Operation has a bad reputation among the public and, at times, the profession. There is no doubt that the right operation by the right surgeon on the right patient for the right condition, brings a satisfactory result to all concerned. Perhaps the bad results are due to one of those four conditions being wrong.

Acupuncture is currently being hailed as the treatment for everything from dandruff to corns.

I think there is valid evidence to show it may be of benefit in reducing chronic pain and, therefore, help those who remain in pain despite many different treatments. Its place in the management of the acute stages of back condition has yet to be shown.

The best advice I can give you if you have, or in the future get, a bad back, is to go to a doctor you know and trust and be guided by his advice.

It is this pressure on nerves where they originate and leave the spinal canal which causes the severe pain called sciatica running down the back of the thigh and the outer leg.

*219/71/1*

Typically, a gynecologist knows that a laparoscopy is indicated when his patient’s complaints of pelvic pain persist for at least six months and he finds that she is not responding to conservative treatment, such as painkillers, or to a regimen of antibiotics (if he found signs of infection). He will need to reevaluate her case at this point: did she have endometriosis at the time of her first visit to his office? Let’s assume that the doctor isn’t sure and now she is back at his office, having followed all his instructions. She is not better, but worse, valiantly struggling with her pain and seeking relief her doctor suggests laparoscopy, since it may be endometriosis that’s causing her symptoms. He assures her that even if it is not, the procedure may help reveal any of several other conditions, such as acute ovarian cysts or even an ectopic pregnancy.

Good diagnostician should be about 95 percent sure that his patient has endometriosis just by taking a very detailed medical history and listening to her progression of symptoms. A follow-up laparoscopy, when indicated, could then confirm the diagnosis. We have discovered, however, that there is another side to the issue: many women have had unfortunate experiences not only with misdiagnosis at the time of their initial visit but with laparoscopy as well. As the patient, you should be aware of what steps your doctor is taking before he recommends a laparoscopy:

• If the doctor believes you have an infection, he should have taken a culture to prove that point,

• If the doctor suggests mat you have a pelvic cyst or tumor, it should have been confirmed first with a pelvic ultrasound.

• If you are not responding to any treatment the doctor prescribes based on this findings, you should then be free and able to openly discuss with him (1) how you feel and (2) what other diagnostic and therapeutic steps could be taken.

• If he first retests you for infections, cysts, and tumors and all the tests are negative once again, a laparoscopy might then be called for.

What happens when a woman willingly undergoes this procedure again and again and is either diagnosed correctly or incorrectly, and either way, the disease is mismanaged?

*44\43\4*

Dermatitis is a pattern of skin inflammation which may follow contact with an injurious substance or may develop without any apparent external cause.

The recognition of skin disorders is essentially a visual art. It requires experience to distinguish what is dermatitis or eczema from what is not; disorders that might be confused with dermatitis or eczema include such conditions as diffuse skin malignancies, known as reticuloses, or infections either fungal or parasitic.

Dermatitis which develops in response to contact with a foreign, but not necessarily a newly-contacted, substance is called Contact Dermatitis. There are two broad types: the irritant, and the allergic.

Clothing Apart from rubber there are a variety of other potential sensitizers in clothes. The pattern of eczema follows the area covered by the offending garment, with accentuation Of the eruption in moist zones and those at which the garment makes closest contact with the skin. The responsible chemicals include dyes (which may cross-react with PPD), formaldehyde and other garment finishes. Shoe dermatitis may be caused by these chemicals, also by those in leather and glues.

Cosmetic dermatitis is probably more common than dermatologists suppose, since most women who find that one cosmetic causes them trouble will simply change to another without seeking medical advice. The principal trouble-makers are perfumes, which contain an array of plant extracts, animal oils and synthetic chemicals.

Nail varnish causes contact dermatitis, not on the fingers but where the nails touch the skin, mainly around the eyes and neck. Lipstick sometimes causes contact dermatitis due to eosin or other dyes. Hair dyes which contain PPD or related compounds may cause dermatitis, which is chiefly seen round the hair line. Finally lanolin and some preservatives in creams and ointments may also cause contact dermatitis reactions.

Plants A few plants are powerful sensitizers and well known for causing contact dermatitis. Poison ivy is the most famous in the United States, as is the primula in the United Kingdom. Chrysanthemum and tulip bulbs may sensitize a few people. In Australia the Rhus tree, a close relative of poison ivy, has leaves which provoke a very severe dermatitis in many people. The resulting rash —which may occur where the skin has touched the plant, or on a face which has been touched by contaminated hands—has a streaked appearance.

Medicaments Contact dermatitis as a reaction to a medicament is confusing, since presumably the skin was abnormal before it was applied. The principal causes of such reactions are antibiotics, anti-histammes, local anaesthetics, ointment bases (such as lanolin), ointment preservatives (such as para bens), and stabilizers (such as ethylene diamine).

The number of other possible skin sensitizers is enormous. Other important ones include epoxy-resin, plastic hardeners, formaldehyde resins, pesticides and fungicides.

*71\44\4*

Adopting life-long healthy eating habits requires a lifestyle fit, with minimum disruption and deprivation. After some experimentation.

Each client will discover what she/he has to do (nutritionally) to control body fat. The key is getting the maximum benefit from minimal change. Each individual will need to set dietary priorities, a process which requires a brief explanation.

Although eating for fat loss requires a reduction in energy intake, counting calories is likely to be counter-productive. It is the source of calories which is important and there is a hierarchy for dietary restriction of specific sources. Fat, with the greatest energy content (9 kcal/g) is a suitable first target for dietary modification. Alcohol has 7 kcal/g and is a secondary consideration. Next on the list is carbohydrates as sugars (4 kcal/g), finally followed by carbohydrate as starch (still 4 kcal/g). If body fat goals are met by targeting fat intake alone, then less emphasis on decreasing other energy sources is required.

If clients cut back on fat, alcohol and sugar and still want to get more off their waistlines, the only thing left is to reduce starchy carbohydrate foods like bread, pasta, rice, potato and corn. This last modification will markedly decrease the volume of food intake, but will challenge hunger and appetite regulation. Severe restrictions in food intake may trigger binges and result in a situation.

Worse than existed initially. This will signal that dietary efforts have been too drastic.

This explanation shows that there is a method for success and that at some stage the limitations of dietary change will be experienced. Going short on the body’s preferred energy fuel (starchy carbohydrates) has its hazards. It is important for clients to be aware of this risk and to put effort into increasing their level of movement Increasing energy expenditure will allow them to eat more, giving flexibility to their eating program.

*124\186\4*

To get the best out of your doctor you need to be well-informed and provide honest and accurate information.

In order to be well informed you should read about the menstrual cycle so that you understand how the cycle works, know about hormonal changes and their effect, and understand what endometriosis is. This can be achieved either by yourself or by your doctor suggesting reading material and other sources of information. You can also contact your local women’s health information centre.

It is important to recognise that your doctor is not a mind reader, and that it is up to you to tell her or him what your problems are so that your doctor can get an overall picture of your illness. Identify the major areas of concern for you — infertility, pain control, improvement of lifestyle.

It may be a good idea to keep a diary in which you can record your visits to your doctor and make notes of any side effects of drugs or surgery or other treatments suggested by your doctor and list questions for future visits.

Be honest about symptoms and make sure the information you give is complete, accurate and relevant. It is of no benefit to you to withhold information.

It is important to be able to talk openly to your doctor and to feel that you can discuss your needs and fears.

If you have concerns about the side effects of drug therapy, you should feel comfortable discussing these with your doctor. If you have printed information about drugs or treatment you want to discuss, take this with you to the appointment so that your doctor can comment.

Always report the positive as well as the negative feelings you may be experiencing.

Vital decisions and concerns such as marriage, sexual relationships, careers and children should also be discussed with your doctor since these make up the total picture.

Imp roving consultations

Start by writing down any information you need prior to the appointment. Your questions should also be written down and added to during the consultation.

Repeat information back to the doctor to make sure that you have heard and understood everything correctly. Ask for diagrams and illustrations to help you understand the information the doctor provides.

Take a friend or partner or relative along for moral support; it is important that family and friends be informed about your disease.

During the appointment take notes if necessary and ask the doctor to write down any instructions.

Although difficult at times, try to control your emotions when talking to your doctor as this will make it easier to understand the information and take notes.

Realistic expectations

It is reasonable to expect your doctor to ask if you understand vital aspects of your proposed treatment regime and for that information to be expressed in terms that you understand. To achieve this your doctor first needs to establish your level of knowledge on both the technical and medical aspects of the disease.

It is not reasonable to put doctors on a pedestal and to accept all their advice without question. Let your doctor know what your expectations are — different women will have different needs and expectations.

It is not reasonable to have unrealistic expectations of what your doctor can achieve. For instance, the disease may not always respond to the best treatment available so it would be unfair to get angry with your doctor. Remember, doctors do not have all the answers to endometriosis — or anything else for that matter. They, too, can get frustrated with the lack of ‘cures’.

Making the right decision

Start by evaluating your doctor’s recommendations in the light of your own needs. If you want advice and guidance but also want to make your own decisions about treatment, then let your doctor know.

Trust

No doctor wants to feel that her or his credibility is being challenged but, equally, no woman should ever feel intimidated.

Let your doctor know that you respect her or his opinion but expect open and mutual communication and trust. You should trust your doctor’s level of knowledge just as the doctor should have respect for your judgements.

Confidentiality is also important and you must feel that information is confidential to both you and your doctor.

Your doctor needs to be able to trust that you have followed the treatment plan you both have agreed upon.

What is informed consent

Informed consent occurs when a woman has sufficient information about the proposed treatments or procedures to consider the options without pressure and to accept — or decline — treatment. Informed consent requires an explanation of the proposed treatment as well as an explanation of the risks and benefits. It is essential that a woman be given enough time to ask questions, discuss alternatives; a woman needs to know that she can withdraw her consent at any time.

It is important that you understand what you are consenting to — so a discussion with your doctor is essential. A doctor may make you feel that she or he is a busy person — far too busy to be bothered by trifling questions. However, you must make sure that you understand fully any treatment your doctor is suggesting for you — whether it be drug treatment or surgery — so that you are capable of giving your informed consent.

A woman who understands is far more likely to co-operate with her future treatment. It is reasonable to expect your doctor to ask if you have any further questions or if there is any other information that you would like.

Getting information

If you feel that you do not have enough information to give your informed consent then you should ask for further information This should include a detailed explanation of the diagnosis, what the diagnosis means and the various ways that your condition could be managed. Talk about the options and their likely outcomes. Other considerations should include:

will there be any pain or discomfort

what are the risks of the proposed treatments

what are the side effects

should I get a second opinion

what are the alternatives

what is the outcome if I have no treatment

how much will it cost

will my health fund cover the cost

how long will I be away from work.

To get answers to all of these questions you may have to be assertive. Many women complain they find it difficult to be assertive and demanding with their doctor but remember it is your body and you must take control.

*113\83\2*

Duphaston has been used to treat women with endometriosis in Australia for over 25 years. It has also been used to treat a variety of other conditions, including amenorrhoea (absence of periods), dysmenorrhoea (painful periods), PMS (premenstrual syndrome) and abnormal uterine bleeding.

Duphaston is a progestogen (a synthetic progesterone) which is very similar to the naturally occurring progesterone produced by the ovaries.

Duphaston is manufactured by Ethnor in the form of small, white tablets, each of which contain 10 milligrams of Duphaston. It is sometimes also known by its chemical name, dydrogesterone.

How Duphaston works

It is not known precisely how Duphaston eradicates endometrial implants because, unlike the other drugs used in the treatment of endometriosis, it does not stop menstruation and it does not usually stop ovulation at the dosages that are most commonly used. It is thought that Duphaston probably works by inhibiting the growth of the misplaced endometrial cells in some way, causing them to gradually waste away.

Dosages of Duphaston generally used

There are several approaches to the use of Duphaston for the treatment of endometriosis. The dosage recommended will depend largely on the practices of the gynaecologist and, to a lesser degree, on the severity of the condition and the woman’s response to the treatment.

The majority of gynaecologists will recommend 10 to 30 milligrams of Duphaston daily (one to three tablets daily) for six to twelve months. A few gynaecologists will recommend taking the tablets cyclically from the 5th to the 25th day of the menstrual cycle each month for six to twelve months.

At these relatively low dosages most women will continue to menstruate and many will continue to ovulate regardless of whether the Duphaston is taken daily or cyclically.

In contrast, some gynaecologists will recommend significantly higher dosages of Duphaston because they believe that the treatment is more likely to be effective if menstruation is stopped. These gynaecologists will generally recommend 30 to 60 milligrams of Duphaston a day (three to six tablets a day) for six to twelve months. The dosage recommended will usually depend on the response to the drug, the final dosage usually being the minimum required to stop menstruation and ovulation.

Although the usual length of treatment with Duphaston is six to twelve months there is no evidence that prolonged or repeated courses cause long-term side effects.

You should make an appointment to visit your gynaecologist about six to eight weeks after you start your course of Duphaston so that you can discuss how the treatment is progressing.

Thereafter, you should visit every two to three months for the remainder of your course of Duphaston.

Duphaston can only be supplied under the Pharmaceutical Benefits Scheme for endometriosis if you have been definitely diagnosed during a laparoscopy or laparotomy and if your doctor fills in a special prescription form known as an ‘Authority’. If this is done one month’s supply of Duphaston will only cost you the maximum cost of a script under the Pharmaceutical Benefits Scheme ($15 in March 1991) as opposed to its full cost (approximately $30 per script in March 1991).

Side effects of Duphaston

Most women using Duphaston only experience one or two mild side effects which sometimes settle with time.

The most common side effects that have been reported include breast tenderness, weight gain, bloating, depression, headaches, lethargy and tiredness, dizziness, nausea, irregular vaginal bleeding and cramps.

The side effects of Duphaston are reversible and they diminish soon after treatment ceases.

There are no known long-term side effects of Duphaston therapy.

How effective is Duphaston

It is extremely difficult to provide any figures regarding the effectiveness of Duphaston in the treatment of endometriosis as there has been almost no research published on the issue. Duphaston has been used as a treatment for endometriosis for many years and it has shown itself to be an effective treatment for many women. One unpublished Australian study suggests that nine months treatment with Duphaston is as effective as six months treatment with Danazol.

The only study published to-date found that 43 of the 49 women had complete or partial relief from their symptoms and of the 19 women with infertility who wished to conceive, 10 did so.

There is no information available on the recurrence rate of endometriosis following treatment with Duphaston.

Duphaston, pregnancy and breastfeeding

The manufacturers of Duphaston state that it should not be used during pregnancy as progestogens may cause abnormalities in the developing foetus.

The use of Duphaston while breastfeeding is not recommended by the manufacturers. Small amounts of progestogens have been found in the milk of mothers taking the drug and effects on the child are unknown. However, some gynaecologists believe that Duphaston can be safely used during pregnancy or breastfeeding.

Interaction with other drugs, alcohol or foods

There are no known interactions of Duphaston with any foods, alcohol or other drugs.

*55\83\2*

Also known as ‘naturopathic medicine’, naturopathy is an extremely broadly-based system of medicine that combines a wide variety of natural therapeutic and healing techniques under one umbrella, and it can perhaps be best described as a mixture of traditional folk wisdom and modern medicine. The main underlying principle of this alternative therapy is that the root-cause of all disease is the accumulation of waste products and toxins within the human body, this usually being the result of a lifestyle that is ‘deficient’.

Like homoeopaths, naturopaths believe that the human body has the innate wisdom and power to heal itself, providing we enhance rather than interfere with this power. As far as actual treatments are concerned, naturopathy relies heavily on herbal preparations and diet management techniques, but depending upon his training, a naturopath may offer any – or even all – of the following therapies: physiotherapy, this based on water, ultrasound, heat or cold; yoga or other breathing exercises; biofeedback techniques; corrective nutrition; as well as many others.

Naturopaths rely heavily upon the practitioner and the patient discussing and agreeing upon what therapies should be used. There is also much emphasis upon the promotion of psychological health and the benefits of stress reduction. Generally, this is an alternative therapy that has a good track record in helping people with chronic ailments of all kinds, especially when the symptoms arise from or are made worse by tension, anxiety or stress.

You can get more information from: The General Council and Register of Naturopaths, Goswell House, 2 Goswell Road, Street, Somerset BA16 OJG; The Natural and Therapeutic and Osteopathic Society and Register, 14 Marford Road, Wheathampstead, Herts AL4 8AS.

*60\124\2*

In the chapter on seasonal affective disorder (SAD) I discussed the value of light therapy for those who become depressed during the dark days, whether these occur during the winter or at other times of the year. What is less well known, however, is that there is growing evidence that light therapy may also be beneficial for patients whose depressions are not seasonal or specifically related to environmental light at all. These people may benefit from enhanced environmental lighting by itself or, more commonly, in conjunction with other forms of anti-depressant treatment.

Fisch and colleagues in Germany set out to investigate whether light therapy might enhance the response of depressed patients to treatment with St John’s Wort. They divided 40 depressed patients, whose mood changes bore no specific relationship to the changing seasons, into two groups of 20. Both groups received standard doses of Hypericum – 900 mg per day. In addition to this, one group was exposed to bright environmental light and the other to dim environmental light for two hours each day. They found that the group exposed to bright light showed superior antidepressant effects after two and four weeks of treatment. After six weeks, however, both groups fared equally well. They concluded that light therapy may speed up the anti-depressant response to Hypericum. Even if enhanced environmental lighting did no more than this, it would still be worth considering since the weeks before an anti-depressant kicks in may seem interminable to a person suffering from the painful symptoms of depression. It is especially difficult to keep up one’s spirits and optimism during the early weeks of treatment since there is no guarantee that the medications will actually work. Signs of an early response are therefore particularly welcome.

It is possible that enhancing environmental lighting may do more than simply speed up the response to an anti-depressant -it may actually enhance the response. Although this effect has not yet been demonstrated for St John’s Wort, Siegfried Kasper and colleagues in Germany studied a group of depressed patients who had failed to respond to an adequate trial of Prozac. These researchers treated half of their patients with bright light and half with dim light while keeping them on Prozac. After two weeks, the patients receiving bright light showed significantly greater improvements than those receiving dim light treatment, an advantage that increased over the following two weeks of the study.

These studies suggest that combining bright light therapy with anti-depressant medications, including St John’s Wort, may be a valuable strategy for enhancing the speed and magnitude of the therapeutic response even in those depressed patients who have not suffered exclusively from winter depressions.

The known interaction between light and Hypericum has raised concerns about possible harmful effects to the eyes in people receiving light therapy while on St John’s Wort. So far, the only study that has addressed this question directly is that of Kasper and colleagues, who examined the eyes of their patients after two weeks of such combination therapy and found no visual changes. A recent study by Brockmoller and colleagues in Germany, showing very little increase in skin tanning in patients on clinically relevant doses of Hypericum, is also encouraging in relation to the safety of this combination. Nevertheless, if you experience any eye irritation while on the combination, check with your doctor about it. What I recommend for my patients if they experience eye strain or irritation while receiving light therapy is that they try to decrease their exposure to bright light either by shortening the daily duration of treatment or sitting further away from the light source until their eyes feel comfortable.

Warning: If you have any history of eye problems, you should always consult an eye doctor before undertaking light therapy.

As the quote from A. Cornelius Celsus suggests, it is possible to derive benefits from enhanced environmental lighting without any formal therapy simply by brightening up the interior of your house. This can be done with more lamps, including indirect lighting bounced off lightly coloured surfaces. Bright colours, especially yellows and oranges, also seem to have a cheering effect on many light-sensitive people I have treated over the years. Finally, there is no substitute for natural lighting and a walk outdoors in the sunshine can combine the healing effects of exercise and light. This benefit was actually documented by Dr Anna Wirz-Justice and colleagues in Switzerland, who showed that as little as half an hour of walking in the morning had a markedly beneficial effect on her patients with SAD. I would wager, though, that other types of depressed patients would stand to benefit from such a daily prescription as well.

*75\75\2*

So far we have considered the principal different types of epileptic seizures.

Paediatricians and neurologists recognize that certain clusters of symptoms and signs and patients’ characteristics go together, and this is what we mean by a syndrome. The idea of epilepsy syndromes goes back many years, but a revised scheme or classification of epilepsy was proposed by the International League Against Epilepsy (ILAE) in 1989. In this classification, an epileptic syndrome is characterized by both clinical and EEG findings. On the clinical side, the age at onset of seizures, the family history, the seizure type(s), and neurological findings are all relevant to the classification, as is the appearance of the EEG between and during seizures. Identifying epileptic syndromes allows greater precision of diagnosis and of prognosis than simply classifying seizure types.

The same type of seizure can occur in different syndromes. For example, tonic-clonic (grand mal) seizures can occur in association with typical absences (primary generalized epilepsy) or in association with partial seizures (location-related epilepsy). Conversely a person with one syndrome may have seizures of more than one type. For example, a child with primary generalized epilepsy may have both absence and tonic-clonic seizures (both petit and grand mal). Identifying an epileptic syndrome helps to select the most appropriate investigations, decide on the most appropriate anti-epileptic treatment, and to predict most accurately the outcome. However, it must be understood that even if an epilepsy syndrome is identified, this does not necessarily give any information about the underlying cause of the epilepsy. Indeed, one syndrome such as West’s syndrome may have several more or less well identified causes.

Many of the different epilepsy syndromes begin in childhood, and are best characterized by onset by age. However, it is important to think in terms of the two great divisions of primary generalized epilepsy, in which the seizure discharge is generalized from the beginning, and location-related epilepsy, in which the seizure begins in one particular part (location) of the cortex, even if the seizure then becomes a secondary generalized one. A location-related epilepsy usually implies some local structural damage to, or disorder of, nerve cells. One example would be seizures following a head injury.

Some syndromes have common features and a predictable outcome. For example, some children develop nocturnal partial seizures often occurring at night, and characterized by large EEG spikes over the central and temporal regions of the brain on one side. Others are rather loose collections of a few common characteristics irregularly linked together.

In the opinion of most experts, only about 40-50 per cent of children with epilepsy can be ‘put into’ an epilepsy syndrome. When these children cannot be ‘put into’ or classified into an epilepsy syndrome, then the children’s epilepsy must be classified according to the seizure type or types that the child is experiencing, and this used as the best basis for prognostic judgement.

The question of inheritance of epilepsy, but with the advances in genetic research, the classification of epilepsy syndromes may eventually become replaced by specific epilepsy disorders or diseases classified genetically. However, for the time being, the concept of epilepsy syndromes is of some use.

*14\188\2*

Home care

Until the hyperactive child has been professionally evaluated and diagnosed, home treatment cannot be undertaken. Once the diagnosis is confirmed, the family of the hyperactive child is given specific recommendations tailored to the child’s needs. Removing from the child’s diet foods that contain artificial colorings, flavorings, or preservatives is believed by some specialists to lessen the incidence of hyperactive behavior. However, others feel that the special attention given to a child whose diet is being controlled, not the diet itself, probably accounts for any improvement in behavior. Ask your doctor before you initiate any changes at home.

Precautions

• True hyperactivity is present from infancy. If your normally active child is over two years old and suddenly becomes overactive, look for clues in the child’s environment.

• Never accept a diagnosis of hyperkinesis from anyone but a trained, skilled, and experienced professional.

• Remember that an accurate diagnosis usually requires a team approach involving all those who care for the child – parents, teachers, doctors, and other professionals.

• Don’t mistake ordinary misbehavior for hyperactivity; if a child is overactive with one family member but not with the others, the child is not hyperactive.

Medical treatment

A child suspected of hyperkinesis must have a complete medical examination, including vision and hearing tests. The doctor will take a detailed account of the child’s medical background, evaluate school reports, and usually recommend a series of tests that are carried out by a psychologist. The doctor may also try various medications. Among the medications that may be given are drugs such as dextroamphetamine, methylphenidate, or permoline. Both you and the child’s teachers will be asked to keep the doctor informed of changes in the child’s behavior once a program of treatment is established. The hyperkinetic child may need special educational placement; also, because hyperkinetic children often have emotional problems resulting from poor social relationships at home and at school, counseling may be indicated.

*121/84/5*