Blood pressure, a “high score” is not good.

Posted on October 4, 2010 by drlesliegreenberg

I wish high blood pressure caused pain.  Not much pain, just enough to compel patients to seek help and to be compliant with medication.

Diagnosis:

  • For children BP is checked on a chart by gender, age and height.  Childhood obesity is rampant, so I check BP during yearly check-ups.  The appropriate sized cuff should be used for an accurate result.
  • For adults hypertension is BP greater than 140 over 90.  If blood pressure is between 140-159/90-99 it should be confirmed within 2 months.  Many patients have home BP monitor, wrist or arm.  I urge my patients to bring the monitors into the office and my nurse will check for accurate calibration.

Treatment:

  • Diet.
  • Weight loss.
  • Exercise.  (What doesn’t that help?)
  • Medication.  There are inexpensive, easy-to-take medication to decrease BP.  Most patients need 2-3 medications (many are available in combinations) to adequately control BP.

When BP is high, it constricts blood vessels.  Blood vessels feed the tissues with blood, meaning nutrients and oxygen.  The most important organs are the brain, heart and kidneys.  Long term high BP predisposes a person to dementia, heart disease and kidney failure.  For men, this can also cause impotence.

Know your BP.  Check it at a pharmacy, grocery, or fire department.  If elevated, seek help.

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Depression

Posted on September 27, 2010 by drlesliegreenberg

Depression is so insidious and pervasive.  When I see a patient for the first time I ask about their medical history: lung and heart problems, seizures, kidney disease AND anxiety and depression. It is that common. . . and that important to treat. Depression seems to zap the joy of life.

I question the patient about

  • thoughts of self-harm or hurting others,
  • if they have a plan,
  • if they’ve had treatment before (was it effective? Why did they stop?).

There are resources: counseling, focus groups, psychotherapy, and pharmacotherapy (drugs). Most medication takes 6-7 weeks to start working. Family may see a benefit before the patient does. The patient should commit to 6 to 9 months of medication, to decrease the risk of relapse. Exercise and other positive lifestyle changes should be encouraged.

 Anti-depressant medications often help greatly. Many formulations also help with anxiety. Frequently patients want to discontinue the anti-depressants as soon as they feel “normal” again. I convince them to stay on the medication. If they insist on weaning I ask them to tell a loved one what they are doing. So that if depressive behaviors resurface, the patient can resume full-dose medication.

My goal for my patient is for them to lead the life they were meant to lead. Depression gets in the way of that. Frequent visits, with a plan geared toward the patient’s needs, works best!

I hope this helps.

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Is the (pharmaceutical) grass greener?

Posted on September 24, 2010 by drlesliegreenberg

Is newer or more expensive better?

I do not necessarily think so.  While in training I was given the advice to not be the first physician prescribing a drug, nor the last.  There is some wisdom in that. 

Our society values brand-name products and is often swayed by marketing that a new drug is somehow better.  Many “new” drugs are new only in formulation—a sustained release or long acting preparations.  This is a patent-extending measure to make the pharmaceutical company more money.   Renamed drugs with new indications are considered “new” and a new brand name means that a generic equivalent cannot be provided. 

Family physicians are uniquely positioned to know the disease entities and their first-line therapy.  I  suggest time-tested drugs, many of which are available in generic form.  The risk and benefits of generic drugs are well-known because the drugs have been around longer.  An analysis combining 38 studies showed no evidence that branded preparations were superior to generic.

 I tell my patients that my family takes generic medication, many look at me in disbelief.   I tell my husband, newer is not better. . . he appreciates that.

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Vaginal bleeding. . . not routine dinner conversation. . .

Posted on September 22, 2010 by drlesliegreenberg

I am asked routinely how to help decrease vaginal bleeding.

 
Every woman bleeds a different amount.  It is only concerning when it becomes a social problem or when the amount changes significantly. 
 
When a teen starts to have a period, it’s usually  irregular (and anovulatory—no egg coming out of the ovary) for 1 to 2 years.  Through the childbearing years, a menstrual period will remain consistent in duration and flow in each individual woman.

There are a few options to decrease amount of menstrual blood loss.

Non-steroidal anti-inflammatory medications decrease the amount of blood loss by 20 to 50%.  Naproxen is the most well-studied medication; it is over the counter.  This medication should be taken at the beginning of the period through the heavy days and then stopped.  Beware that it may cause irritation of the stomach.
 
Birth control pills have the benefit of contraception and also regulating a menstrual period.  The “Pill” when taken daily at the same time of day will

  • decrease the amount of bleeding,
  • start the menstrual cycle “like clockwork”, and
  • decrease the pain, cramping, and PMS. 

The low dose “Pill” of today does not increase the risk of breast or endometrial or ovarian cancer.  Women can stay on the Pill until they want to conceive or through the perimenopausal period.  The pill is dangerous for those with history of blood clots or smoking AND being over 35.
 
The Mirena intrauterine device is another method.  It is a small “T” shaped device that sits inside the uterus and emits progesterone daily.  It can stay in for 5 years and has 99.5% contraceptive effectiveness.  It is an easy in-office procedure that takes 15 -30 minutes.  The patients with the Mirena make less endometrium, so there is less to shed each month.  More than 85% of women bleed less than without the Mirena and many have NO menstrual periods after one year.  (Tempting isn’t it?)

I hope this helps.

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Pelvic pain in women

Posted on September 18, 2010 by drlesliegreenberg

I care for a lot of women.  Many present with pelvic pain.  This is a challenging diagnosis because symptoms and signs are vague and hard to tease out.  I was taught to always rule out the urgent life-threatening conditions first.

  • Ectopic pregnancy (a pregnancy outside of the uterus)
  • Appendicitis
  • Ruptured ovarian cyst

 Certainly, with pelvic pain, fertility-threatening conditions would be a close second to rule out and treat.

  • Pelvic inflammatory disease (complication of an STD)
  • Ovarian torsion (twisting of the ovary on its blood-supply stalk)

 A careful history (focusing on pain characteristics, gynecologic, sexual and social history) will be paired with a physical exam and lab work to help narrow the list.

Imaging is sometimes helpful.  A transvaginal ultrasound is frequently the best modality to use: good pictures of female internal anatomy  without  radiation exposure. 

Multiple studies have shown that 20-50% of women presenting with pelvic pain have pelvic inflammatory disease.  This means that these women in the past may have had a sexually transmitted disease which festered long enough to cause scarring in the fallopian tubes.  The CDC suggests testing adolescents for sexually transmitted infections every year or anyone with risk factors by a vaginal exam.  STD screening is for the pelvic health and future fertility of that patient.

I hope this helps.

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Erectile dysfunction

Posted on August 27, 2010 by drlesliegreenberg

I see many male patients who feel like they are underperforming in the bedroom.

Anything limiting blood flow to the penis can cause impotence, now called erectile dysfunction. The most common conditions include cigarette smoking, diabetes, high blood pressure, alcoholism, drug abuse, normal aging, and depression.

Control blood pressure. Know your blood pressure. Most pharmacies have a self-inflating cuff. Check yours. BP should be under 140/90. If high, see a doctor for help.

Tobacco. Stopping smoking has innumerable benefits: better lung function , less cancer and helps blood flow throughout the body.

Drug Use. Some recreational drugs increase sexual arousal, but most all decrease sexual ability.

Exercise. A recent study of 178 healthy men showed those who reported exercise of 9 metabolic equivalents (like brisk walking for 30 minutes a day, 4 days per week) scored significantly higher on a sexual functioning survey. The mean sexual function scores were 42 for sedentary men, 50 for active men, 72 for moderately active men and 70 for highly active men.  This was statistically significant. The study controlled for all other factors and found that men reporting moderate or high levels of physical activity were 65% less likely to have sexual dysfunction than sedentary men.

 Diabetes. Some cases of diabetes are preventable. Most adult onset diabetics are obese. Exercise and weight loss can ward off or stop diabetes. Aim for a body mass index (BMI) of 25 or less.

Evaluate medication use. Many commonly prescribed medications can interfere with male sexual function. Ask your doctor if any medications you are taking may worsen the problem and if a substitute medication could be started.

Some sexual therapy is free and should be started years BEFORE there is a problem. Stop tobacco and recreational drug use, excessive alcohol consumption and start a moderate exercise program.

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Reasons to be taking hormonal contraception. . . .other than contraception.

Posted on August 25, 2010 by drlesliegreenberg

I had a patient today who has menstrual migraines. . . and has had her tubes tied. We discussed starting her on hormonal contraception for noncontraceptives reasons.

I reviewed the ACOG (American College of Obstetrics and Gynecology) 2010 bulletin on noncontraceptive benefits of hormonal contraception. Beware: lots of numbers ahead. . .

Pain.  Oral contraceptives with estrogen and progesterone (“combination pills”) relieve painful with menses in up to 80% of women (even those with endometriosis). Depot medroxyprogesterone (“Depo shot”) and the levonorgestrel IUD (Mirena) also treat menstrual pain.

Bleeding.  Women with heavy bleeding benefit with up to 50% less blood loss with combination birth control pills or up to 97% less in 12 months with insertion of Mirena IUD.

Cancer.  Combined oral contraceptives may reduce endometrial cancer by 50% with cancer protection lasting up to 20 years after medication discontinuation. There is a 20% decreased risk of ovarian cancer for every 5 years of use. There is an 18% risk reduction for colorectal cancer, but this reduced risk stops when medication stopped.

Other potential noncontraceptive benefits of hormonal contraceptives

  • Menstrual cycle regularity
  • Prevention of menstrual migraines
  • Treatment of acne
  • Treatment of bleeding from fibroids
  • Treatment of painful periods
  • Treatments of unwanted facial hair growth (hirsutism)
  • Treatment of heavy menstrual periods
  • Treatment of “PMS”—premenstrual syndrome.
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Rashes. . . . mysteries I love to solve.

Posted on August 20, 2010 by drlesliegreenberg

My non-medical friends are horrified when they see my delight with rashes.  I have given a dermatology talk to medical students monthly for 10 years: dermatology 101. 

One common rash is contact dermatitis.  There are two kinds: 

1.  irritant–which is caused by non-immune-modulated irritation of the skin by a substance and

2.  allergic–a delayed hypersensitivity reaction (when a foreign substances comes into contact with the skin). 

Most common causes of contact dermatitis include

  • poison ivy (allergic)
  • nickel (14% of all contact dermatitis)
  • fragrances (14% of all contact dermatitis)
  • neomycin (11.6% of all contact dermatitis—I do not recommend Neosporin for this reason)

The rash will look different depending on the length of exposure to the agent.  More recent dermatitis may look red with blisters or more chronic exposure may cause thickened skin with cracks and fissures. 

acute allergic contact dermatitis

Other masquerading causes. . . fungal infection, psoriasis, eczema, scabies or bacterial infection of the skin.

My priority is to identify and avoid the causative substance. Cool compresses can soothe the symptoms while calamine lotion and oatmeal baths may help dry and soothe acute, oozing lesions.  Steroids may work well too–topical lotions work well for a small area or oral steroids if involvement is more than 20% of skin surface area.

 If treatment fails, patch testing by an allergist may be performed.  It is expensive, time-consuming, and prohibits the patient from showering during testing.  Skin prick and radioallergosorbent tests are used for respiratory, latex and food allergies—not contact dermatitis.

Oh, what fun!

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Allergic rhinitis

Posted on August 4, 2010 by drlesliegreenberg

“My nose is running all the time.”  Hmmmmm. . . . . .

This is a common complaint.  This spring and summer in Wichita have been SUPER-allergic—even those who have been well controlled.  There are really four ways to help:  patient education, allergen avoidance, pharmacotherapy and immunotherapy. 

The best symptom relief comes from intranasal steroids (FDA approved down to age 2 years old!).    No long term adverse effects have been found.  Some intranasal sprays make your nose sting or smell like flowers, but it will decrease symptoms. Oral antihistamines also help.  Benadryl is available over the counter—this is great at bedtime, because it can make you so drowsy that you HAVE to go to bed.  Non-sedating second-generation antihistamines Claritin and Allegra are effective.

Immunotherapy is performed by an “allergist”—a specialized area of medicine.  Moderate or severe persistent allergic rhinitis not responsive to usual treatments may be helped when given small amounts of allergen extract given under the tongue or skin over the course of a few years.  Also, DNA technology has allowed for allergen-specific vaccines to be developed!

I do like alternative medicine, WHEN it has been definitively shown to help.  As for nonpharmacologic therapies. . . randomized controlled trials have NOT found that acupuncture or probiotics or herbal preparations  to help. 

Lastly, here is a common sense approach.  Avoid exposure to cigarette smoke, pets, and allergens you  know you are sensitive to.  Nasal irrigation (sinus wash) at home may help flush allergens out.  These are available at any pharmacy OTC.  Neti pot or low-pressure squeeze bottle are superior to saline sprays.  Washing hair at bedtime and changing pillow cases nightly may help keep allergens caught in hair to affect you at nighttime. 

. . . I’m reminded of that kid-joke ending in . . . It’s SNOT funny.

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Swimmer’s ear, nothing that a swimmer wants.

Posted on July 25, 2010 by drlesliegreenberg

“Ow!  My ear hurts.”  I heard that four times last week.  It is swimming season here in Wichita and swimmers ear and pools go hand-in-hand.   The story is usually. . . one-sided ear pain, tender-to-touch ear, hurts to chew AND recent exposure to water.

 

When water gets inside the ear canal and can’t get out it’s like when you were a kid and had your cast cut off.  The skin under the cast that got wet STAYED wet.  That skin becomes macerated and weeps (just like swimmer’s ear stays wet).  Ick! Uniquely, the dermis comes into contact with the periosteum (bone) –thus, minimal inflammation in the ear causes significant pain.

Some people are more prone to otitis externa with frequent water exposure, inability to clear the water from their ears, or mishapen/tortuous ear canals.  (One example of misshapen ears are  “cauliflower ears” of wrestlers who bruise their ear after having it mashed into the mat.)  Protectively, ear wax helps create an acidic environment in the ear which fights bacteria and fungal growth.

Your doctor may perform an  ”aural toilet” (ear wash) to help clear out bacterial overgrowth or place an ear wick.  Antibiotic drops with steroid help the ear canal tissue be less inflamed, hurt less, and fight the infection.

To decrease your risk of swimmer’s ear. . .

  • Stop scratching the inside of your ear
  • Do not excessively clean wax out of ears
  • Beware of devices that block the ear: hearing aids, headphones or diving caps.
  • Instill rubbing alcohol and vinegar in the ears or gently blow dry ears after swimming

The ears are self-cleaning (kinda like my oven).  The old adage “Don’t put anything smaller than your elbow in your ear” is right!

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