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Women's Health Newsletters 6/17/01- 7/22/01



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****** Woman's Diagnostic Cyber Newsletter *******
                   June 17, 2001
This week from Woman's Diagnostic Cyber

1. What is obesity?
2. Recurrent yeast infections - A theory of cause
3. Reader submitted Q&A - HRT and breast cancer
4. Migraines and hormones - What you should know
5. Seniors are also at risk for HIV
6. Health tip to share - Wolff-Parkinson-White Syndrome
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. What is obesity?
The term 'obesity' hits us right in the midsection 
-- or elsewhere. It is defined as a body mass 
index (BMI) of 30 or higher. In other words, at 
various heights for women, the following weights 
or higher would be classified as obesity: 

height  weight lbs
5'0"      153
5'1"      158 
5'2"      164
5'3"      169
5'4"      174
5'5"      180
5'6"      186
5'7"      191 
5'8"      197 
5'9"      203
5'10"     209
5'11"     215
6'0"      221

Unfortunately no other recipe than 'more calories 
in than calories out' leads to obesity. Therefore 
the primary treatment is a long term 'more 
calories spent than are taken in'. 

The main conditions known to promote obesity are: 

genetics - with one or both obese parents, your 
chances increase to 25-30% 

medications - tricyclic antidepressants, steroids 
including DepoProvera  

aging - we all lose muscle mass as we age and our 
calorie requirement goes down 

hypothyroidism - about 2% of obesity is explained 
by low thyroid function. 

Inactivity - It is easy with sedentary activity to 
expend 500 less calories a day. If eating goes on 
the same rate as before this decreased activity, a 
weight gain of almost 50 pounds a year is 

For a list of suggestions as to how you might take 
off some weight, see this article below at 
Mayoclinic.com. Also see our past article on the 
health consequences of an elevated BMI. 

Guidelines for Healthy Weight

2. Recurrent yeast infections - A theory of cause
Recurrent yeast infections can be difficult to 
treat. One of the big questions that faces 
physicians is whether a recurrent yeast infection 
represents reinfection after successful treatment 
or whether it represents reemergence of the yeast 
overgrowth from an infection that was not 
completely treated. 

The following study tries to answer that question 
by looking at the specific strains of yeast that 
could be cultured after an infection. Yeast have 
many different strains that can be measured by 
their DNA configurations and other properties. In 
a series of 22 women who had recurrent vaginal 
yeast infections the investigators looked at 
whether the recurrent infection had a different 
strain of yeast than the previously treated one. 

They found that the same strain of yeast was 
responsible for the initial and recurrent episode 
in 17 out of 22 women (77%). The other 5 women had 
different strains or a different species of yeast 

This implies that in about 3/4's of the cases, 
perhaps we need to have longer courses of 
treatment because the yeast does not seem to be 
fully eradicated. The other 25 percent of cases 
represent a vaginal environment that is simply 
just too conductive to growing yeast and the 
environment needs to be changed. 

For those of you who have recurrent yeast 
infections, you might ask you doctor about a 
regimen of 100-150 mg of Diflucan once a week. 
That has worked well in our practice although it 
is not a common way to prescribe for recurrent 
yeast. Remember also to change the environment by 
taking lactobacillus acidophilus as a separate or 
a food supplement. 

Recurrent yeast infections

3. Reader submitted Q&A - HRT and breast cancer
"What are the risks of cancer when taking Fem-HRT? 
I am 48 and my Dr. put me on it a year ago. I go 
on it for awhile then read about HRT and quit 
taking it for fear of cancer. But it does help 
with severe hot flashes." 

"My mother and grandmother never took HRT. They 
both had strokes. My mom had throat cancer. I 
worry about how safe Fem-HRT is." - T J. 

This is a question the doctor cannot answer for 
you; you have to answer it for yourself. Hormone 
replacement therapy (HRT) has been used for 
decades and there is a good body of knowledge 
about the risks and benefits of it. Fem-HRT(R) is 
a fairly new combination of estrogen and progestin 
but both components have been used extensively 
and there is no reason to think that it will react 
or produce differently than other more extensively 
studied HRT. 

Estrogens have benefits and risks. You know the 
short term benefits of the hot flash reduction and 
counteraction of vaginal dryness. The long term 
benefits are the protection of the new occurrence 
of heart disease and osteoporosis. There also 
appears to be a 50% reduction of colon cancer and 
Alzheimer's disease in women who are on long term 


The main concern most women have is the 
possibility of a slightly higher incidence of a 
well-differentiated breast cancer. The risk ratio 
for developing breast cancer may be 1.3-1.4 to 1. 
There are other factors that are more important 
for breast cancer risk than taking HRT. The Gail 
model is the most commonly associated risk 
assessment tool to predict breast cancer risk and 
the factors it uses are: 

number of 1st degree relatives with breast cancer 
age at first menstrual period 
age at first delivery of a child 
number of previous breast biopsies 
previous history of atypical ductal hyperplasia on 
  breast biopsy 
past history of ductal carcinoma in situ or 
  lobular carcinoma in situ 

These above factors are much more important than 
whether you take HRT. If you do have some of these 
risk factors, use the Gail model to calculate your 
risk. If you are at least 35 yrs of age with a 5-
year predicted breast cancer risk of 1.67% or more, 
as calculated by the Gail model, then you would be 
considered at high risk and I would not suggest 
taking HRT. 

Am I at risk for breast cancer?

Risk model software

If you are at high risk or are just concerned 
enough that you do not wish to take HRT, then you 
might want to consider taking phytoestrogens such 
as that found in soy or red clover. It is only 
about 50% as effective in preventing hot flashes 
and preventing osteoporosis as estrogens but it is 
better than not taking anything. Promensil(R) 
which is available at health food stores and many 
pharmacies is my choice (taking 40 mg of 
isoflavones a day). 

If you still have hot flashes, you may just need 
to manage them conservatively. 

The Non Hormonal Treatment of Hot Flashes

To summarize, this is an agonizing question for 
all women. Try to read as much as you can and keep 
an open mind. Discuss your specific concerns with 
your doctor and when your questions seem to be 
answered as best they can be, make your choice. 

4. Migraines and hormones - What you should know
In women who have migraine headaches, the question 
arises as to whether hormones will make the 
headaches worse or if a woman who has migraines is 
at risk for strokes from hormones. Traditionally 
all types or forms of migraine headaches have been 
lumped together when assessing for the risk of 
ischemic stroke. 

This article below represents a current 
neurological opinion about the risk of stroke in 
women with migraines and whether or not they take 
hormones including oral contraceptives (OCs) or 
postmenopausal estrogen replacement (HRT) therapy. 
The opinion is based on how the International 
Headache Society Task Force assessed the efficacy 
of treatment of women with OCs or HRT. 

It concludes that women who do not have an aura 
with their migraines can take oral contraceptives 
safely. If they do have migraines with aura or 
have other risk factors for stroke (e.g., previous 
stroke or ischemic heart disease) then they are at 
risk if they take OCs. They also conclude that 
postmenopausal hormone replacement therapy neither 
increases nor decreases stroke risk in women with 
migraines whether or not they have auras 
associated with the headache. 

An aura with a migraine is an unusual visual 
episode of "seeing stars" or spots in the eyes, 
seeing wavy or jagged lines or color patterns. The 
visual disturbance usually precedes or coincides 
with the headache; rarely it can take place even 
without the headache. 

Migraines and hormones - What you should know

5. Seniors are also at risk for HIV
"`When we were going together, I always used 
condoms,' she said of her second husband, ... who 
died seven years ago. `But when we got married I 
felt, well, husband and wife, I didn't think he 
could've had the (HIV) virus.'" 

Doctors forget to counsel seniors about safe sex. 
The Center for Disease Control (CDC) says that 
AIDs is growing twice as fast among individuals 
over 50  years of age as among those under 50 
years old. The suspected reason for this is 
basically because those under 50 are probably 
using more precautions in sexual relationships 
than are those older individuals. 

There also seems to be a delay in diagnosis of 
AIDs in more elderly individuals. This may be 
because seniors have more medical conditions that 
are difficult to differentiate from the early 
symptoms of AIDs. Symptoms such as chronic fever, 
sore throat or rashes may not trigger the 
investigation for AIDs in seniors as it does in 
younger individuals. 

With the more frequent use of Viagra and a 
refractoriness to using condoms by elderly men, 
AIDs may continue to rise in frequency unless 
physicians start to remind seniors about using 
precautions and seniors themselves begin to 
realize it can happen to them. 

Seniors are also at risk for HIV

6. Health tip to share - Wolff-Parkinson-White Syndrome
"I have Wolff-Parkinson-White syndrome and my tip 
on how to live with this is by taking my meds and 
saying to myself 'it could always be a lot worse'"  
:)  Deborah 

(editor note - Wolff-Parkinson-White syndrome is a 
condition in which a rapid heart rate is caused by 
abnormal electrical pathways in the heart.) 

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
Unity Candles
I was escorted to a wedding by my twenty-four-year-old
bachelor son. He appeared unaffected by the ceremony
until the bride and groom lighted a single candle with
their candles and then blew out their own. With that he
brightened and whispered, "I've never seen that done
I whispered back, "You know what it means, don't you?"
His response:  "No more old flames?"

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

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****** Woman's Diagnostic Cyber Newsletter *******
                June 24, 2001
This week from Woman's Diagnostic Cyber

1. Bone density testing
2. Weight loss obsession
3. Reader submitted Q&A - Rectocele after hysterectomy
4. Laparoscopic surgery for uterine prolapse
5. Cancer in patients with hidradenitis suppurativa
6. Health tip to share - Breathing for relaxation
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. Bone density testing
Unfortunately many insurance plans do not pay for 
bone mineral density testing unless you already 
have a diagnosis of osteoporosis. This makes it 
very difficult to get an initial test to diagnose 
whether you are at risk or not. 

The 'gold standard' test for osteoporosis is dual 
energy X-ray absorptiometry (DEXA) scan. It 
measures the bone mass in the spine and hips which 
are very important for predicting hip fractures 
and spinal vertebrae compression fractures. It 
also estimates total body bone mass. Unfortunately 
a DEXA scan is expensive so other less costly 
devices have been developed in order to estimate 
bone loss. 

These devices are explained in the article at 
mayoclinic.com. They are made to measure the heel, 
finger or wrist bone density. Those joints or 
bones may or may not reflect the bone density in 
the critical areas of the hip or the spine, so if 
they are used for screening and the results are 
abnormal, then the DEXA scan must be performed for 
confirmation as to whether there is a problem at 
the hips or in the spine. 

Results are given in T-scores. Those T-scores 
measure how far your measurements are away from 
the average measurements of other women your age. 
If you have a score of -2.5 or more  (eg., -2.6, -
3.0) then that joint is at fracture risk. If the 
score is -1.0 or less (eg., -0.5 or +1.5) then you 
do not have osteoporosis in that joint. 

There is a quite a variability among joints so 
while one hip could be bad, the other may be 
better than the average woman's. The scan is 
repeated after a year's treatment to make sure 
bone loss is arrested or even some bone is 

Medicare now pays for screening scans even if you 
do not yet have osteoporosis but if you meet the 
following conditions: 

If you are postmenopausal and at risk of 

If you have a condition called primary 

If you have certain spinal abnormalities that 
might indicate a fracture 

If you are on long-term corticosteroid therapy, 
such as prednisone 
2. Weight loss obsession
We have written about obesity before as a health 
risk and it certainly is. Even when women are not 
significantly overweight, many are still obsessive 
about dieting to the extent of being willing to 
submit their bodies at any cost to the latest and 
greatest weight loss plan. 

The article below at personalmd.com points out a 
survey where, if given a choice between losing 20 
lbs permanently or living to 90 years of age, over 
half of the women chose the weight loss. Thus it 
is not for health reasons that most women 
desperately want to lose weight. This trait has 
made women very susceptible to the  marketing 
efforts of any company trying to sell a painless 
weight loss solution. 

With the last fen-phen diet debacle, women 
literally lost their lives trying to diet. It is 
this obsession with weight loss that makes women 
especially prone to unproven or poorly tested diet 
regimens. A woman needs to know the extent to 
which she is targeted by companies trying to make 
money. The companies hype the need for weight loss 
and quickly offer to sell you the solution. 

The moral of the story is not to be so gullible 
for every new diet pill. To lose that gullibility, 
a woman has to give up the obsession for weight 
loss and just focus on lifelong healthy eating 
habits. Don't let the marketers con you. 

Women's weight loss obsession

3. Reader submitted Q&A - Rectocele after hysterectomy
"Is it normal or usual to develop a rectocele 
after a vaginal hysterectomy?  Is surgery the only 
way to repair/reverse the condition?" 

"I am 56 and have had 4 children delivered 
vaginally; menopause 2 years prior to surgery; 
otherwise healthy." - J.A.E. 

It is not normal to develop a rectocele right 
after hysterectomy but it also is not unusual. The 
most common reason for it to occur within a few 
months is that the rectocele was not recognized 
prior to surgery and thus was not repaired at the 
time of the vaginal hysterectomy. It may not have 
been symptomatic (difficulty with defecation) for 
you before the hysterectomy because the uterus and 
cervix which had dropped down somewhat could have 
been preventing the rectum from protruding very 
much and causing symptoms. 

Another reason for rectocele occurrence closely 
related to vaginal hysterectomy is lack of support 
of the vaginal vault from the surgery itself. If 
the ligaments from the sacral bone that are 
primary support of the uterus and vagina are not 
well attached to end of the vagina, or if with 
coughing or straining after surgery those sutures 
are broken or pull out of the tissue, then the end 
of the vagina  becomes unsupported. The vaginal 
end (like the end of a sock), which is now the 
superior portion of support of the rectovaginal 
wall, will drop down with straining and allow the 
posterior vaginal wall (rectocele) to protrude 
from the vagina. 

Finally, with any vaginal surgery and repair, the 
weak points are reinforced and made stronger. Any 
subsequent intraabdominal straining attacks the 
weakest areas which then may quickly develop 
herniation. Water behind a storm dyke will always 
find the weakest area to break through and that 
can happen in the pelvis. There may not have been 
any recognizable weakness at the time of surgery 
but as soon as the weakest areas were supported, 
the rectocele quickly developed in an unrepaired 
weak spot. This can happen especially where you 
had an episiotomy or vaginal tearing with any of 
your 4 vaginal deliveries. That weakness was never 
evident until you became menopausal and the mesh 
of blood vessels around the vagina (which gave 
additional support) has shrunk and gone away. 

If you have a rectocele now (you did not mention 
if you did and how soon it developed), then the 
main consideration is what other pelvic support 
defects are still present. You do not want to have 
a rectocele surgically repaired and then a few 
years later find out you need bladder support 
surgery and or vaginal vault suspension. Be sure 
that your doctor is well versed with these 
different support defects. 

Remember that the main reason gynecologic surgeons 
are able to remove the uterus vaginally is because 
of pelvic support weakness. A woman who has not 
delivered children vaginally will usually have to 
have an abdominal hysterectomy or a laparoscopic 
assisted hysterectomy and is much less likely to 
develop these support problems because they did 
not have weakening of the tissue in the first 

Muscle exercises such as Kegel's do not usually 
help a rectocele. They can help stress 
incontinence and anterior wall bladder support but 
not posterior wall rectal support. A pessary, a 
silicone object placed in the vagina,  can give 
support to the rectal wall and can be effective in 
relieving some symptoms, but most women of your 
age do not choose to use them for long term 
treatment.  Unless your health is bad, you will 
probably want to have surgical repair so you can 
remain physically active for several decades. 

Cystocele, rectocele and pelvic support surgery

4. Laparoscopic surgery for uterine prolapse
Many women ask if uterine prolapse can be fixed 
without having a hysterectomy. While vaginal 
hysterectomy has been the most common treatment, 
uterine prolapse can be treated with a 
hysteropexy, or a suspension of the uterus. 

In recent years, suspension of the uterus 
(hysteropexy) has been performed via laparoscopy 
so it can be done with only several small 
incisions. It is not as effective as removing the 
uterus but up until now we have not had good 
statistics to know how successful it is. 

The article below followed 43 women prospectively 
for a year after a laparoscopic hysteropexy. They 
found that approximately 80% of the procedures 
were successful at preventing symptoms. Two women 
even conceived after hysteropexy and delivered by 
Cesarean section. 

As long as a woman understands that this surgery 
is not always successful, it is a very good 
procedure to fix uterine prolapse. Symptoms of 
early uterine prolapse, before the uterus/cervix 
is actually protruding out of the vagina at rest, 
are pelvic pressure, sometimes low back pain and 
pain or discomfort with sexual intercourse when 
the uterus is hit during the thrusting of sex. 

If you think you may be having symptoms of 
prolapse, discuss this with your doctor. 

Laparoscopic surgery for uterine prolapse

5. Cancer in patients with hidradenitis suppurativa
Hidradenitis suppurativa is an infectious 
condition of the sweat glands of the skin that 
causes lumps and bacterial abscesses which may 
drain pus. It is like having several to quite a 
few boils on the skin very close together. It is 
very difficult to treat. 

The most common areas affected are the armpits 
(axillae) and the vulva although anywhere with 
sweat glands can be affected. A big question when 
it affects the vulva is whether or not there is a 
higher incidence of vulvar cancer in women with 
hidradenitis of the vulva. 

The following Swedish study looked at over 2100 
people with hidradenitis of all skin locations and 
determined how many of them had non melanoma skin 
cancer. They did not just look at cancer of the 
vulva but rather all skin cancers except the 
malignant melanomas. 

They found that those with hidradenitis had a 50%  
increased risk for any type of cancer and had 4 
times increased incidence of skin cancer. 

Women with hidradenitis of the vulva (or any skin 
location) need to be examined frequently for 
possible cancer. 

Cancer Among Patients With Hidradenitis Suppurativa  

6. Health tip to share - Breathing for relaxation
A helpful technique for relaxing from the stress 
of everyday life when you only have 5 minutes is 
"tummy breathing". To do it, let your stomach just 
below your ribs move out a little as you breathe 
in, and then go back down when you breathe out. 
Don't let your chest move when you breathe. Do 
this softly and gently until it feels like you are 
breathing into your stomach a little, maybe 5-10 
breaths. Once you get used to it. Use this 
technique to relax for about 5 minutes at a time. 
(From respire.net) 

Relax with tummy breathing

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
"Vacation Term Translation"

In case any of you are still thinking about 
picking a vacation spot, be aware of the following 
advertising lingo... 
Old world charm ....................
No bath

Tropical ...........................

Majestic setting ...................
A long way from town
Options galore .....................
Nothing is included in the itinerary
Secluded hideaway ..................
Impossible to find or get to
Pre-registered rooms ...............
Already occupied
Explore on your own ................
Pay for it yourself
Knowledgeable trip hosts ...........
They've flown in an airplane before
No extra fees ......................
No extras
Nominal fee ........................
Outrageous charge

Deluxe .............................
Superior ...........................
One free shower cap
All the amenities ..................
Two free shower caps
Plush ..............................
Top and bottom sheets
Gentle breezes .....................
Occasional Gale-force winds
Light and airy .....................
No air conditioning
Picturesque ........................
Theme park nearby
Open bar ...........................
Free ice cubes

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

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****** Woman's Diagnostic Cyber Newsletter *******
                July 1, 2001
This week from Woman's Diagnostic Cyber

1. Knee injury to anterior cruciate ligament
2. What is dysplasia?
3. Reader submitted Q&A-Constant menstrual bleeding
4. Endometrial hyperplasia rate of progression
5. Condom effectiveness in preventing herpes
6. Health tip to share - No BHT for herpes
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. Knee injury to anterior cruciate ligament

Injury to the anterior cruciate ligament (ACL) of 
the knee is a somewhat frequent sports injury. You 
do not need to be a competitive athlete to injure 
it, however. It can be injured from a slip-and-
fall, a sudden twisting motion, a hyper extension 
injury in which the foot slips forward and the 
knee goes backward or even the opposite in which 
the knee goes suddenly forward while the foot goes 
backward. Characteristically one hears a loud 
"pop" sound when the ligament tears. 

Women get torn ACL ligaments much more frequently 
than men. In fact a recent study suggests that 
women may tear the ligament more often at mid 
menstrual cycle during ovulation than at other 
times. No one is sure of why there is a gender 
difference in frequency of a torn ACL. 

The ligament is does not heal after it is torn. 
All that can be done is to strengthen the muscles 
surrounding the knee to keep the joint stable so 
the main calf/shin bone (tibia) does not move 
excessively across the main thigh bone (femur). 
You can wear a knee brace to aid in stability of 
the joint during any fitness activities. You may 
need to alter your usual sports and leisure or 
daily living activities so that the joint is not 
reinjured. It may take years before the pain 
finally leaves completely if you do not keep 
reinjuring the knee. 

Non surgical treatment with physical therapy, a 
brace and altering daily activity is usually the 
first choice of treatment but surgery can also be 
an option. The ligament cannot be repaired but it 
can be replaced. Since surgery can have 
complications of permanent pain or continued joint 
instability, it should not be undertaken lightly. 

2. What is dysplasia?
Dysplasia is an abnormal growth of the skin cells 
of the cervix, vagina or vulva. The nucleus of the 
cell enlarges and the whole cell becomes more 
active. Dysplasia is not cancer but it is felt 
that dysplasia cells are on a growth pattern in 
which they can turn into a cancer over time. When 
the cells get to a point where they are so active 
they are reproducing faster than they are dying 
off, the extra cells grow into normal tissue and 
become an invasive cancer. 

No one knows for sure what causes these cells to 
become so actively growing but it is strongly 
suspected that certain strains of human papilloma 
virus (HPV) cause or promote these changes. The 
Pap smear picks up these nuclear activity changes 
but in early phases it can not always distinguish 
between inflammatory or irritation changes. These 
Paps are classified as atypical squamous cells of 
undetermined significance (ASCUS) or mild 

Much work is going on with HPV typing of abnormal 
Pap smears (The Digene Hybrid Capture(R) HPV test) 
to try to tell if the particular strain of HPV 
that is associated with the abnormal Pap is one of 
the "high risk" strains of HPV known to be 
associated with cancer. In theory if the HPV is a 
high risk type, doctors might need to be more 
aggressive in treating the tissue involved rather 
than waiting for the Pap smear to get worse before 
treating. Conversely, if the virus associated with 
an abnormal Pap is a low risk (for cancer) type, 
then screening with repeat smears can be put off 
longer. In practice, it becomes very expensive to 
do both tests and the long term outcome is not 
much different. 

Some studies have even suggested that HPV typing 
smears may be cost effective in replacing Pap 
smears for the detection of moderate and severe 
dysplasia to prevent cancers of the cervix. We are 
not at that point yet but this test bears 

Dysplasia 101  
3. Reader submitted Q&A - Constant menstrual bleeding
"I have had nearly constant menstrual-type 
bleeding for the last two years. I have been 
diagnosed in the past with uterine cysts and 
cervical dysplasia. Even though I am very 
concerned about the bleeding, my gynecologist is 
not. Should I get a second opinion?" 

"I am 39, and have had regular periods from age 14 
through 36. After the birth of my child (at 36), 
periods have been very long (15-20 days) or I have 
intermittent bleeding all month. I had one 
laparoscopy after a "mass" was found, but nothing 
was removed (it had disappeared)."  - Gyl 

Two years of constant bleeding is about 22 months 
too long. If your doctor has not performed any 
investigation into the cause of the bleeding then 
you should definitely seek a second opinion. 

You did not mention being on any hormone therapy 
so at age 39, the most likely cause of this type 
of bleeding is either polyps in the uterus or 
fibroids. Some type of diagnostic testing needs to 
be performed such as an ultrasound or saline 
sonohysterogram or even going straight to a 
hysteroscopy and D&C. 

See our article below for an explanation of what 
is involved in diagnosing and treating this 
prolonged bleeding: 

Constant Menstrual Bleeding at Age 39

4. Endometrial hyperplasia rate of progression
Hyperplasia of the lining of the uterus 
(endometrium) is not the same as dysplasia of the 
cervix. It is not associated with HPV or any other 
virus as far as we know. However, it sometimes can 
be considered a premalignant lesion just like 
dysplasia. This is especially true if the 
hyperplasia has areas in it microscopically that 
the pathologist considers "atypical". Then there 
is chance that this tissue, if left alone for a 
time, could go on to form an invasive cancer of 
the uterus (endometrium). 

When a woman has abnormal uterine bleeding, 
especially after the age of 35 or 40, and the 
doctor performs and endometrial biopsy or D&C and 
the tissue returns with hyperplasia, then there 
may be a concern about this being a premalignant 
lesion. One question we are commonly asked is 
"what is the rate that these hyperplasias can go 
on to turn into a cancer of the uterus?". There is 
not good data to say precisely how worrisome this 

A recent Japanese study looked at 77 women with 
endometrial hyperplasia and followed them 3 years 
without any surgery other than doing a total 
curettage every 12 months for 3 years. They looked 
at how often the lesion progressed to cancer and 
how often it just regressed to normal on its own. 
They classified the hyperplasias into 4 grades: 

simple hyperplasia without atypia    (SH)
complex hyperplasia without atypia (CH)
simple hyperplasia with atypia        (SHA)
complex hyperplasia with atypia     (CHA)

They had the following findings for progression to 
cancer and regression to normal: 

              Progression        Regression 
              to Cancer           to normal
SH              0%                    79%
CH              0%                    94% 
SHA             0%                   100%
CHA             9%                    55%

Older studies indicate that any hyperplasia with 
atypia can progress to cancer although complex 
hyperplasia with atypia does so more often (up to 
20%). The bottom line is that any endometrial 
hyperplasia with atypia can go on to become 
cancerous and should be monitored closely,  but 
the others can be followed with just periodic D&C 
(not just endometrial biopsy) rather than having 
to have a hysterectomy. 

Endometrial hyperplasia progression

5. Condom effectiveness in preventing herpes 
Herpes virus, type 2 (HSV-2), that infects the 
vulva in women and penile skin in men, is for the 
most part a sexually transmitted disease (STD). It 
is estimated that over 22% of the adult population 
has been infected with HSV-2. While condom use is 
recommended to prevent transmission of any STD, we 
are not sure how well condoms work to prevent 
this. Women may get the active lesions on the 
vulvar area where a condom will not be protective. 

This study below in the Journal of the American 
Medical Association (JAMA) looked at couples in 
which one person was infected with HSV-2 while the 
other one was not, as measured by blood 
antibodies. They followed 528 couples over about 
30 months and measured whether the HSV-2 free 
partner contracted herpes or not. The methods they 
used to try to reduce transmission were 
encouragement of everytime condom use and 
decreasing the frequency of sexual intercourse 
when one's partner had an active herpes lesion. 

They found:

Only 10% of the women and 2% of the men newly 
   contracted HSV-2 
The rate of infection transmission with these 
   methods was approximately 1/1000 sex acts. 
Younger partners and partners that were positive 
   for both HSV-1 (cold sore herpes) and HSV-2 
   had slightly higher transmission rates. 
Condom use less than 25% of sexual acts was not 
   protective for women at all. 

Therefore, while not perfect, condom use can 
significantly reduce the transmission of HSV-2. 

Condom effectiveness in preventing herpes transmission

6. Health tip to share - No BHT for herpes
There has been a resurgence in interest in using 
butylated hydroxytoluene (BHT) as a treatment for 
genital herpes ulcers due to the resurrection of 
some old articles in the Web. This is based on 
studies about 15 years ago and topical BHT was 
shown not to be significantly effective. Oral BHT 
has also been used but it has liver toxicity and a 
small margin of safety in comparison with lethal 
doses in animals. For that reason it is NOT 

You would be better off using L-lysine (1000 mg 
three times a day) which has been shown to reduce 
herpes outbreaks. - FRJ 

Herpes and topical BHT

L-Lysine for recurrent herpes

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
Mother was having a hard time getting her son to 
go to school in the morning. 

"Nobody in school likes me," he complained. "The 
teachers don't like me, the kids don't like me, 
the superintendent wants to transfer me, the bus 
drivers hate me, the school board wants me to drop 
out, and the custodians have it in for me. I don't 
want to go to school." 

"But you have to go to school," said his mother 

"You're healthy, you have a lot to learn, you have 
something to offer others, you are a leader. And 

you are 45 years old and you are the 'Principal'." 

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

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****** Woman's Diagnostic Cyber Newsletter *******
                July 8, 2001
This week from Woman's Diagnostic Cyber
1. Postmenopausal ERT use reduces cataracts
2. Marijuana chemicals for chemotherapy nausea
3. Reader submitted Q&A - It hurts during sex
4. How risky is vaginal birth after Caesarean (VBAC)
5. Cholesterol Challenge - low cost testing
6. Health tip to share - Diet and blood pressure
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. Postmenopausal ERT use reduces cataracts
Estrogen replacement (ERT) during menopause has 
previously been associated with a reduced 
incidence of an eye disease called macular 
degeneration that can lead to blindness, However, 
there have not been consistent findings on whether 
ERT reduces clouding of the lens of the eye which 
results in cataracts and extremely poor vision if 
not blindness. 

This study in the Archives of Internal Medicine 
looked at surviving members of the original 
subjects of the Framingham Heart Study who also 
participated in the Framingham Eye Study (1986-
1989). It included 529 women aged 66 to 93 years 
and looked at their estrogen use versus how much 
clouding of the eye lens they experienced. It also 
looked at whether they had undergone surgical 
versus natural menopause. 

Basically the study found that estrogen use of 10 
years or more resulted in a 60% reduction of 
nuclear lens opacities. Also, women who underwent 
natural menopause had a lower incidence of 
opacities than women who had surgical menopause. 
Their main conclusion was that "reduction in the 
risk of lens opacities may be an additional 
benefit of postmenopausal estrogen use." 

ERT Use, Type of Menopause, and Lens Opacities 

2. Marijuana chemicals for chemotherapy nausea
You may or may not have been following the recent 
push to have marijuana or its chemical components 
legalized for certain medical uses. The main 
indication cited is to treat the severe nausea and 
vomiting that some cancer chemotherapy treatments 

A review article in the British Medical Journal 
looked at all of the high quality scientific 
studies that investigated how effective the 
chemical components of marijuana, called 
cannabinoids, are at reducing nausea and vomiting 
from chemotherapy compared to traditional 
prescription medications. Non of the studies 
looked at just smoking marijuana but rather all of 
them looked at either natural or synthetic 
extracts of the chemicals in marijuana that are 
know to be the active agents for nausea. Those 
extracts were given either orally or by 
intramuscular injection. 

The summation of the 30 randomized studies was 
that these components of marijuana were slightly 
more effective than traditional medications, 
patients more often preferred the cannabinoids as 
treatment, but they also had a higher 
discontinuance rate because of adverse effects. 
The cannabinoids produced more beneficial side 
effects such as a "high", sedation, and /or 
euphoria, but they also produced more harmful side 
effects such as dizziness, feeling awful or 
depression, hallucinations, paranoia and 

The authors felt that despite some advantages of 
the cannabinoids for treatment of cancer 
chemotherapy induced nausea and vomiting, the 
potentially serious side effects were likely to 
limit their widespread use if such treatments were 
made legal and widespread. 

Cannabinoids for chemotherapy induced nausea and vomiting

3. Reader submitted Q&A - It hurts during sex
"I feel pain when having intercourse, I also feel 
pain, just before and during orgasm, can you 
please tell me what is causing this.  Sometimes it 
is so sore that I lose the desire to have sex.  
Sometimes it is also difficult for me to reach 
orgasm, please let me know if you can help me." 

"I am 21 years old, and I also suffer from 
constant bleeding, I've been on the Depo for 
nearly 5 or 6 years and I still have spotting all 
the time, the doctors can't help me". C. 

In order to help you, we first need to determine 
the original cause of the pain and to what degree 
you are having an involuntary reaction to fear of 
having pain each time you have sex. If we can then 
make sure the original cause of the pain is 
treated as best as possible, what remains is the 
body's reaction to the fear of pain which in turn 
causes vaginal muscle spasms that cause a 
secondary pain. This fear of pain may be conscious
or subconscious but is also decreases the ability
to have orgasm. 

It is important to know if the pain started 
originally at the opening of the vagina (vulva, 
introitus), the inside of the vagina or only deep 
inside the pelvis when thrusting moves the pelvic 
contents such as the cervix, uterus or ovaries. It 
should be easy for you to tell if the entrance to 
the vagina (introitus) was the original painful 
part. It would have hurt just with touching the 
area with your fingers or a pad rubbing against 

Vaginal pain is a little harder to tell. The pain 
would be present mostly upon your partner entering 
the vagina and with the movement back and forth 
without deep penetration. You probably have some 
degree of this pain now even though you may not 
have had it originally. This is because the 
vaginal muscles now involuntarily contract because 
of fear of being hurt and the contraction makes 
the vagina and opening smaller instead of larger 
which is the normal response. Since you are on 
DepoProvera (R) which is known to cause vaginal 
dryness, this could have been or can still be your 
main problem. 

Deep pelvic pain is much worse when you are having 
intercourse and you are on the "top" position. 
This results in the deepest penile penetration and 
often moves the pelvic organs. Any pathology such 
as endometriosis, an ovarian cyst or uterine 
abnormalities can be painful with deep 
penetration. If that is your original pain problem 
then a pelvic exam and possibly a pelvic 
ultrasound will help clarify the cause. 

Possible causes of painful sex (dyspareunia)

Vulvar entrance
  congenital abnormalities of the hymen
  post traumatic scarring of the entrance
  episiotomy scarring or delivery lacerations
  post laser treatment of condyloma 
  vulvar hypersensitivity or allergic reactions 
  periorificial (irritant) dermatitis 
  cyclic/recurrent yeast vulvovaginitis 
  cyclic/recurrent bacterial vulvovaginitis 
  vulvar vestibulitis 
  dysesthetic vulvodynia 
  vulvar dermatoses

   lack of estrogen
     breast feeding 
     menopausal estrogen deficiency 
     use of DepoProvera (R) 
     use of progestin only birth control or 
       ovarian suppression 
   vaginismus (involuntary pelvic muscle 
   vaginal foreign body 

   interstitial cystitis 
   ovarian neoplasm 
   ovary adhered to uterus/vaginal apex 
   prolapse of fallopian tube 
   pelvic adhesions 
   uterine prolapse/descensus 
   uterine retroversion 
   posterior uterine fibroid 
   other uterine neoplasms 

As you can see the list of possibilities is 
extensive and treatment must be directed toward 
the initial cause. Once the initial cause of pain 
has been treated, any secondary vaginismus due to 
a learned fear of pain must be treated. This is a 
slow process and will involve your partner's help 
in getting the pelvic muscles to relax rather than 
contract. You will need you doctor's help or that 
of a professional sex therapist for instructions 
on manual massage of the vaginal muscles to induce 

4. How risky is vaginal birth after Cesarean (VBAC)
Prior to the decade of the 1990's, doctors felt 
that once a woman had a Cesarean section for 
delivery of her child, she should always have a 
Cesarean section for subsequent deliveries. The 
main concern was that surgery on a uterus can 
weaken it and with the high intrauterine pressures 
of labor, the old surgical scar might rupture 
where it previously had been sewn back up. Uterine 
rupture carries not only the increased risk of 
hemorrhage, infection, injury to bladder and 
possible need for hysterectomy, but also the baby 
can die if the placental blood supply is disrupted 
by the rupture before an emergency C-section can 
be performed. 

Data in the 70's and 80's seemed to indicate that 
the rate of uterine rupture for a normal C-section 
incision (called low transverse) was about 1% or 
less. It was shown through prospective 
experimental studies that about 2/3's to 3/4 of 
women who had  a previous C-section could 
successfully deliver vaginally even after they had 
had a previous C-section birth. This is called 
vaginal birth after Cesarean or VBAC. The 1% risk 
of rupture was felt to be acceptable risk in order 
to reduce the surgical morbidity of the 65-75% of 
women who were saved a repeat C-section. 

Recently some physicians have questioned whether 
this uterine rupture rate is acceptable at all so 
studies are trying to look at the comparisons in 
women who have routine, scheduled repeat Cesarean 
sections versus those who attempt VBAC. VBAC has 
a generally lower chance of maternal complications 
but the one serious complication of uterine 
rupture is potentially catastrophic for baby and 
very serious for mother. 

This study recently reported in the New England 
Journal of Medicine is not the first such study to 
look at large numbers of deliveries to determine 
how often uterine rupture occurs but it also 
includes different complication rates in the 
subgroups of women. They found: 

Group                     Rate of uterine rupture

Repeat C/S, no labor         .16% (1.6/1000)
Previous C/S spontaneous     .52% (5.2/1000) 
Previous C/S induced         .77% (7.7/1000)
  labor (not using 
Previous C/S induced        2.45% (24.5/1000)
  labor using prostaglandin 

An obvious conclusion is not to induce labor 
using prostaglandin for women who wish to 
attempt VBAC. Also, the study shows if the uterus 
ruptures, there is a 5.5% chance that the baby 
would die. 

When you use these numbers to calculate the 
difference for a mom between choosing repeat C-
section versus choosing VBAC, we see that with 
VBAC there will be a 3.6/1000 (.36%) higher rate 
of uterine rupture and the chance of the baby 
dying is about .2/1000 or 1/5000 women who choose 
VBAC. This is a very small number but it does 
represent an increase in risk.

These are numbers that a woman needs to know when 
deciding about attempting a vaginal delivery 
versus a scheduled repeat C-section. 

Risk of uterine rupture with VBAC

5. Cholesterol Challenge - low cost testing
Occasionally we receive press release 
announcements that we think are worth passing 

BIOSAFE Medical Technologies, Inc. announced that 
it will use its new Cholesterol Test System to 
make FREE cholesterol testing available to all 
Americans.  The BIOSAFE test utilizes a small 
blood sample (three drops) placed on a special 
card and collected through a simple nick of a 
finger. The card is then mailed to BIOSAFE's CLIA 
Certified Laboratory for testing.  The 
quantitative results, which meet the College of 
American Pathologists (CAP) guidelines, are then 
mailed back to you.  The BIOSAFE system eliminates 
the need for a trip to the doctor for a standard 
blood draw from the arm. 

The collection kit will be sent free of charge 
directly to the home without the need for a visit 
to a doctor or clinic.  Recipients of free kits 
will be asked to pay shipping and handling of 
$6.95 and will be given the opportunity to upgrade 
the free test to a full Cholesterol Panel, which 
includes Total Cholesterol, HDL (good 
cholesterol), LDL (bad cholesterol), and 
Triglycerides for an additional $9.95 - a $39.95 
This FREE Cholesterol Test offer is limited to one 
test per person, is subject to change without 
notice, and is NOT available in New York or where 
prohibited by law.  Participants should allow 4-6 
weeks for delivery.  For more information or to 
get your free kit, call 1-800-200-TEST (8378). 

6. Health tip to share - Diet and blood pressure
"I am 53 yrs old and have had my blood pressure 
monitored since I was 20, because it fluctuates 
around 140/90, being lower most of the time.  Six 
months ago I was introduced to hacres.com  where I 
learned about the Hallelujah Diet.  I began eating 
85% raw fruits and veggies and 15% cooked food, 
limiting or eliminating white flour, sugar, salt, 
dairy and meat except for cold water fish.  This 
week my physician announced that my blood pressure 
was 118/82 and asked me where I learned how to eat 
this way.  I shared the web site with her.  She 
said she would look it up and share the info with 
other patients." 

"I also am losing the extra weight I have carried 
all of my adult life and most of my childhood.  
It's so simple, but effective!! - Rebecca R. 

The Hallelujah Diet

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
If Men Got Pregnant...
Maternity leave would last for two years...with 
full pay. 
There'd be a cure for stretch marks. 
Natural childbirth would become obsolete. 
Morning sickness would rank as the nation's number 
one health problem. 
All methods of birth control would be improved 100 
percent effectiveness. 
Children would be kept in the hospital until they 
were toilet trained. 
Men would be EAGER to talk about commitment. 
They wouldn't think twins were quite so cute. 
Fathers would demand that their SONS be home from 
dates by 10:00pm. 
Men could use THEIR briefcases as diaper bags. 
They'd have to stop saying, "I'm afraid I'll drop 
Paternity suits would be a line of clothes. 
They'd stay in bed for the entire nine months. 
Menus at most restaurants would list ice cream and 
pickles as an entree. 
Women would rule the world! 
That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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****** Woman's Diagnostic Cyber Newsletter *******
                July 15, 2001
This week from Woman's Diagnostic Cyber

1. Overweight, diabetes and exercise
2. Vestibular pain versus generalized vulvar pain
3. Reader submitted Q&A - Endometrial stripe
4. Calcium robbers
5. Insect bites this summer
6. Health tip to share -  Hyland's for bladder
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. Overweight, diabetes and exercise
Which comes first, becoming overweight or the 
adult onset diabetes? Papers from the Nurses 
Health Study suggest that the weight gain, lack of 
exercise, and eating of high glycemic foods 
(simple sugars,carbohydrates) come first and cause 
the adult onset diabetes. Women who are at low 
risk for adult onset diabetes (type 2) had a body 
mass index under 25; performed moderate physical 
activity for at least a half hour daily; were non 
smokers, ate foods "high in cereal fiber and 
polyunsaturated fat and low in transfat and 
glycemic load; and consumed an average of at least 
a half a drink of an alcoholic beverage daily." 

Another interesting characteristic studied is 
people's inability to accurately recall what they 
have eaten. Its not that a person consciously lies 
about their food intake, rather they just do not 
register all of the unscheduled food (snacks, 
stress eating) or perhaps report what they think 
the interviewer wants to hear. The more obese a 
woman was, the greater chance of under- reporting 
of caloric intake. 

Overweight Pivotal Cause of Most Diabetes

2. Vestibular pain versus generalized vulvar pain
Vulvodynia, vulvar burning, vulvar vestibulitis, 
and vulvar dysesthesia are all confusing terms 
even for physicians. Pain and the word component, 
"dynia", mean the same thing. Therefore vulvodynia 
and vulvar pain are identical terms. The entire 
vulva is different than the vestibule of the 
vulva. The vestibule is a small area of the vulva 
just in front of the hymen but not extending to 
the dry skin of the labial lips. 

So if someone labels pain as vestibulodynia, that 
would mean the pain is confined to the vestibule. 
The condition called vulvar vestibulitis is 
confined to the vestibule area and produces pain 
or burning. Therefore it would labeled as 
producing vestibulodynia. The doctor checks with a 
Q-tip on pelvic exam touching the area of the 
vestibule and then other areas of the vulva. If 
the pain in only in the vestibule, that makes the 
diagnosis of vulvar vestibulitis. If the pain is 
anywhere else on the vulva, some other condition 
is causing it. 

Vulvar dysesthesia is a term also used to describe 
vulvar pain that is beyond the vestibule and for 
which no obvious cause such as recurrent 
vaginitis, irritant vulvitis, or vulvar skin 
conditions are known. 

For a review of vuvlar pain, see this article at 

Vestibulodynia: tracing and treating vulvar pain

3. Reader submitted Q&A - Endometrial stripe
"What does endometrial stripe mean? My doctor 
ordered a pelvic ultrasound. The nurse called and 
said it showed an endometrial stripe but she 
didn't know what that meant and I needed to see a 
obgyn?" - Anonymous 

On pelvic ultrasound, one of the views is of the 
uterus showing it as if it were cut down the 
middle. This shows the anterior (toward the 
abdominal wall) and posterior (toward the back) 
thickness of the uterine cavity. In this view it 
just looks like a double line. Doctors measure the 
thickness of that double line to get an idea of 
how much skin lining (endometrium) there is in the 

Normally a woman who is in the first week of her 
menses will have a thin lining. A post menopausal 
woman will also have a thin stripe. In the second 
two weeks of a normal menstrual cycle, the stripe 
will become thicker until just before menses 
starts. After menopause, a thickened endometrium 
can mean a cancer of the endometrium or a 
hyperplasia that can become cancerous. 

If the endometrial stripe is not straight but 
rather like a wavy or indented line, that may 
indicate endometrial polyps or a fibroid of the 
uterus impinging upon the uterine cavity. If the 
line is straight and you are premenopausal, 
endometrial thickness has no meaning at all. Many 
radiologists have been confused about this and 
report linings at the upper range of normal as 
thickened. Your doctor has no choice but to refer 
you to an ObGyn for follow-up but it may be 

If you are postmenopausal, the thickness of the 
lining may be significant. Originally, the stripe 
was looked at in women with postmenopausal 
bleeding and if the stripe was thin (less than 5 
mm) an endometrial biopsy could be avoided. The 
converse, a thickened stripe does not indicate any 
concern if there is no abnormal bleeding. 

You did not give us enough information about the 
circumstances surrounding why you had an 
ultrasound in the first place or age or menopausal 
status so it is difficult to precisely say whether 
this ultrasound finding is of significance or not. 

4. Calcium robbers
Experts recommend 1000-1200 mg/day of calcium but 
most women only ingest about half of that. If you 
do not ingest enough calcium, your body takes it 
from your bones. Even if you are getting enough 
dietary calcium, you do not want to do anything 
that will rob it from your body. 

There are some commonly known calcium robbers. 
They are: 

low levels of vitamin D - needed for absorption 
from the GI tract. 

salt - too much lets calcium be lost through the 

certain medications - water pills (diuretics), 
steroids, anti-seizure medications, immuno-
suppressive medications, non-steroidal anti-
inflammatory drugs (NSAIDs like ibuprofen, 
naproxen), asthma medications with steroids 

excessive lifestyles - cigarette use, too much 
alcohol (more than 2 drinks a day) 

sedentary lifestyle - lack of weight bearing 
exercise such as  walking, running, weight 
lifting, fitness workouts 

Too much caffeine or too many sodas can also 
inhibit calcium absorption. So in general, it is a 
good idea to take some additional calcium in the 
form of pill supplements or food supplements where 
calcium and vitamin D have been added. 

Are You Bad to Your Bones? 

5. Insect bites this summer
Bug bites are a fact of summer. Most are not 
serious but some can be. Do you know how to take 
care of insect bites when they happen to you? 

For most bites, you need to gently scrape off the 
stinger if there is one, using a edge such as a 
credit card. Wash with a disinfectant and then 
apply a baking soda paste. If you tend to react 
with a large reddened skin area to a bite or swell 
in reaction to a bite, be sure to take an 
antihistamine such as Benedryl(R), Tylenol Severe 
Allergy (R) or chlorpheniramine maleate (Chlor-
Trimeton (R), Teldrin (R). 

Most women who have serious reactions to bug bites 
know the emergency measures they must take to 
avoid shock but if you have a severe reaction such 
as difficulty breathing or swelling of the throat, 
contact emergency services or 911. 

Two potentially serious bites to the non allergic 
are ticks which may carry Lyme disease and the 
brown recluse spider and the black widow spider. 
Lyme disease is carried by deer ticks and  is 
spread to humans after a tick has been attached 
tot he skin for 24-48 hours. If you are in a tick 
infested area and routinely check your skin each 
day for ticks, you can prevent Lyme disease which 
causes joint pains, a rash and fever. If you find 
a tick, gently remove it with tweezers without 
squeezing it and save it in a plastic bag in case 
you develop any symptoms. 

Spider bites can be quite serious if they are due 
to a black widow or a brown recluse spider. They 
only rarely can cause death but they can make you 
very sick with severe pain in the bite area and 
nausea and vomiting. The important part is to try 
to identify the spider so if symptoms worsen you 
can be treated. 

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