fluids and minerals.

Zinc supplements may also be given by the doctor. Please ask your doctor for more information.

Know More About Rotavirus

In Malaysia, a study carried out in Hospital Kuala Lumpur and Sarawak General Hospital found that Rotavirus was the infective agent in 49% of the total number of children hospitalised for diarrhoea.

Rotavirus is a wheel-like virus and is one of the most common causes of gastroenteritis. Rotavirus gastroenteritis is the most common cause of diarrhoea among children under the age of five years.

If your baby is infected, he may also experience abdominal pain, vomiting, headache, fever, and chills.

The Rotavirus enters the body through the mouth, usually after consumption of contaminated food or water. Rotavirus gastroenteritis results in inflammation of your baby's intestinal lining as the virus replicates there. The virus causes damage to the villus, where nutrient absorption occurs. It impairs your baby's body's ability to absorb sodium, glucose, and water.

Prevention

The best way to protect your baby against Rotavirus is by giving him a vaccine during early infancy. It is given orally and the goal of this vaccine is to stimulate immunity from an early age so that your child's first encounter with Rotavirus will only cause a mild infection, or one without symptoms.


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World Alzheimer's Day on Sept 21

This year's flurry of educational events held in conjunction with World Alzheimer's Day will take place in over 50 countries and focus on : 'Diagnosing Dementia : See It Sooner'.

Why is early detection important? Because Alzheimer's is incurable, but appropriate care and medical treatment can slow its progression and improve patient quality of life.

The sooner it is detected, the sooner intervention can take place, and the better the outcome for patients, caregivers, and the community at large.

Stages of Alzheimer

Alzheimer is the most common cause of dementia (the loss of control of conscious mental processes) among older people, but it is not part of the normal ageing process.

In Alzheimer, nerve cells in the brain progressively die. At the same time, the brain produces less of the chemicals that allow nerves to communicate with each other.

As the parts of the brain typically affected first are those that store and retrieve new information, memory is usually affected first. Early stage patients may also experience difficulty in finding the right words and mood swings. Do not dismiss these symptoms as part and parcel of old age!

Later stage patients may suffer deeper lapses of memory and have difficulty understanding what they are told. They may forget daily living skills, undergo personality changes, or appear indifferent to those around them.

Advanced stage patients may become unable to speak, walk, and eat independently. Some lose their sense of time and place, and may wander off with no idea where they are headed or recollection of how they got there. Some lose their inhibitions and sense of propriety, and may undress in public or make inappropriate sexual advances.

Some drugs can slow disease progression and alleviate symptoms like depression, paranoia, insomnia, and hallucinations. But loving care, patience, understanding, and a safe, stable environment are what a patient needs most.

What You Can Do

* Attend a talk to learn more.

* Watch A Cup of Tea, a (very) short film produced by Alzheimer's Disease International at globalcharter.org/film.

* Contribute to Alzheimer's care. For example, at the Alzheimer's Disease Foundation Malaysia (ADFM) two centres, RM30/day pays one person's way, covering meals, daily activities, staff salaries, and maintenance.

Sign the Global Alzheimer’s Disease Charter if you feel all governments should promote awareness and understanding of Alzheimer’s; respect the human rights of people with the disease; recognise caregivers; provide patient access to health and social care; stress the importance of optimal treatment after diagnosis; and increase prevention by improving public health.


More info on ALZHEIMER here.

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Top 10 Causes of Bleeding After Sex

by Dr. Norashikin Mokhtar

There are a few things that can ruin a pleasant post-coital haze – one of them is if your partner immediately rolls onto his back and begins snoring. This can be frustrating, but it is surely not as frightening as going to the bathroom and discovering that you are bleeding!

Bleeding after sex can be due to a number of causes, and usually means that either the skin lining the cervix or vagina is thin or inflamed, or that there is a lesion on the cervix.

It is not to be taken lightly, so if you discover that you are bleeding after intercourse, do see a doctor as soon as possible. Below are the ten most common causes of bleeding after sex.

No. 10 Cervical Dysplasia

One cause of the bleeding could be cervical dysplasia, which means that there are abnormal cells growing on the surface of the cervix. This is a pre-cancerous condition and could lead to cancer if the abnormal cells are not removed.

You may be at risk of cervical dysplasia if you have multiple sexual partners, have sex before age 18, give birth before age 16, or have had a sexually transmitted disease.

Cervical dysplasia can be detected early if you go for regular pap smears. It can be treated with cryosurgery or conisation.

No. 9 Chlamydia

Bacteria is a common culprit of vaginal bleeding. Chlamydia is a type of bacterial infection that is usually sexually transmitted. Apart from bleeding, women with chlamydia may also have abnormal vaginal discharge or feel a burning sensation while urinating.

Chlamydia infection must be treated with antibiotics, or it may lead to future problems like pelvic inflammatory disease and even infertility. To prevent being infected, be sure to practise safe sex and use condoms.

No. 8 Gonorrhoea

Another sexually transmitted bacterial infection that could cause post-intercourse bleeding is gonorrhoea, sometimes called 'the clap'. Just like chlamydia, it can also cause other symptoms like vaginal discharge, burning and pain while urinating, and increased urination.

If the infection spreads, it can cause fever and severe pain in the lower abdomen.

Gonorrhea should be treated with the right type of antibiotics so that it does not cause complications that could lead to infertility.

No. 7 Vaginitis or Cervicitis

Inflammation and infection of the vagina, or of the cervix, could also lead to some bleeding. These conditions could be caused by a bacterial or fungal infection, which can be treated with antibiotics or antifungals.

Sometimes, cervicitis occurs after inserting a foreign device like a cervical cap or a diaphragm into the pelvic area. It can also be caused by an allergic reaction to contraceptive spermicides or to latex in condoms.

No. 6 Cervical Polyps

Sometimes you may have growths in your cervix called polyps. These are smooth finger-like growths that are red or purple in colour. They grow out of the mucous layer of the cervix or the cervical canal, and are extremely fragile.

The good news is, cervical polyps can be removed easily and painlessly by tying a surgical string around the base and cutting it off. The base can be then be removed with electrocautery or with a laser.

No. 5 Trichomoniasis

Another sexually transmitted culprit of bleeding after sex is trichomoniasis, a disease caused by a parasite. It can also cause discomfort during sex, vaginal itching, a greenish-yellow, frothy or foamy vaginal discharge with a foul or strong smell, swelling of the labia and itching of the inner thighs.

Rarely, trichomoniasis can be transmitted through tap water, hot tubs, urine, on toilet seats, and in swimming pools.

This infection can be treated with antibiotics. To prevent from getting it, practise safe and healthy sex.

No. 4 Yeast Infection

Occasionally, the bleeding could be due to a very common condition in women – a yeast infection caused by a fungus called Candida albicans. This infection occurs when the normal fungi that lives in the vagina overgrows and upsets the healthy balance of microorganisms in the vagina.

You may note that you have a yeast infection by the other symptoms, like itching and burning in the vaginal area, as well as an odourless, white vaginal discharge with a cheese-like texture.

You should see your doctor or gynaecologist for proper treatment, especially if it is your first yeast infection.

No. 3 Endometritis or Adenomyosis

Endometritis is the inflammation of the endometrium, which is the innermost layer of the uterus. Adenomyosis occurs when the tissue of the endometrium attaches itself to the uterus or the ovaries, and grows outside of the uterus.

Endometritis can cause other symptoms like general discomfort, fever, lower abdominal or pelvic pain, abnormal vaginal discharge, discomfort with bowel movement (constipation may occur) and an enlarged abdomen. Adenomyosis causes prolonged, heavy and painful menstrual bleeding.

Endometritis can be treated successfully with antibiotics, but adenomyosis may require a hysterectomy.

No. 2 Uterine Polyps

Polyps may also grow in the uterus, which occurs when the endometrium overgrows and protrudes into the uterus. Besides bleeding after sex, you may experience bleeding between periods, excessive or prolonged menstrual bleeding, bleeding after menopause and breakthrough bleeding during hormone therapy.

Uterine polyps can be removed surgically, where the doctor will use a hysteroscope to see inside your uterus and cut away the polyps.

No. 1 Fibroid Tumours

Although the word 'tumour' often means cancer, this is not the case with fibroid tumours. These are solid masses of fibrous tissue that grow in the uterus and are usually benign (non-cancerous).

Although these fibroids can cause post-intercourse bleeding, some women do not experience any symptoms at all.

Fibroid tumours may disappear on their own after menopause. However, they can be treated with various methods such as uterine artery embolisation (cutting off the fibroids’ blood supply), focused ultrasound surgery (using high frequency sound waves to destroy the fibroids), or myomectomy (surgical removal of the fibroids).

Bleeding after sex is nothing to be afraid or ashamed about. It could be caused by just a simple infection or it could be a symptom of another problem that needs to be investigated.

So, do go and see your doctor or gynaecologist immediately; do not wait and hope that the bleeding will go away on its own.


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FAQ On Menopause

I am experiencing irregular periods now. I am in my mid-forties. Am I having menopause? My friends say I cannot be having menopause because menopause comes with 'hot flashes'.

Every woman experiences menopause differently, and menopause isn't a single one-off event. It’s an accumulation of transitory events.

It can start as early as in the 30s or as late as the 60s. Most women experience it during their 40s or 50s. There are grandmothers in kampungs at the age of 60 still getting pregnant and giving birth!

You cannot say you are having menopause now because you have only one symptom of menopause. A woman may experience signs and symptoms of menopause well before her periods stop permanently. But it’s safe to say that once you don’t have your period for 12 months, you’ve had menopause.

Why does menopause occur?

When you age, your ovaries make decreasing amounts of the hormones oestrogen and progesterone, the ones which regulate your menstrual cycle, ovulation and pregnancy.

Menopause is divided into:

Perimenopause – beginning from the time when you start experiencing menopausal signs and symptoms. You may still be ovulating during this time. Your hormone levels are uneven and your periods are irregular. This part may last four to five years or longer.

Postmenopause – When you have had 12 months of no period, you are considered to have reached menopause. Then the years that follow are called postmenopause.

Other than irregular periods, what kind of symptoms will I experience with menopause?

Every woman experiences menopause differently, so her signs and symptoms are also going to be very different. You cannot compare what your mother or sister went through with what you are going through now.

Some women have very few symptoms. Other women suffer greatly. But the things you generally have to look out for are :

Irregular periods – Some women stop menstruating suddenly. Some find their menstruation tapering off. Yet other women find their menstruation getting heavier for a while, and then stopping altogether.

But it’s safe to say that if your periods have been regular and predictable, and they suddenly become irregular and unpredictable, this might be the first sign you are going through menopause.

Decreased fertility – You become less likely to become pregnant. Anyway, this happens with age.

Vaginal and urinary changes - Your vaginal and urethral tissues become drier, thinner and less flexible. This is caused by decrease of the hormone oestrogen. You may experience burning or itching in the area because there is decreased vaginal fluid to lubricate it.

Sexual intercourse may become painful or difficult. There is also an increased risk of vaginal or urinary tract infections. Not all women will experience this.

Hot flashes – Again, this is caused by dropping levels of oestrogen. Your blood vessels may expand, causing more blood to rush to your skin. This can lead to a feeling of warmth that moves upwards from your chest to your shoulders, neck and head (“hot flash”).

Your face is flushed, and red blotches may appear on the affected skin. This may be associated with sweating (including night sweats), chills and weakness. Some women even feel slightly faint. Most hot flashes last from 30 seconds to several minutes.

Sleep disturbance – Some women experience difficulty falling asleep or sleeping well through the night.

Weight gain – Some women gain about 3kg on average during menopause. The fat that was once in your hips and thighs may settle around your waist instead. Your breasts may sag. Your hair may thin and your skin may wrinkle. All this is because of dropping oestrogen.

Emotional and memory changes – Some women are irritable, tired and have problems with memory and concentration.

My mother says that if I don’t have children, I will get menopause earlier. Is this true?

No. But there are some conditions that can hasten menopause.

If you have your womb and ovaries removed for any reason at all, the removal of your ovaries will hasten menopause simply because oestrogen is not produced anymore. When you remove your womb alone, it doesn’t cause menopause.

If you have had chemotherapy and radiotherapy for cancer, this can induce menopause.

About 1% of women also experience menopause before age 40 due to genetic factors or autoimmune disease. This is called premature menopause.

Is there anything I can take for menopause?

Yes. Hormone therapy relieves the symptoms of menopause. The newer hormone therapies are safer than the older ones. Ask your doctor to tell you your options.

As for your diet, you should eat plenty of vegetables, grains, fruits, and calcium. This will help combat osteoporosis.

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Avoid Using Washable Masks

2009/09/04
NST Online
by Annie Freeda Cruez

KUALA LUMPUR : The Health Ministry does not recommend the use of washable face masks to stop the spread of influenza A (H1N1).

Health director-general Tan Sri Dr Ismail Merican said the mask, sold at 'pasar malam' for RM5 each, had not been evaluated by the ministry.

"People should use 3-ply and N95 masks if they have influenza-like illness (ILI)."

N95 masks fit tightly over the face, filtering out 95% of small particles.

Studies show that people can cut the risk of getting sick by 60 to 80% by using masks in combination with frequent hand-washing and avoiding close contact with sick persons.

Dr. Ismail said masks should be used once and then thrown away.

"Wearing masks is not the solution. It helps, of course, especially if you are sick and want to move around. Malaysians should also observe strict personal hygiene, washing hands with soap and water, use of alcohol rubs or sanitisers, practise cough and sneeze etiquette and stay home if unwell."

The official death toll now stands at 73, as the ministry's mortality review committee has yet to confirm 3 deaths reported earlier.

Dr. Ismail said there were still many people with ILI symptoms who out in public without wearing masks or adhering to cough and sneeze etiquette.

"Please follow our advice as by not doing so, you are spreading the virus to others, especially those who fall under the high risk category. Because of you, they may suffer complications and some may even die," he said.

The World Health Organisation has reported 246,221 confirmed cases of H1N1 with 2,958 deaths in 182 countries.


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How to Manage Insomnia

by Dr. Milton Lum

The body rests and recovers from previous activities during sleep. Normal sleep comprises cycles of non-rapid eye movement (NREM) and rapid eye movement (REM). NREM sleep is followed by REM sleep, which occurs 4 to 5 times during the usual 8-hour sleep period.

The first REM period of the night may be last less than 10 minutes, while the last may exceed an hour. The NREM and REM cycles vary in length from 70 to 100 minutes initially, to 90 to 120 minutes later in the night.

During the first third of the night, deep NREM sleep predominates, while REM sleep predominates in the last third of the night. REM sleep takes up 20% to 25% of total sleep time.

Insomnia

Insomnia refers to the disturbance of a normal sleep pattern. The different types of insomnia are:

* Difficulty getting to sleep (sleep onset insomnia) which is most common in young people.

* Waking up in the night which is most common in older people.

* Waking up early in the morning, which is least common.

* Not feeling refreshed after sleeping, leading to irritability, tiredness and difficulty concentrating during the day.

* Waking up due to disturbances such as noise or pain.

The duration of insomnia varies. It may be :

# Transient, lasting 2 to 3 days

# Short-term, lasting more than a few days, but less than 3 weeks

# Chronic, that is, it occurs on most nights for 3 weeks or more.

Everyone has experienced insomnia. It is generally accepted that about one-third of the population has insomnia.

How Much Sleep?

The need for sleep varies with age. A newborn may sleep 16 to 20 hours, and an infant 12 to 14 hours. Toddlers may sleep 10 hours or more. Primary school children need 9 to 10 hours of sleep, while normal adults need 6 to 10 hours of sleep.

It takes an adult about 10 to 20 minutes to fall asleep. Most of those who have less than 5 to 6 hours of sleep are probably not getting enough sleep.

After a good sleep, a person would feel refreshed on waking and can stay alert throughout the day, without the need for naps or sleeping in on weekends.

Symptoms and Causes

The symptoms of insomnia vary. They include lying awake for a long period at night prior to sleeping, waking up several times at night, waking up early in the morning and not being able to go back to sleep, feeling tired and not refreshed, inability to function properly during the day, and feeling irritable.

The causes of insomnia :

* Physiological : working at night, light, noise, snoring, partner's movements, and jet lag.

* Medical : pain or discomfort caused by arthritis, headaches, back pain, menopausal hot flushes, gastrointestinal disorders and pruritus (excessive itching).

* Psychological and psychiatric : examination stress, work worries, relationship problems, anxiety, depression, bereavement and dementia.

* Sleep disorders : sleep apnoea and sleep walking.

* Medicines : antidepressants, appetite suppressants, beta-blockers, corticosteroids and decongestants.

* Alcohol.

Management

Consult a doctor. He will look into the history of your condition and conduct a physical examination. The doctor will enquire about your sleeping routines, previous and current medical conditions, psychological or psychiatric conditions, if any, consumption of caffeine, medicines and alcohol, substance abuse including narcotic drugs, diet and exercise. The cause may be detected through this approach in many instances.

If the cause is not obvious, the doctor will ask for a sleep diary to be kept. This involves recording the time when one goes to sleep, when one wakes up in the morning and when one wakes up at night.

A referral to a specialist may be necessary if the cause is still not obvious. Laboratory tests and polysomnography may be carried out. The latter is used in the diagnosis of sleep apnoea and sleep disorders. This involves recording many parameters when one is asleep, including brain electrical activity; movements of the eye, jaw and leg muscles; and heart and lung functions. The doctor will discuss with the patient prior to any videotaping which may be considered necessary.

Once a diagnosis of the underlying condition has been made, the cause will be treated. For example, if the cause is anxiety or depression, the problem will go away once it is treated.

General measures which do not involve the use of medicines are preferred. It may involve counselling if the insomnia is due to stress or bereavement. Cognitive behavioural therapy which involves changes in thinking and behavioural patterns is useful. Measures like limiting caffeine or alcohol intake, exercise and keeping to a regular sleep routine are helpful.

Sleeping pills may be considered by the doctor for severe or short-term insomnia if general measures do not work. Doctors are usually reluctant to prescribe sleeping pills as they relieve the symptoms but do not address the underlying cause. An individual can also become dependent on sleeping pills, which are not without side effects.

Many of the sleeping pills available belong to a group of medicines called benzodiazepines which require a doctor's prescription. Benzodiazepines are anxiolytics and hypnotics, that is, they reduce anxiety and promote calmness and sleep. Benzodiazepines can lead to dependence and side effects like a hangover and drowsiness during the day. This can lead to accidents when driving. Examples of benzodiazepines include lormetazepam and temazepam.

The short-acting 'Z-pills' that is, zopiclone and zolpidem, act on the same receptors as benzodiazepines but are not classified as such because their molecular structures are different. They were initially thought to be less addictive and habit forming than benzodiazepines but this view has changed with reports of addiction in the past few years. The side effects are similar to benzodiazepines.

The lowest possible dose of sleeping pills should be taken for the shortest possible time. One should only take them under medical supervision. There is no place for self-medication. Do not stop intake abruptly as this may cause withdrawal effects. The doctor's advice is crucial here.

Melatonin is a hormone that is involved in the regulation of the sleep cycle or circadian rhythm. It is a short-term medicine for insomnia and cannot be consumed for more than 3 weeks. Although side effects are uncommon, they include dizziness, migraines, irritability, constipation and abdominal discomfort.

Getting Good Sleep

Getting a good night's sleep is vital. This can be achieved by various means :

* Having a routine facilitates sound sleep. This means going to bed and getting up at about the same time every day. It is important to relax before getting into bed as activity just before bedtime may keep one awake.

* Having an early dinner helps. The digestive system goes to sleep at about 7 o'clock. A light dinner is helpful.

* Avoid caffeine after lunch as caffeine keeps one awake.

* Avoid alcohol as its breakdown produces chemicals that stimulate the individual. It also increases the likelihood of snoring as it relaxes the muscles. This leads to lighter and less refreshing sleep.

* Avoid naps. The afternoon nap may keep one awake at night.

* Avoid light. This is because melatonin, the hormone that helps a person sleep, is produced in the dark.


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