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Women's Health Newsletters 5/6/01 - 6/10/01



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****** Woman's Diagnostic Cyber Newsletter *******
                May 6, 2001
This week from Woman's Diagnostic Cyber

1. Embarrassed by chronic blushing?
2. Clomid for unexplained fertility
3. Reader submitted Q&A - PMS after menopause?
4. What is a cataract? 
5. The truth about latex condoms 
6. Health tip to share - Carpal tunnel exercises
7. Humor is healthy

Spread the word! Send a copy of this newsletter
to someone you know.

Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.

1. Embarrassed by chronic blushing?
Blushing is not the same as hot flashes. Some 
women have a problem with chronic blushing almost 
all of their adult life.  Anything can trigger it; 
even a fear of blushing. Mistakes, criticism, 
unexpected attention or praise can cause this 
reaction which is embarrassing to those who have 

Anyone who has social anxiety is at risk for 
chronic blushing. While surgery is an option, it 
is much better to try biofeedback or even 
cognitive therapy with a counselor. With this 
method, people learn to change the thought pattern 
that results in the sympathetic nerve discharge. 

Dietary change and anti-anxiety meds such as 
Paxil(R) are also options prior to any surgery. 
There is a procedure, however, called thoracic 
sympathectomy which can alleviate chronic 
blushing. It is now performed with an endoscope 
and involves cutting some nerves that control 
blushing. This surgery is also used for those 
individuals that have extremely sweaty palms all 
of the time. 

For more information about this procedure, see 
this article at PersonalMD.com 


2. Clomid for unexplained fertility
Clomid (clomiphene, Serophene(R)) treatment is 
often used for women who do not ovulate. Sometimes 
it may be used in cases of unexplained fertility 
in women who already ovulate. The theoretical 
reason is that some unexplained infertility may be 
due to ovulations that are not "adequate" to 
produce sufficient hormonal levels to support 
implantation of the fertilized egg. 

It is believed by some scientific investigators 
that Clomid can improve the quality of ovulations 
and thus result in a higher pregnancy rate even if 
a woman ovulates regularly. Cochrane reviews look 
at the scientific trials that have been conducted 
using Clomid for this limited purpose and 
comparing its use with placebo. 

They have found that although the pregnancy rate 
is still low in women with unexplained fertility, 
those who received Clomid had a 2 - 2.5 times higher 
pregnancy rate. They conclude that the cost is low 
and therefore Clomid should be tried even in women 
who ovulate regularly after all other causes have 
been ruled out. Remember, however, there is a 10% 
multiple pregnancy rate when using Clomid. 

Clomid for unexplained fertility

3. Reader submitted Q&A - PMS after menopause?
"I am 60 years old and I had my last period in 
1987. Since then my (PMS), or whatever it is, is 
so bad it takes at least a week out of my month! I 
have a woman obgyn because I thought she would 
understand my problem. She doesn't. I have talked 
to some other women about it and they have never 
heard of having such a bad time after no periods. 
I have headaches, backaches, cramps, bad-bad 
depression, and even nightmares. Can you help? I'm 
on hormones, Wellbutrin(R) and aspirin plus a high 
blood pressure med." -  mjb 

The "whatever it is" is the key to this problem. 
Premenstrual Syndrome (PMS) only occurs with 
ovulation from the ovary and since you are 
postmenopausal, your ovaries are no longer 
producing eggs and hormones each cycle. Therefore 
we have to look for other hormone sources that are 
mimicking PMS symptoms or perhaps look for other 
conditions entirely. 

You mention that you are taking hormones and I 
assume those are estrogen and progestin 
replacement. If you are taking the estrogen daily 
and the progestin for two weeks or less, i.e., 
cyclically, that would be the easiest explanation 
for your cyclical symptoms. 

In PMS, investigators attribute the physical and 
mood symptoms to either progesterone or an excess 
of progesterone over estrogen. With postmenopausal 
hormone replacement (HRT), many women have mood 
and physical symptoms from the specific progestin 
that is used. Provera(R) (medroxyprogesterone 
acetate used in PremPro(R) or PremPhase(R)) tends 
to produce more physical symptoms such as low back 
pain, bloating, and cramps. Another progestin used 
in HRT is norethindrone acetate found in 
Aygestin(R), Activella(R), and FemHRT(R). It has 
been shown to produce more mood symptoms. Women 
who had PMS before menopause tend to react more to 
these progestins after menopause. 

If you are taking your HRT with cyclical 
progestins (5-14 days a month), then changing to a 
continuous regimen will avoid the cyclical nature 
of your symptoms. Unfortunately, it may also 
produce some of your symptoms, albeit less severe, 
all of the time. In that case you will need to ask 
your doctor to switch your HRT to one with a 
different progestin such as norgestimate in Ortho-
Prefest(R) or natural micronized progesterone such 
as in Prometrium(R). 

If you are currently taking your HRT continuously 
such that the progestin is taken every day, then 
switching progestins may be helpful although it 
does not explain why you get your symptoms for 
only one week out of a month. You may need to keep 
a symptom calendar to make sure when you get 
symptoms in relationship to your medications and 
activities. That may shed more light on the cause. 

Other non hormonal medications can also play a 
role. You may be having some side effects from 
your medications that just for some reason seem to 
occur cyclically rather than constantly. This can 
sometimes be due to interactions between 
Wellbutrin (bupropion) and beta blockers used for 
hypertension. Also, Wellbutrin can cause headaches 
and muscle pains on its own. 

Finally, the fact that you mention more nightmares 
makes me suspect you are having low blood sugar 
problems. Progestins can cause that and so can the 
Wellbutrin and anti-hypertensives if taken at 
night. High insulin and low blood sugar often 
produces nightmares. You may want to have your 
doctor check you out for diabetes or hypoglycemia. 
The nightmares can be lessened with a protein/fat 
snack before bed such as a small cup of yogurt or 
a piece of cheese. If you are taking any of your 
medicines at night (except the aspirin should not 
make a difference) then switch them to the morning 
or take earlier in the evening. 

If you do find the medications are causing the 
problems, you may have to be switched to different 
medications or even evaluate if the benefit of the 
medications outweighs the side effects you may be 

This question very well illustrates why we have a 
paid subscriber service for personal health 
questions. Many situations require an iterative 
process to make sure  all the correct information 
is available to give you the best advice on how to 
solve a health problem. The process  for you to 
try some different regimens may take one to 
several months or more with revision of what to 
try next coming after each different trial failure 
or success. 

4. What Is a Cataract? 
A cataract is a clouding of the lens of the eye 
most commonly associated with aging. In fact over 
half of Americans 65 or older have cataracts. The 
clouding is caused by proteins in the lens that 
precipitate and clump just like an egg white gets 
more solid as heat is applied. 

The clouding may not affect vision for a while but 
if it spreads throughout the lens it makes visual 
images blurry and colors fade. Poor night vision 
is a result with worsening halos around 
headlights. Double vision and frequent eyeglass 
prescription changes indicate a cataract is 

Diseases such as diabetes or steroid use can cause 
cataracts in younger people. Smoking and excessive 
sun exposure are very strong risk factors. 
Sunglasses with ultraviolet ray protection may 
prevent or delay age-related cataract development 
if used regularly. 

When a cataract gets so bad it prevents driving, 
reading or watching TV then it needs to be 
treated. Initially an eyeglass prescription change 
may be all that is needed. Eventually, however, a 
cloudy lens needs to be removed. It can be 
replaced with an artificial lens which will 
improve vision. 

For a primer on what to expect if you develop a 
cataract and need to have it treated, see the site 
at the National Institute of Health's National Eye 

What Is a Cataract? 

5. The truth about latex condoms 
Condoms are very effective at preventing both 
pregnancy and sexually transmitted diseases such 
as HIV and chlamydia when used correctly. In fact 
when studying couples in which one partner had HIV 
and the other did not, regular and correct condom 
use prevented the negative partner from 
contracting HIV over the 20 month average follow-
up period. 

If the couples did not use the condoms 
consistently or they did not use them at all, the 
rate of HIV conversion was 10% and 15%. This is 
approximately the same efficacy of condoms for 
preventing pregnancy, i.e., when used consistently 
and correctly, pregnancy rates are very low (about 
2%) but when use is not with every episode of 
intercourse, pregnancy rates are 12%. 

So what constitutes using a condom incorrectly? 

not using the condom every time
using brittle, damaged condoms (heat damages)
not withdrawing immediately if breakage is felt
not withdrawing right after ejaculation while 
still erect 
using oil based lubricants such as vegetable oils, 
baby oil, hand lotion or petroleum jelly 

You may want to print out this fact sheet from 
SIECUS, the Sexuality and Information and 
Education Council of the United States, for your 
partner just as a gentle nudge. 

6. Health tip to share
"I had a small booklet that suggested hand 
exercises to alleviate carpal tunnel syndrome.  
Extend your arms, putting the affected hand(s) 
straight out in front of you.  Put your palms 
straight out, as if pushing something, with hands 
completely opened.  Then make a fist, bending your 
hands down at the wrist.  Bring your hands up 
again, palms facing out, again as if pushing 
something.  This does wonders to relieve my carpal 
tunnel syndrome.  I have severe nerve involvement 
to my right hand and minor to my left.  I have not 
opted for the surgery yet and may not if I can 
stave off with these exercises.  Water retention 
absolutely worsens my carpal tunnel symptoms." - 

If you have discovered ways of coping with a 
disease or condition and it works for you, please 
share it with us: 

Health tip suggestion form

7. Humor is healthy

Golfing Guru

Two women were paired together as partners in a 
club tournament and met on the putting green for 
the first time. 

After introductions, the first golfer asked the 
second, "What's your handicap?" 

"Oh, I'm a scratch golfer," the other replied. 

"Really!" exclaimed the first woman, suitably 
impressed that she was paired up with such a 
strong player. 

"Yes, I write down all my good scores and scratch 
out the bad ones! 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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****** Woman's Diagnostic Cyber Newsletter *******
                May 13, 2001
This week from Woman's Diagnostic Cyber

1. Attacking home allergens
2. All about ovulation - natural and artificial 
3. Reader submitted Q&A - Morning muscle pains
4. What are gall stones?
5. Faking illness on the internet
6. Health tip to share - 
7. Humor is healthy

Spread the word! Send a copy of this newsletter
to someone you know.

Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.

1. Attacking home allergens
The air in your home is estimated to be as much as 
70 times more polluted than the outside. Even 
recently built homes have a moderate amount of 
particles and pollutants in the air. There can be 
a million dust particles in a cubic inch of air. 
On the other hand, opening the windows for fresh 
air may not be the answer because of heavy pollen 

So what is the answer if you suffer from allergies 
or asthma? There are several steps you can take: 

Place all mattresses and pillows in allergen-
impermeable covers. 

Wash all bedding weekly in water at least 130 
degrees F. 

Don't spend much time reclining on upholstered 

Remove all carpeting in the bedroom. 

Clean up surface dust as often as possible, 

Avoid aerosols or spray cleaners in the bedroom 
and don't clean when someone with allergies or 
asthma is present. 

If you are allergic and must do the cleaning, wear 
a face mask and avoid the use of chemical 

Remove stuffed animals, and remove any objects 
under the bed that can collect dust. 

Clean closets regularly, often removing off-season 

Maintaining in house humidity at 35-40% is also 
critical to minimize the multiplication of dust 
mites and at the same time avoiding so much 
dryness of the respiratory passages that worsens 
respiratory problems significantly. 

Attacking home allergens

2. All about ovulation - natural and artificial
How the ovary works to ovulate an egg each month 
may not be of interest to most women as long as 
the process functions normally. However, if you 
are trying to conceive, if you are having a 
problem with ovarian follicle cysts or polycystic 
ovarian disease, or if you are having abnormal 
menstrual bleeding after skipping periods, then 
you may want to know how the ovulation mechanism 

At birth, a woman has all of the follicles she 
will ever have. They remain in the resting state 
until the start of menses at which time several 
follicles will start to develop each month. These 
developing follicles look like tiny cysts in the 
ovary on ultrasound but usually each month, only 
one follicle goes on to develop fully into the egg 
that will be ovulated that month. 

If a dominant follicle (egg) does not develop, the 
ovaries tend to remain in a polycystic state with 
multiple small follicles until an ovulation 
finally occurs. If a dominant follicle develops 
but does not ovulate, then a follicular cyst 
results which can swell up fairly big and produce 
pain. Gradually it will go away on its own but 
sometimes there is some bleeding inside the cyst 
("bruised ovary") which makes it painful and last 
fairly long. 

If there is something wrong with the follicle 
development phase or the ovary is arrested in 
follicle development from polycystic ovarian 
syndrome, clomiphene (Clomid (R)) may be used to 
restart the system. If clomiphene is not enough 
and a woman wants to conceive, then stronger 
medicines are used to stimulate follicle 
development and ovulation. 

One company that makes some of these products, 
Organon Inc., has a very good tutorial on the 
entire process that you may want to read if you 
are interested in that aspect of female 

All about ovulation

3. Reader submitted Q&A - Morning muscle pains
"I woke up the morning before I started my first 
period in 11 months with leg muscle pains. I 
attributed this to tramping around the city on a 
getaway that previous weekend.  Each morning the 
pains in my muscles have worsened, mainly in my 
hamstrings, not in my joints. My range of motion 
in my arms has significantly decreased also.  
Early morning is the worst and when I am in one 
position for a long time; i.e. driving, sitting at 
my desk, etc.  stair climbing difficult.  My 
ankles, knees, hips are all okay with movement and 
reflexes normal.  what could this be?" 

"I am 48 and take no medications except vitamins. 
I walk every day, am slightly overweight (15 lb) 
but otherwise healthy except for stress to the max 
with an at risk teenage daughter and elderly 
parents." -   jls 

You have very well described the pain as affecting 
the muscles and not the joints. If you are still 
within a week or two of your city excursion, the 
pain could still be from that if it was quite 
strenuous. If not, the only serious condition that 
this may represent that I am aware of is 
fibromyalgia. It is characterized by increased 
muscle pain in the morning that generally affects 
many areas of the body. A hallmark feature of the 
muscle pain of fibromyalgia is that if you press a 
finger on the muscle area that hurts, there is a 
significant increase in the level of the pain. If 
pressing on the muscle does not seem to aggravate 
the pain or it actually feels good to massage the 
muscle, then you probably do not have 

The other main cause of muscle pain which is worse 
in the morning is from overuse of the muscles 
themselves. This may be because your muscles are 
still not used to the walk that you take each day 
or it may be that the stress you have is tensing 
the muscles abnormally during each day. At night 
you may also be tensing your muscles during sleep 
because of the stress or you may have a sleep 
problem such as restless legs syndrome (RLS) that 
results in abnormal leg activity while you sleep. 
These are very difficult conditions to overcome 
and you will need to work with your physician if 
stress or RLS is a problem. 

When the body's salts are out of sync, e.g., 
sodium (Na), potassium (K), calcium (Ca) and 
magnesium (Mg), muscle cramps are more common. 
Sometimes taking a calcium/magnesium supplement, 
potassium rich foods such as bananas or just a 
sports drink with salts (e.g., Gatorade), can help 
decrease muscle cramps if that is the source of 
your pain. 

Finally, aging seems to produce more muscle 
soreness. I hate to say that or even to attribute 
muscle stiffness to that but it happens. Be sure 
to see your physician to have the other things 
checked out first, especially if this persists and 
if you have pain in the muscles with any finger 

4. What are gallstones?
Gallstones are solid chunks of cholesterol or 
calcium salts that precipitate from the gall 
bladder secretions called bile. Most people never 
know they have them because 80% of the time 
the stones do not produce any symptoms. They may 
be discovered incidentally on x-ray or ultrasound 
imaging for other problems. 

The only serious hazard that gallstones present 
are the possibility that smaller ones may block 
off the common bile duct from the gall bladder and 
liver on its way to empty into the intestinal 
tract. If that happens, one gets severe pain due 
to distension of the gall bladder full of liquid 
bile and liver damage and jaundice from bile 
backed up into the liver. 

If not fully obstructing the duct, lesser symptoms 
include heartburn, nausea, bloating or mild pain 
in the upper abdomen. Sometimes a woman may have a 
more intense pain shortly after a meal lasting for 
15 minutes to several hours. This would be called 
a gall bladder attack. They may come infrequently  
or more regularly but if you are having pain on a 
daily basis, it is probably not due to gall 
bladder attacks. 

Complete blockage of the bile duct does not always 
produce severe pain. Sometimes it just produces 
symptoms of yellowing skin (jaundice), clay 
colored stools, tea or coffee-colored urine or a 
high fever with shaking chills. These can indicate 
duct obstruction and require surgical 

Women who are taking estrogen replacement are at 
higher risk for gallstones. Maintaining a low fat, 
high fiber diet and maintaining your weight in the 
ideal range is the only way to help prevent 
5. Faking illness on the internet
Munchausen syndrome is a condition where a person 
fakes an illness or disease mainly to get 
attention from with the medical profession or from 
their family and friends. Sometimes it is done to 
obtain sympathy, act out anger or even to control 
the behavior of others. It is not common but it 
happens occasionally. Now it is happening on the 

When you discuss a condition with a person in a 
chat room or reply to questions and comments on a 
message board, you may be communicating with a 
person who is just faking the problem. But how 
would you know? That person may also be playing 
several roles in the chat room or message board. 
They have simplified the deception by taking to 
the internet rather than attending a hospital 
emergency room or doctor's office. 

The following article by Marc D. Feldman MD, who 
has followed patients with this condition over the 
years, gives tips for recognizing this syndrome on 
the Net: 

"the posts consistently duplicate material in 
other posts, in books, or on health-related 

the characteristics of the supposed illness emerge 
as exaggerated; 

near-fatal bouts of illness alternate with 
miraculous recoveries; 

claims are fantastic, contradicted by subsequent 
posts, or flatly disproved; 

there are continual dramatic events in the 
person's life, especially when other group members 
have become the focus of attention; 

there is feigned blitheness about crises (e.g., 
going into septic shock) that will predictably 
attract immediate attention; 

others apparently posting on behalf of the 
individual (e.g., family members, friends) have 
identical patterns of writing. 

Let us know if you think you have witnessed this 
going on in any of the women's health forums/chat 
rooms you have visited. 

Munchausen by Internet: Faking Illness Online

6. Health tip to share - Get checked for glaucoma
Don't forget that your eyes need to be 
periodically checked to make sure the fluid 
pressure of the eyeball is not too high. Glaucoma 
is an increased eye pressure condition that can 
silently lead to blindness if not discovered 

Recommended screening frequency at your eye doctor 
or with a personal physician who checks the 
pressure in your eyes, is: 

every 3-5 years after age 38, 

every 1-2 years after age 64 

every 1-2 years if you are at high risk due to:
  African ancestry, 
  family history of glaucoma, 
  high blood pressure, 
  history of cortisone use or eye surgery

Glaucoma - get tested

If you have discovered ways of coping with a 
disease or condition and it works for you, please 
share it with us: 

Health tip suggestion form

7. Humor is healthy
"He Loves Me, He Loves Me Not..." 

Susan and Jane are old friends. They have both 
been married to their husbands for a long time, 
Jane is upset because she thinks her husband 
doesn't find her attractive anymore. 

"As I get older he doesn't bother to look at me!" 
Jane cries. 

"I'm so sorry for you, as I get older my husband 
says I get more beautiful every day." replies 

"Yes, but your husband is an antique dealer!" 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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****** Woman's Diagnostic Cyber Newsletter *******
                May 20, 2001
This week from Woman's Diagnostic Cyber

1. Lipid lowering recommendations
2. Moles or not? 
3. Reader submitted Q&A - FSH to measure menopause
4. Withdrawal Symptoms from Paxil(R)
5. Pain in the tailbone
6. Health tip to share - Pulse pressure as a sign
7. Humor is healthy

Spread the word! Send a copy of this newsletter
to someone you know.

Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.

1. Lipid lowering recommendations
By now, many of you have heard that there are some 
new, medical expert panel recommendations for 
goals of maintaining low cholesterol levels. 
Specifically, low density lipoprotein levels 
(LDL), the "bad cholesterol", is the target of the 
outcome goals. The different categories of risk 
and what the goal should be for diet, exercise and 
lipid lowering drugs called "statins", can be 
somewhat confusing. 

Risk factors include:

age over 55
family history of heart disease in first degree 
  female relatives under age 65 or in first degree 
  male relatives under age 55 
blood pressure over 140/90 on anti-hypertensive 
a high density lipoprotein (HDL) level of less 
  than 40 mg/dl 

Risk categories are:

0-1 of above risk factors - LDL goal less than 160 
2+ risk factors - LDL goal less than 130 mg/dl
current coronary heart disease or diabetes - LDL 
  goal less than 100 mg/ml 

The main new recommendations from this recent 
report are:

1. Diabetes should be treated as a severe risk 
factor as much as already having coronary artery 
disease even if a person has no yet had a heart 
attack or angina. The goal in this highest risk 
category is to maintain LDL cholesterol levels at 
under 100mg/dl 

2. The category of two or more risk factors uses 
the Framingham Heart Study risk assessment scoring 
system to further divide that group into a higher 
risk category that needs more aggressive 
cholesterol lowering goals of an LDL of less than 
130 mg/dl 

3. The identification of a metabolic syndrome that 
is associated with insulin resistance and requires 
more intensive LDL lowering. This is defined as 
any 3 of the following in women: 

waist circumference of more than 35 inches (88 cm)
triglycerides greater than 150 mg/dl
HDL level less than 50 mg/dl
fasting glucose greater than 110 mg/dl
blood pressure greater than 135/85

The new recommendations are not different at all 
for those who are at low risk, i.e., have 0-1 risk 
factors, which is the majority of women. Statin 
drugs are not really recommended for those low 
risk women unless you have extremely high LDL 
levels over 190 mg/dl. 

You may want to see these recent recommendations 
as well as our past article on cholesterol and 
lipid disorders. 

National Cholesterol Education Program (NCEP)

Cholesterol and Lipid Disorders

2. Moles or not?
Moles are pigmented skin lesions that are either 
flat or raised. The medical term for them is nevi. 
For the most part they are benign skin lesions 
that people have on their skin for many years; 
sometimes all of their lives. More moles appear as 
you age. The only worrisome concept about moles is 
that they can change from a benign growth into a 
skin cancer called malignant melanoma. 

Malignant melanoma is a very  aggressive cancer so 
recognizing a mole that has recently changed is 
critical to successful treatment. It is much 
different than a basal cell cancer of the skin 
which doesn't seem to spread very quickly at all. 
The warning signs of a mole becoming malignant can 
be remembered by the pneumonic of the ABCDs 

Asymmetry - One half does not match the other half. 

Border irregularity - the edges are irregular, 
blurred or may have finger-like projections. 

Color - There are various shades of color within 
the same mole. 

Diameter - any mole greater than 6mm (the size of 
a pencil eraser) bears evaluation by a 

This article below at Dermadoctor.com points out a 
very key ingredient in watching out for malignant 
melanoma. Most people are amazed that a mole they 
have had for years and years all of a sudden 
changes in shape or size or forms irregular 
borders. Dr Kunin says that all of her patients 
that develop melanoma declare "but I have ALWAYS 
had that mole; it could not be skin cancer!" 

3. Reader submitted Q&A - FSH to measure menopause
"How do I know if my condition is menopause or 
something else? I am 45 years old, take no 
medications other than a multivitamin, vitamin E 
and calcium supplement.  I have not had a period 
in 3 months.  Over the past year or so, my periods 
have been very irregular, and I had what I thought 
were probably hot flashes a few times. Before 
this, my periods were regular and every 21 days. 
Sometimes it feels as though I am about to start, 
with lower abdominal pressure and some back pains.  
However, I have not even had these symptoms in 
over a month." -  S.F. 

Follicle stimulating hormone (FSH), a blood test, 
is the only way to know for sure about menopause. 
When the ovaries quit functioning for good, the 
FSH levels become high. It depends upon which lab 
measures the FSH because they all have somewhat 
different normal ranges. A value of over 40 IU/L 
is confirmatory of menopause. However some labs 
feel that any value over 25 IU/L represents 

Values between 10-25 IU/L indicate an ovarian 
resistance that comes with approaching menopause 
(perimenopause). Unfortunately this range can also 
indicate midcycle ovulation in a normally 
ovulating woman. Therefore if you had a lab 
measurement in this range and an episode of 
bleeding within two weeks, you would not know for 
sure if you were menopausal or just had a sporadic 

Estrogen levels below 50 pg/ml also may indicate 
menopause. Just like FSH, low estrogen levels can 
indicate conditions other than menopause such as a 
suppression of menses by a stress induced 
(hypothalamic) anovulation. 

In order to clarify whether you are menopausal or 
not with one blood draw and one visit to the 
doctor, drawing blood tests for both FSH and 
estradiol almost always solves the problem: 

Condition       FSH            Estradiol

menopause     over 40 IU/L    under 50 pg/ml

stress induced
anovulation   under 10 IU/L   under 50 pg/ml

perimenopause 10-40 IU/L      under 100 pg/ml

ovulation     10-25 IU/L      over 100 pg/ml

In any cases, if estrogen (estradiol) levels are 
under 50 pg/ml, an estrogen supplement will make 
you feel better. In the perimenopause very low 
dose birth control pills (1/20) or low dose 
estrogen patches (0.0375 - .05 mg/day) for this 
supplementation. You can confirm the low estrogen 
levels by some of the home salivary estrogen 
tests, but there is no home test for FSH. 

4. Withdrawal Symptoms from Paxil(R)
The selective serotonin reuptake inhibitor (SSRIs) 
class of drugs has helped make great strides in 
the treatment of anxiety and depression and other 
mental health conditions. Drugs such as Paxil 
(paroxetine), Zoloft (sertraline), and Prozac 
(fluoxetine) are heavily prescribed and used and 
of benefit to daily functioning. 

What happens though, when you decide to stop the 
medications either because you do not believe they 
are working or perhaps because you are feeling 
better or the cause of your anxiety has gone away? 
Can you just stop them or do you need to taper 

Most people have just been in the habit of 
stopping the medications all at once because they 
and their doctors may be unaware of side effects 
with discontinuance. As it turns out there are 
definite antidepressant discontinuation symptoms 
although not everyone suffers from them. 

Withdrawal starts within 1-2 days after stopping 
the medication. Symptoms peak about day 5 and 
usually resolve within 2-3 weeks. These include 
dizziness, headache, nausea, and flu-like symptoms 
as well as anxiety, confusion, irritability, 
excessive dreaming and insomnia. 

In one randomized clinical trial, Paxil was found 
to produce the worst withdrawal symptoms and 
Prozac the least, with Zoloft in between. It has 
even been reported that in patients switched from 
one medication to another, e.g., Paxil to another 
drug, that the symptoms from withdrawal have been 
misinterpreted as side effects to the new drug. 

The bottom line is to be aware that the SSRI 
drugs, especially Paxil, must be tapered gradually 
(over 2-3 weeks) when being discontinued or even 
when being switched to a different drug. 

Withdrawal from Paxil

Comparison of withdrawal side effects

5. Pain in the tailbone
The tail bone at the end of the spine is called 
the coccyx. Sometimes if it becomes injured and 
does not heal properly, it can produce a chronic 
pain. People who have this coccydynia pain are 
unable to sit comfortably at all. Standing or 
lying on their side are the only tolerable 
positions. Sometimes even walking can make the 
coccyx move slightly and cause pain. Leg numbness 
is NOT a part of this problem. If leg numbness is 
present, there may be some involvement of the 
sacrum bone or the lumbosacral spinal cord and 
this will require an MRI to investigate it. 

While a fall or some sort of trauma is the most 
common cause of tail bone pain, labor and delivery 
of a child can also break the attachment of the 
coccyx to the sacrum bone. Usually it heals back 
in place but a woman needs to be careful not to 
keep moving it out of place and thereby developing 
chronic pain. 

Diagnosis is made by history and physical exam and 
x-ray of the coccyx and sacrum. Treatment is 
almost always conservative in an attempt to allow 

A donut type of cushion or pillow is the only way 
to sit comfortably and keep pressure of the 
coccyx, to keep it from moving so it can heal in a 
fixed position. These donut cushions or pillows 
can usually be obtained at a medical supply shop 
or by mail order from special catalogs. This is 
the best way to get the coccyx to heal non-

Anti-inflammatory drugs are very useful to help 
with the pain while the coccyx is healing. Heat 
and ultrasound treatments may also be used to help 
any topical ointments be absorbed through the 
skin. Sometimes injection of the joint with 
steroids is used for pain relief until healing can 
take place. Rarely, if all of these non surgical 
treatments fail to relieve the pain of coccydynia, 
then surgical removal of the coccyx may be the 
last resort. 

For more background on this unusual but painful 
condition , look at spinesolver.com. 

Coccydynia a pain in the tailbone 

A coccyx pillow can be obtained at internet stores 
and may also aid women with hemorrhoids who sit 
for hours at work and the pillow can be turned 
around for those who have bad vulvodynia: 

Tush-Cush Tailbone Pillow

6. Health tip to share - Pulse pressure as a sign
Pulse pressure is the measure of the difference 
between your systolic blood pressure minus your 
diastolic blood pressure. In other words if your 
blood pressure is 130/80 then the pulse pressure 
is 50. A blood pressure of 170/90 has a pulse 
pressure of 80. As you get older, the pulse 
pressure can be more predictive of the potential 
for heart attacks and strokes than the blood 
pressure itself. 

If you are over the age of 60, pulse pressures of 
over 60 (e.g., 160/90) are more predictive of 
atherosclerosis. Under age 50, the diastolic 
pressure (the lower reading) is most predictive of 
future heart problems. You may want to discuss 
this with your doctor. 

Pulse pressure

If you have discovered ways of coping with a 
disease or condition and it works for you, please 
share it with us: 

Health tip suggestion form

7. Humor is healthy
"You Know You Are Getting Older When....."

1. You and your teeth don't sleep together. 

2. Your try to straighten out the wrinkles in your 
socks and discover you aren't wearing any. 

3. At the breakfast table you hear snap, crackle, 
pop and you're not eating cereal. 

4. Your back goes out, but you stay home. 

5. When you wake up looking like your driver's 
license picture. 

6. It takes two tries to get up from the couch. 

7. When your idea of a night out is sitting on the 

8. When happy hour is a nap. 

9. When you're on vacation, and your ENERGY runs 
out before your money does. 

10. When you say something to your kids that your 
mother said to you, and you always hated it. 

11. When all you want for your birthday is to not 
be reminded of your age. 

12. When you step off a curb and look down one 
more time to make sure the street is still there. 

13. Your idea of weight lifting is standing up. 

14. It takes longer to rest than it did to get 

15. Your memory is shorter and your complaining 
lasts longer. 

16. Your address book has mostly names that start 
with Dr. 

17. You sit in a rocking chair and can't get it 

18. The pharmacist has become your new best 

19. Getting "lucky" means you found your car in 
the parking lot. 

20. The twinkle in your eye is merely a reflection 
from the sun on your bifocals. 

21. It takes twice as long - to look half as good. 

22. Everything hurts, and what doesn't hurt - 
doesn't work. 

23. You look for your glasses for half an hour, 
and they were on your head the whole time. 

24. You sink your teeth into a steak - and they 
stay there. 

25. You give up all your bad habits and still 
don't feel good. 

26. You have more patience, but it is actually 
that you just don't care anymore. 

27. You finally get your head together and your 
body starts falling apart. 

28. You wonder how you could be over the hill when 
you don't even remember being on top of it. 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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****** Woman's Diagnostic Cyber Newsletter *******
                May 27, 2001
This week from Woman's Diagnostic Cyber

1. Elements of good treatment for hypertension
2. A monthly injectable contraceptive
3. Reader submitted Q&A - Disability from pelvic pain 
4. Causes of leg pain.
5. Is there a male menopause?
6. Health tip to share - Acidity of cola products
7. Humor is healthy

Spread the word! Send a copy of this newsletter
to someone you know.

Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.

1. Elements of good treatment for hypertension
Hypertension has many different treatments, most 
of which are very effective in reducing blood 
pressure. The main purpose of treating 
hypertension is to reduce or eliminate the long 
term consequences of heart attacks, strokes or 
other vascular complications. High blood pressure 
is also a very highly studied entity. Many 
different medications have been used and 
scientifically evaluated. 

The question arises as the whether all of the 
different types of antihypertensives are equally 
effective in preventing hypertensive complications. 
Analysis of all of the scientific trials where a 
given medication is compared with a placebo 
blindly should be able to show a trend of which 
types of antihypertensive medications are the most 
effective. A recent study published in the British 
Medical Journal looked at this specifically. 

After reviewing over 1500 studies, the authors 

1. For the initial treatment for hypertension, a 
single blood pressure drug may work but sometimes 
a combination of two or more different drugs may 
be needed to control the  blood pressure. 

2. Anti-hypertensive treatment definitely works. 
It decreases risks of fatal and non-fatal stroke, 
cardiac events, and death and it may improve 
the quality of life because of less serious 

3. Thiazide diuretics (e.g., hydrochlorthiazide 
(Diuril(R)), chlorthalidone) seem to be the best 
first line agents for reducing rates of stroke and 

4. Angiotensin converting enzyme (ACE) inhibitors 
(Accupril(R), Altace(R), Captopril(R), 
Lotensin(R), Monopril(R), Vasotec(R)), some  beta 
blockers, and some long acting calcium channel 
blockers are effective alternatives as first line 

5. Short acting alpha antagonists (doxazosin 
(Cardura(R)) should be avoided as a first line 

6. Short acting calcium channel blockers should be 
avoided (felodipine or isradipine) because of 
higher side effect rates. 

In most cases, doctors feel that by controlling 
and lowering an elevated blood pressure, that will 
result in the best long term result. But the 
absolute blood pressure and serious outcome events 
of heart attacks or strokes do not always go hand 
in hand. We need to keep focused that the goal 
is to prevent these serious complications. 

Therefore it is interesting that the evidence 
shows that simple (and inexpensive diuretics - 
water pills) are still considered the first line 
drugs to treat high blood pressure. Also, if they 
are taken alone and or in combination with other 
antihypertensive medications, they still show the 
best or equivalent success at the long term 
prevention of serious consequences from 

My impression is that in recent years, many women 
get started on other more expensive drugs first 
and if they do, diuretics may never be added as a 
combination drug. Remember that diuretics do not 
tend to affect sexual functioning as do some of 
the other antihypertensive medications. Since 
they are also very effective, inexpensive and 
have low side effects, you may want to inquire 
with your physician if you are hypertensive but 
not taking a diuretic. 

What are the elements of good treatment for hypertension?

2. A monthly injectable contraceptive
Occasionally we get questions about what new 
contraceptives are available. You might want to 
know about this one called Lunelle(R) which is a 
monthly shot that still results in monthly 
menses. It is not for everyone but it may have a 
place for you. 

The shot is comprised of microcrystals of estrogen 
and progesterone and should be taken every 28-30 
days and not greater than 33 days apart. The blood 
levels of estrogen and progesterone rise and fall 
in a somewhat different pattern than when you 
normally ovulate, but the pattern is closer to 
natural than with birth control pills or with 
DepoProvera injections. 

The main comparison points to the other frequently 
used injectable contraceptive, Depo Provera(R), 

Lunelle(R)               DepoProvera(R)

monthly injection        every 3 months injection
monthly menses           often no menses at all
low break thru bleeding  frequent spotting
less vaginal dryness     more vaginal dryness
? any appetite effect    frequent appetite increase
reliable protection      reliable protection

This monthly injectable contraceptive may be for 
the woman who has difficulty remembering to take 
pills on a daily basis but who can remember to get 
a monthly shot. It may also be better than 
DepoProvera(R) for a woman who has had frequent 
spotting or moderate appetite increase on 
DepoProvera. It may play a role in perimenopausal 
therapy in women having some hot flashes or 
irregular bleeding but who are not yet fully 
menopausal (and do not smoke). 

Ask your doctor about it if you think you might be 

Lunelle injectable contraceptive

3. Reader submitted Q&A - Disability due to pelvic pain
"Are chronic pelvic adhesions considered a 
disability under the "Americans with Disabilities 
Act?" Is it legal to terminate someone for 
excessive absenteeism with this diagnosis? " 

"I was diagnosed with this chronic disease in 
1998. Through the years I have been in pain on and 
off and was taken out on short-term disability for 
this disease. I returned back to work for three 
days and then started having unbearable pain when 
walking and sitting. I called in sick on the 4th 
day of work and went to my doctor who prescribed 
new medication and advised in writing that I stay 
home for one week. I was called at home and 
terminated by my manager. This disease is 
sometimes very debilitating. How can they fire me 
for this when if the disease was diabetes or 
lupus, termination would never have happened." - 

Chronic pain of any type can play havoc with a 
job. Employers are often intolerant of missing 
work due to illness or doctor's appointments but 
certainly the extent of their intolerance varies 
with their company's policies and your immediate  
supervisor's own personality. You may wonder to 
what degree an employee has the right to expect 
sick leave without being fired for taking it too 

As it turns out, employers may have to make some 
accomodations to help a disabled employee 
continuing working under the Americans with 
Disabilities Act, 42 U.S.C. §§ 12101-12771. On the 
other hand, if you cannot perform the work because 
of the problem, you do not qualify for any 
protection under the act. 

For a discussion of disability from chronic pelvic 
pain in the workplace and its role in retaining a 
job, see our health law article at: 

Job Termination Due to Pelvic Pain

4. Causes of leg pain.
Leg pain is a common complaint among both women 
and men. It may occur after sitting in a fixed 
position for awhile or also commonly at night 
during sleep. The most frequent cause is previous 
muscle exertion that the legs are not used to. 
Also loss of salts such as sodium (Na), potassium 
(K) and calcium (Ca) can be associated with leg 
pains as we discussed in the newsletter not too 
long ago. 

Morning leg pains

There are many other causes of leg pains that you 
should be also be aware of. The pain may arise 
from arterial or venous problems of the blood 
vessels to the legs. Varicose veins are common and 
if you press on the vein directly and it hurts, a 
varicose vein is likely to be the source of the 
pain. Deeper veins can also be the source of the 
pain. In this case the pain feels as if it is deep 
in the muscle of the back of the calf or thigh. 
This may represent a thrombophlebitis and in many 
cases is associated with swelling of the leg. It 
usually affects only one leg rather than both at a 
time. It is a serious problem because it may 
result in blood clots to the lung. 

Joint pain or bone pain is different than muscle 
pain as far as the etiology. If joint movement 
reliably reproduces the pain then arthritis is 
likely and you should see your physican for that. 
Pain that seems to be deep in the bone may 
represent infection of the bone especially if 
there has been previous trauma in that area. 

Other less common causes of leg pain might include 
nerve damage, fractures or past trauma to the 
bones, or side effects to drugs. Narrowing of the 
arteries is a serious cause of leg pain and if 
exercise immediately produces leg pain, see 
your physician right away. The medical term  for 
this is claudication and it can be a complication 
of diabetes or severe atherosclerosis. 

For a list of leg pain possiblities see this 
article at Adam.com 

Causes of leg pain

5. Is there a male menopause?
In a woman's natural menopause, there is a gradual 
decline in many hormones such as growth hormone, 
testosterone, and DHEA  with a more abrupt 
lowering of estrogen at the time of ovarian 
failure. Men have the same gradual lowering  of 
all hormones without any abrupt change at about 
age 50 like women but if you look at age 60, you 
would not see any real difference in the overall 
decline of hormones in men versus women compared 
to their own earlier values in their 30's for 

Many people, including physicians feel, that such a 
condition like male menopause does not exist. 
Others believe that the decline in testosterone  
in men is significant at sometime between 45 and 
60 label it as "andropause. They say the symptoms 
of male menopause "will sound familiar to any 
woman who already has undergone the change: 
irritability, mood swings, depression, anxiety, 
palpitations, memory loss. About one in 10 men 
even suffer hot flashes." Loss of muscle mass and 
a decreased need to shave on a daily basis are 
also warning signs. 

Testosterone levels in males spike more than women 
so several blood levels need to be drawn and an 
average is taken to see if they are low. The 
treatment for this is testosterone supplementation 
usually by shot, skin patch or skin gel. 

Unfortunately testosterone supplementation in men 
carries some of the same consequences as in women, 
especially if the replacement levels are too high. 
Baldness (hair loss), acne, elevation of 
cholesterol, increase in blood pressure and fluid 
retention are all side effects that men (and 
women) can develop or have worsen when taking 
testosterone replacement therapy (TRT). 

Therefore any replacement should be administered 
under a physician's guidance and the benefits and 
risks need to be carefully weighed in an 
individual's case. 

For information about this, see the article at 

Is there a male menopause?

6. Health tip to share - Acidity of cola products
Some women have questioned whether the caffeine in 
Coke or cola products is bad for your stomach. 
Actually the caffeine is not the problem; acid is. 
Coke has a pH acid measurement of 2.5 which is 
extremely acidic (neutral is 7.0). Actually Coke 
syrup has been reported as quite soothing to the 
stomach. It is the carbon dioxide gas that is 
dissolved and turns into carbolic acid that is the 
main gastrointestinal irritant. Women with 
gastroesophageal reflux disorder (GERD) would be 
well advised to avoid most carbonated beverages. 

If you have discovered ways of coping with a 
disease or condition and it works for you, please 
share it with us: 

Health tip suggestion form

7. Humor is healthy

Stress Kit

An old one with a new face:

As a new bride, Aunt Edna moved into the small 
home on her husband's ranch.  She put a shoe box 
on a shelf in her closet and asked her husband 
NEVER to touch it. 

For fifty years Uncle Jack left the box alone 
until Aunt Edna was old and dying. One day when he 
was putting their affairs in order, he found the 
box again and thought it might hold something 
important. Opening it, he found two doilies and 
$82,500 in cash. 

He took the box to her and asked about the 

"My mother gave me that box the day we married," 
she explained. "She told me to make a doily to 
help ease my frustrations every time I got mad at 

Uncle Jack was very touched that in 50 years she'd 
only been mad at him twice. 

"What's the $82,500 for?" he asked. 

"Oh, that's the money I made selling the rest of 
the doilies." 

Contributed by: Robert

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

Back to top

****** Woman's Diagnostic Cyber Newsletter *******
                June 3, 2001
This week from Woman's Diagnostic Cyber

1. Red yeast rice lowers cholesterol like a statin
2. Natural products for sexual dysfunction 
3. Reader submitted Q&A - Finding the best treatment
4. The many causes of urinary incontinence
5. Piriformis syndrome causing hip and leg pain
6. Health tip to share - CocaCola acidity 
7. Humor is healthy

Spread the word! Send a copy of this newsletter
to someone you know.

Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.

1. Red yeast rice lowers cholesterol like a statin
Red yeast rice is a Chinese traditional product 
called Hong Qu. It is made by the fermentation 
of a special yeast over rice. It is an 
interesting nutritional supplement because the 
yeast converts some of the rice into byproducts 
that are the same as statins, the prescribed 
medicines used to lower blood cholesterol. 

The statins found in this product are quite 
similar to cholesterol lowering medications such 
as Mevacor(R) and Pravachol(R). In fact one 
clinical trial using Red Yeast Rice found 
approximately a 20% lowering effect of total 
cholesterol and LDL cholesterol.  The dose used 
was 2.4 grams a day of a proprietary Red Yeast 

Because prescription grade statins have side 
effects, it is prudent to assume that Red Yeast 
Rice could also have some of those side effects. 
Liver toxicity is a theoretical worry. In 
practice, however, the side effects seem to be 
quite low. There may be about a 1-2% problem with 
GI upset and about 1% severe dizziness, Still, it 
is wise to let your physician know you are taking 
something like this. 

Red yeast rice and cholesterol

2. Natural products for sexual dysfunction
Everyone looks for natural products that may help 
with a minor symptom or ailment and this is true 
especially for conditions that modern medicine 
does not seem to do a good job with. Sexual 
dysfunction and decreased libido is one area that 
is often the subject of looking for relief from 
natural products. 

As it turns out, there are some successful natural 
therapies for certain sexual problems. For example 
anti-depressant associated sexual dysfunction has 
been improved using Gingko biloba extract. One 
study using 120 mg of Gingko biloba extract twice 
a day found a positive effect in improving the 
ability to become sexually aroused in men and 
women using paroxetine (Paxil(R)) and sertraline 

Ginseng and yohimbine may also help anti-
depressant associated sexual dysfunction but they 
seem to have a much higher incidence of side 
effects including hypertension. Using them would 
best be under a physician's monitoring or at least 
a regular check of blood pressure. 

Damiana is another herb that has been used to 
stimulate sexual desire. It does have some 
progesterone receptor activity but has not been 
well enough studied to recommend for or against 
its use. 

For a discussion of these and other natural 
products and their effect upon sexual dysfunction, 
see this article: 

Natural products for sexual dysfunction

3. Reader submitted Q&A - Finding the best treatment 
"My daughter has lupus and we are searching for 
the BEST treatment we can for her.  She has not 
been in remission in the three years since her 

"My question is: How does one go about finding the 
premier hospital for looking at best practices 
known for a particular disease and applying them 
to an individual patient?"  - T. J. 

This question is very difficult as you may 
surmise. The main problem is that there is no 
definition of premier quality medical care and for 
most medical conditions there is not universal 
agreement as to the "gold standard" of care.

The first approach you use should involve asking 
and working with your personal physician to find a 
provider to give you a second opinion. While some
physicians may react to a perceived lack of trust, 
almost all of them will comply with your request 
if you are just polite and persistent.

The internet has given us tools to search for the 
latest medical research as well as to find out the 
names and membership of medical specialty 
societies, associations and organizations. Support 
groups which include those who have suffered and 
been treated for these conditions at various 
locations around the country, can also be a source 
of advice. Using multiple sources to cross 
reference a list of possible resources for second 
opinions, you can search out nationally known 
physicians that may provide the answers you are 

For a discussion of how you might go about this 
task, see our article at:

Finding the best medical treatment

4. The many causes of urinary incontinence
The most common types of urinary incontinence are 
stress incontinence, urge incontinence and a 
mixture of the two (mixed incontinence). Stress 
incontinence is mostly associated with an 
anatomical problem in which the bladder neck moves 
freely and "drops" with any increase in 
intraabdominal pressure such as that associated 
with coughing, sneezing or laughing. 

Urge incontinence is due to an abnormal frequency 
or intensity of bladder contractions. Usually we 
can control when the bladder detrusor (emptying) 
muscle contracts but with urge incontinence, the 
muscle just functions at seemingly random times. 
The force of the emptying muscle overcomes our 
ability to hold the urine in by voluntary 
contraction of the urethral sphincter muscle. The 
end result is leakage of urine before we can make 
it to the bathroom. 

As we age and as we acquire certain medical 
diseases, urge incontinence is more and more 
common. Loss of estrogen to the urethral lining 
makes it harder to hold urine. Prolapse of any 
type seems to stimulate the bladder to want to 
contract. Stroke, heart failure, constipation, 
obesity, chronic lung disease, diabetes mellitus, 
multiple sclerosis and Parkinson’s disease all can 
cause or worsen urge incontinence. 

If there are not major nervous system or spinal 
cord conditions such as stroke or spinal cord 
trauma, urge incontinence is often treatable by 
bladder retraining (timed voiding), medications, 
and other non surgical approaches. 

For a discussion of the types of urinary 
incontinence and their diagnosis and treatment, 
see this article in Clinical Geriatrics at: 

The many causes of urinary incontinence
5. Piriformis syndrome causing hip and leg pain
The piriformis muscles on the right and the left, 
run from the broad part of the tailbone (sacrum) 
to the outer part of the hip bone on each side. 
The muscle helps rotate the whole leg out or in. 
The large nerve that goes down the leg, the 
sciatic nerve, lies under this muscle between it 
and the pelvic bones. If the piriformis muscle 
becomes contracted or goes into spasm, it not only 
produces buttock pain on the side the muscle is 
affected, but also pain that shoots down the leg 

So what are the causes of this muscle spasm or 
contraction? It can occur from just sitting in a 
fixed or unusual position, overuse of the buttock 
(gluteus) muscles, or abnormal walking, posture or 
sitting habits. Just driving on a long trip with 
one of your legs externally rotated (knee away 
from the body) can cause this. 

Stretching and strengthening the muscle are the 
primary and best treatments for piriformis 
syndrome. From About.com-Sports Medicine, we get 
the following instructions to stretch the RIGHT 
piriformis muscle: 

"lay on your back, bend your knees and cross your 
right leg over your left so your right ankle rests 
on your left knee in a figure four position. Bring 
your left l
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