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Research Methodology; Types, Aims, Characteristics

Research Methodology is careful consideration of the study regarding a particular concern or problem using scientific methods. According to the American sociologist Earl Robert Babbie, “Research is a systematic inquiry to describe, explain, predict, and control the observed phenomenon. Research involves inductive and deductive methods.”

Research is conducted with a purpose to understand

  • What do organizations or businesses really want to find out?
  • What are the processes that need to be followed to chase the idea?

Types of Research Methodology

Qualitative research – Qualitative research stems from using more personal communication and tends to be more focused on a smaller population.[rx]. Qualitative research is a method that collects data using conversational methods. Participants are asked open-ended questions. The responses collected are essentially non-numerical. This method not only helps a researcher understand what participants think but also why they think in a particular way.

  • Qualitative research is a process that is about the inquiry. It helps create an in-depth understanding of problems or issues in their natural settings. This is a non-statistical method.
  • Qualitative research is heavily dependent on the experience of the researchers and the questions used to probe the sample. The sample size is usually restricted to 6-10 people. Open-ended questions are asked in a manner that encourages answers that lead to another question or group of questions. The purpose of asking open-ended questions is to gather as much information as possible from the sample.
  • Qualitative research is a structured way of collecting data and analyzing it to draw conclusions. Unlike qualitative methods, this method uses a computational and statistical process to collect and analyze data. Quantitative data is all about numbers.

The following are the methods used for qualitative research:

  • One-to-one interview
  • Focus groups
  • Ethnographic research
  • Content/ Text Analysis
  • Case study research

Quantitative research  – Quantitative research stems from using data and numerical values and can be used for large populations.[rx]Qualitative research is a structured way of collecting data and analyzing it to draw conclusions. Unlike qualitative methods, this method uses a computational and statistical process to collect and analyze data. Quantitative data is all about numbers.

  • Quantitative research involves a larger population — more people means more data. With more data to analyze, you can obtain more accurate results. This method uses closed-ended questions because the researchers are typically looking to gather statistical data.
  • Online surveys, questionnaires, and polls are preferable data collection tools used in quantitative research. There are various methods of deploying surveys or questionnaires.

Depending on what the researcher is doing, they may be required to use both qualitative and quantitative methods to achieve their results.

  • Primary Research – is conducted by the researchers themselves.”[rx] This data is highly accurate and collected first-hand. The questions are specified for the target market.
  • Secondary Research – is a method where information has already been collected by research organizations or marketers.”[rx] The data has already been collected from primary sources and is then combined to make conclusions.

Characteristics of Research Methodology

  • A systematic approach must be followed for accurate data. Rules and procedures are an integral part of the process that sets the objective. Researchers need to practice ethics and a code of conduct while making observations or drawing conclusions.
  • Research is based on logical reasoning and involves both inductive and deductive methods.
  • The data or knowledge that is derived is in real-time from actual observations in natural settings.
  • There is an in-depth analysis of all data collected so that there are no anomalies associated with it.
  • Research creates a path for generating new questions. Existing data helps create more opportunities for research.
  • Research is analytical in nature. It makes use of all the available data so that there is no ambiguity in inference.
  • Accuracy is one of the most important aspects of research. The information that is obtained should be accurate and true to its nature. For example, laboratories provide a controlled environment to collect data. Accuracy is measured in the instruments used, the calibrations of instruments or tools, and the final result of the experiment.

What are the Other Types of Research Methodology

Following are the types of research methods

  • Basic research – A basic research definition is data collected to enhance knowledge. The main motivation is knowledge expansion. It is non-commercial research that doesn’t facilitate in creating or inventing anything. For example, an experiment to determine a simple fact.
  • Applied research – Applied research focuses on analyzing and solving real-life problems. This type refers to the study that helps solve practical problems using scientific methods. Studies play an important role in solving issues that impact the overall well-being of humans. For example: finding a specific cure for a disease.
  • Problem-oriented research – As the name suggests, problem-oriented research is conducted to understand the exact nature of a problem to find out relevant solutions. The term “problem” refers to multiple choices or issues when analyzing a situation. For example, the revenue of a car company has decreased by 12% in the last year. The following could be the probable causes: there is no optimum production, poor quality of a product, no advertising, or economic conditions.
  • Problem-solving research – This type of research is conducted by companies to understand and resolve their own problems. The problem-solving method uses applied research to find solutions to existing problems.

Also, the research is classified into

  • Descriptive research
  • Analytical research
  • Fundamental research
  • Conceptual research
  • Empirical research
  • One time research or longitudinal research
  • Field-setting research or laboratory research or simulation research
  • Clinical or diagnostic research
  • Exploratory research
  • Historical research
  • Conclusion oriented research
  • Case study research
  • Short term research

What Is The Purpose of The Research?

  • Online surveys, questionnaires, and polls are preferable data collection tools used in quantitative research. There are various methods of deploying surveys or questionnaires.
  • Online surveys allow survey creators to reach large amounts of people or smaller focus groups for different types of research that meet different goals. Survey respondents can receive surveys on mobile phones, in emails, or can simply use the internet to access surveys.

What Is the Purpose of Research?

There are three purposes of research:

  • Exploratory – As the name suggests, exploratory research is conducted to explore a group of questions. The answers and analytics may not offer a final conclusion to the perceived problem. It is conducted to handle new problem areas that haven’t been explored before. This exploratory process lays the foundation for more conclusive research and data collection.
  • Descriptive – Descriptive research focuses on expanding knowledge on current issues through a process of data collection. Descriptive studies are used to describe the behavior of a sample population. In a descriptive study, only one variable is required to conduct the study. The three main purposes of descriptive research are describing, explaining, and validating the findings. For example, a study conducted to know if top-level management leaders in the 21st century possess the moral right to receive a huge sum of money from the company profit.
  • Explanatory – Explanatory research or causal research is conducted to understand the impact of certain changes in existing standard procedures. Conducting experiments is the most popular form of casual research. For example, a study conducted to understand the effect of rebranding on customer loyalty.

To understand the characteristic of research design using research purpose here is a comparative analysis

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Exploratory Research Descriptive Research Explanatory Research
Research approach used Unstructured Structured Highly structured
Research conducted through Asking research questions Asking research questions By using research hypotheses.
When is it conducted? Early stages of decision making Later stages of decision making Later stages of decision making

 

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The research method is defined as the tools or instruments used to accomplish the goals and attributes of a study. Think of the methodology as a systematic process in which the tools or instruments will be employed. There is no use of a tool if it is not being used efficiently.

Research begins by asking the right questions and choosing an appropriate method to investigate the problem. After collecting answers to your questions, you can analyze the findings or observations to draw appropriate conclusions.

When it comes to customers and market studies, the more thorough your questions, the better. By thoroughly collecting data from customers through surveys and questionnaires, you get important insights into brand perception and product needs. You can use this data to make smart decisions about your marketing strategies to position your business effectively.

Types of research methods and research example

Types of qualitative methods include

  • One-to-one Interview – This interview is conducted with one participant at a given point in time. One-to-one interviews need a researcher to prepare questions in advance. The researcher asks only the most important questions to the participant. This type of interview lasts anywhere between 20 minutes to half an hour. During this time the researcher collects as many meaningful answers as possible from the participants to draw inferences.
  • Focus Groups – Focus groups are small groups comprising of around 6-10 participants who are usually experts in the subject matter. A moderator is assigned to a focus group who facilitates the discussion amongst the group members. A moderator’s experience in conducting the focus group plays an important role. An experienced moderator can probe the participants by asking the correct questions that will help them collect a sizable amount of information related to the research.
  • Ethnographic Research – Ethnographic research is an in-depth form of research where people are observed in their natural environment without This method is demanding due to the necessity of a researcher entering a natural environment of other people. Geographic locations can be a constraint as well. Instead of conducting interviews, a researcher experiences the normal setting and daily life of a group of people.
  • Text Analysis – Text analysis is a little different from other qualitative methods as it is used to analyze social constructs by decoding words through any available form of documentation. The researcher studies and understands the context in which the documents are written and then tries to draw meaningful inferences from it. Researchers today follow activities on a social media platform to try and understand patterns of thoughts.
  • Case Study – Case study research is used to study an organization or an entity. This method is one of the most valuable options for modern This type of research is used in fields like the education sector, philosophical studies, and psychological studies. This method involves a deep dive into ongoing research and collecting data.

Quantitative Research Methods

Quantitative methods deal with numbers and measurable forms. It uses a systematic way of investigating events or data. It is used to answer questions in terms of justifying relationships with measurable variables to either explain, predict, or control a phenomenon.

There are three methods that are often used by researchers:

  • Survey Research – The ultimate goal of survey research is to learn about a large population by deploying a survey. Today, online surveys are popular as they are convenient and can be sent in an email or made available on the internet. In this method, a researcher designs a survey with the most relevant survey questions and distributes the survey. Once the researcher receives responses, they summarize them to tabulate meaningful findings and data.
  • Descriptive Research – Descriptive research is a method that identifies the characteristics of an observed phenomenon and collects more information. This method is designed to depict the participants in a very systematic and accurate manner. In simple words, descriptive research is all about describing the phenomenon, observing it, and drawing conclusions from it.
  • Correlational Research— Correlational research examines the relationship between two or more variables. Consider a researcher is studying a correlation between cancer and married Married women have a negative correlation with cancer. In this example, there are two variables: cancer and married women. When we say negative correlation, it means women who are married are less likely to develop cancer. However, it doesn’t mean that marriage directly avoids cancer.

Importance of Research Methodology

To choose the appropriate types of research, you need to clearly identify the objectives. Some objectives to take into consideration for your business include:

  • Find out the needs of your clients.
  • Know their preferences and understand what is important to them.
  • Find an appropriate way to make your customers aware of your products and services.
  • Find ways to improve your products or services to suit the needs of your customers.
  • After identifying what you need to know, you should ask what research methods will offer you that information.
  • Organize your questions within the framework of the 7 Ps of marketing that influences your company – product, price, promotion, place, people, processes, and physical tests.
  • A well-organized customer research process produces valid, accurate, reliable, timely, and complete results. Results that rigorously reflect the opinions and needs of your clients will help you grow your sales and improve your operations. To obtain the results, you need to establish and follow the processes that you have detailed out for your organization:

Set your goals

  • Consider the client’s objectives and define those that identify with yours. Make sure that you set smart goals and objectives. Do not presume the results of your surveys.

Plan your research

  • Good planning allows the use of creative and logical approaches to select the methods that gather the most accurate information. Your plan will be influenced by the type and complexity of the information you need, the skills of your market research team, and how soon you need the information. Your budget also plays a large role in your ability to collect data.

Collect and collate your results

Make a list of how you are going to carry out the research process, the data you need to collect, and collection methods. This will help you keep track of your processes and make sense of your findings. It will also allow you to verify that your research accurately reflects the opinions of your clients and your market. Create a record table with:

  • The consumer research activity
  • The necessary data
  • The methods for data collection
  • The steps to follow for data analysis.
  • Remember, research is only valuable and useful when it is valid, accurate, and reliable. Relying on imperfect research is dangerous. Incorrect results can lead to customer churn and a decrease in sales.

It is important to obtain information about how the collection of customer information was carried out, and to ensure that your data is:

  • Valid – founded, logical, rigorous, and impartial.
  • Accurate – free of errors and including required details.
  • Reliable – that can be reproduced by other people who investigate in the same way.
  • Timely – current and collected within an appropriate time frame.
  • Complete – includes all the data you need to support your business decisions.

Analyze and understand your research

Analysis of the data can vary from simple and direct steps to technical and complex processes. Adopt an approach, and choose the method of data analysis based on the methods you have carried out.

Keep the findings ready

Choose a spreadsheet that allows you to easily enter your data. If you do not have a large amount of data, you should be able to manage them with the use of basic tools available in survey software. If you have collected more complete and complex data, you may have to consider using specific programs or tools that will help you manage your data.

Review and interpret the information to draw conclusions

Once you have gathered all the data, you can scan your information and interpret it to draw conclusions and make informed decisions. You should review the data and then:

  • Identify the main trends and issues, opportunities, and problems you observe. Write a sentence describing each one.
  • Keep track of the frequency with which each of the main findings appears.
  • Make a list of your findings from the most common to the least common.
  • Evaluate a list of the strengths, weaknesses, opportunities, and threats that have been identified in a SWOT analysis.
  • Prepare conclusions and recommendations about your research.

Review your goals before making any conclusions about your research. Keep in mind how the process you have completed and the data you have gathered help answer your questions. Ask yourself if what your research revealed facilitates the identification of your conclusions and recommendations. Review your conclusions and, based on what you know now:

Choose some strategies that will help you improve your business

  • Act on your strategies
  • Look for gaps in the information, and consider doing additional research if necessary
  • Plan to review the results of the research, and consider efficient strategies to analyze and dissect results for interpretation.

References

Melanocytic Tumor, Causes, Symptoms, Treatment

Melanocytic Tumor/Melanoma is a growth on the skin that develops when pigment cells (melanocytes) grow in clusters. Most adults have between 10 and 40 common moles. These growths are usually found above the waist on areas exposed to the sun. They are seldom found on the scalp, breast, or buttocks. Although common moles may be present at birth, they usually appear later in childhood. Most people continue to develop new moles until about age 40. In older people, common moles tend to fade away.

melanocytic nevus (also known as endocytic nevusnevus-cell nevus and commonly as a mole)is a type of melanocytic tumor that contains nevus cells.[rx] The majority of moles appear during the first two decades of a person’s life, with about one in every 100 babies being born with moles.[rx] Acquired moles are a form of benign neoplasm, while congenital moles, or congenital nevi, are considered a minor malformation or hamartoma and may be at a higher risk for melanoma.[rx] A mole can be either subdermal (under the skin) or a pigmented growth on the skin, formed mostly of a type of cell known as a melanocyte. The high concentration of the body’s pigmenting agent, melanin, is responsible for their dark color.

Familial atypical multiple mole melanoma (FAMMM) syndrome is an autosomal dominant genodermatosis characterized by multiple melanocytic nevi, usually more than 50, and a family history of melanoma [rx]. It is associated with mutations in the CDKN2A gene and shows reduced penetrance and variable expressivity. Some FAMMM kindreds show an increased risk for the development of pancreatic cancer and possibly other malignancies [.

Melanocytic Tumor

Types of Skin Mole/Melanoma

According to The Physical appearance type of mole are

  • Common moles – Non-cancerous moles are typically pink, tan or brown. They are one color. They can be flat or raised, round or oval, and are typically smaller than a pencil eraser. If you have 50 or more common roles, you are at increased risk for skin cancer and should consult your doctor.
  • Atypical moles (dysplastic) – See your doctor if you have any large, unusually shaped, or multi-colored moles, as these may be more likely to develop into skin cancer.
  • Congenital moles (birthmarks) – These are moles that you are born with. Very large congenital moles put you at greater risk for melanoma, so you should consult your doctor regularly to check for signs of skin cancer.
  • Spitz nevi – These moles look like melanoma (skin cancer). They are usually pink or multicolored, raised, and domed shaped. They may bleed or ooze. You will need a biopsy to ensure such a mole is not cancerous. Spitz nevi are more common in children and young adults.
  • Melanoma – A melanoma is a cancerous mole. It will need to be removed. See your doctor immediately if you suspect you have a melanoma.

According to the location of the mole Types

  • Junctional nevus – the nevus cells are located along the junction of the epidermis and the underlying dermis. A junctional nevus may be colored and slightly raised.[rx]
  • Compound nevus – A type of mole formed by groups of nevus cells found in the epidermis and dermis.[rx]
  • Intradermal nevus – A classic mole or birthmark. It typically appears as an elevated, dome-shaped bump on the surface of the skin.[rx]
  • Dysplastic nevus (nevus of Clark) – usually a compound nevus with cellular and architectural dysplasia. Like typical moles, dysplastic nevi can be flat or raised. While they vary in size, dysplastic nevi are typically larger than normal moles and tend to have irregular borders and irregular coloration. Hence, they resemble melanoma, appear worrisome, and are often removed to clarify the diagnosis. Dysplastic nevi are markers of risk when they are numerous (atypical mole syndrome). According to the National Cancer Institute (NIH), doctors believe that when part of a series or syndrome of multiple moles, dysplastic nevi are more likely than ordinary moles to develop into the most virulent type of skin cancer called melanoma.[rx]
  • Blue nevus – It is blue in color as its melanocytes are very deep in the skin. The nevus cells are spindle-shaped and scattered in deep layers of the dermis. The covering epidermis is normal.
  • Spitz nevus – a distinct variant of intradermal nevus, usually in a child. They are raised and reddish (non-pigmented). A pigmented variant, called the ‘nevus of Reed’, typically appears on the leg of young women.
  • Acquired nevus – Any melanocytic nevus that is not a congenital nevus or not present at birth or near birth. This includes junctional, compound and intradermal nevus.
  • Congenital nevus – Small to large nevus present at or near the time of birth. Small ones have a low potential for forming melanomas, however, the risk increases with size, as in the giant pigmented nevus.
  • Giant pigmented nevus – these large, pigmented, often hairy congenital nevi. They are important because melanoma may occasionally (10 to 15%) appear in them.
  • Intramucosal nevus – junctional nevus of the mucosa of the mouth or genital areas. In the mouth, they are found most frequently on the hard palate. They are typically light brown and dome-shaped.
  • Nevus of Ito and nevus of Ota – congenital, flat brownish lesions on the face or shoulder.[rx]
  • Mongolian spot – congenital large, deep, bluish discoloration which generally disappears by puberty. It is named for its association with East Asian ethnic groups but is not limited to them.[rx]
  • Recurrent nevus – Any incompletely removed nevus with residual melanocytes left in the surgical wound. It creates a dilemma for the patient and physician, as these scars cannot be distinguished from a melanoma.[rx]


Causes of Skin Mole/Melanoma

Although anyone can develop melanoma, people with the following risk factors have an increased chance of melanoma [rx]:

  • Having a dysplastic nevus
  • Having more than 50 common moles
  • Sunlight – Sunlight is a source of UV radiation, which causes skin damage that can lead to melanoma and other skin cancers. Sunlight can be reflected by sand, water, snow, ice, and pavement. The sun’s rays can get through clouds, windshields, windows, and light clothing.
  • Tanning – Although having skin that tans well lowers the risk of sunburn, even people who tan well without sunburning increase their chance of melanoma by spending time in the sun without protection.
  • Lifetime sun exposure – The greater the total amount of sun exposure over a lifetime, the greater the chance of melanoma.
  • Severe, blistering sunburns – People who have had at least one severe, blistering sunburn have an increased chance of melanoma. Although people who burn easily are more likely to have had sunburns as a child, sunburns during adulthood also increase the chance of melanoma.
  • Sunlamps and tanning booths – UV radiation from artificial sources, such as sunlamps and tanning booths, can cause skin damage and melanoma. Health care providers strongly encourage people, especially young people, to avoid using sunlamps and tanning booths. The risk of skin cancer is greatly increased by using sunlamps and tanning booths before age 30.
  • Personal history – People who have had melanoma have an increased risk of developing other melanomas.
  • Family history – Melanoma sometimes runs in families. People who have two or more close relatives (mother, father, sister, brother, or child) with melanoma have an increased chance of melanoma. In rare cases, members of a family will have an inherited disorder, such as xeroderma pigmentosum, that makes the skin extremely sensitive to the sun and greatly increases the chance of melanoma.
  • Skin that burns easily – People who have fair (pale) skin that burns easily in the sun, blue or gray eyes, red or blond hair, or many freckles have an increased chance of melanoma.
  • Certain medical conditions or medicines – Medical conditions or medicines (such as some antibiotics, hormones, or antidepressants) that make the skin more sensitive to the sun or that suppress the immune system increase the chance of melanoma.

Symptoms of Skin Mole/Melanoma

Melanocytic Tumor

According to the American Academy of Dermatology[rx], the most common types of moles are skin tags, raised moles and flat moles. Benign moles are usually brown, tan, pink or black (especially on dark-colored skin). They are circular or oval and are usually small (commonly between 1–3 mm), though some can be larger than the size of a typical pencil eraser (>5 mm). Some moles produce dark, coarse hair. Common mole hair removal procedures include plucking, cosmetic waxing, electrolysis, threading, and cauterization.

  • The Ugly Duckling Sign New Growths, Moles, Spots or Lesions – The most significant sign is a mark, mole or any new growth on the skin that looks different from the other spots on your skin. (An Ugly Duckling – A lesion looking a bit different from the other spots on your skin). With the uniqueness of each person comes the uniqueness of our skin and its moles and marks. But if a mole or mark stands out from the other lesions on your skin you should pay closer attention.
  • New Moles or Lesions When You’re Older Than 35 – Below the age of 35 years, it is completely normal to develop new moles. After that age, it becomes less common. In adults, 71% of melanomas show up as new moles or marks on the skin.[rx] Be extra attentive to new mole looking lesions if you are over 35 and remember to check areas you don’t look at often, such as your back. Taking a photo of these difficult areas is recommended to discover any new lesions early.
  • Sores that do not heal
  • Pigment, redness or swelling that spreads outside the border of a spot to the surrounding skin
  • Itchiness, tenderness or pain
  • Changes in texture, or scales, oozing or bleeding from an existing mole
  • Blurry vision or partial loss of sight, or dark spots in the iris


Diagnosis of Skin Mole/Melanoma

Healthy moles are usually round or oval in shape and tend to be only one color. They normally aren’t very big (less than 6 mm in diameter).

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The following ABCDE checklist can be used to tell melanoma apart from a normal mole

Asymmetry: The mole has an uneven (asymmetrical) shape. It often has one or more raised areas and is flatter elsewhere.
Border: The mole has an irregular border (edge), and may appear ragged, blurred or notched.
Color: The mole changes color. It may be several different colors, or an unusual color such as white, blue or red.
Diameter: The diameter is greater than 6 mm (wider than an average-sized pencil).
Evolving: The mole is changing: It might bleed, leak fluid, itch or crust over. Changes in size, shape, color or the surface are possible, and the mole may become raised.

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The ABCDE rule helps to recognize melanoma. But not all criteria apply to every melanoma: For instance, if it starts growing on normal skin (not in an existing mole), it often has a smaller diameter than 6 mm. Additionally, the most dangerous form of melanoma, nodular melanoma, has its own criteria:

  • Elevated – Raised moles are especially likely to develop into melanoma.
  • Firm – Cancerous moles often become firm or hard to the touch.
  • Growing – Moles that are growing are special causes for concern.

If you have a lot of moles and aren’t sure how to best keep track of them all, it might help to use the “ugly duckling” method. “Ugly ducklings” are moles that stand out from the crowd. This can make it easier to spot abnormal changes in the skin.

  • Skin Cancer Screening – In February 2009, the US Preventive Services Task Force published an update stating that there is insufficient evidence available to recommend for or against skin cancer screening. Furthermore, there has never been a randomized, controlled trial examining the efficacy of skin cancer screening. Thus, no data exist to demonstrate the effectiveness of early detection of skin cancer or the benefits on morbidity and mortality, including a reasonable calculation of the benefits of screening in the general population.
  • Role of Total Body Photography and Dermoscopy – Total body photography (TBP) is used to sequentially document the stability of skin lesions, detect subtle changes in existing lesions, and to recognize new lesions. Additionally, TBP was shown to help identify melanoma in its earlier stages and promote continued surveillance of skin lesions via the patient performing SSE.
  • Dermoscopy – is a simple and inexpensive technique that permits the visualization of morphologic characteristics that are not readily detectable with the naked eye. It is a real-time, in vivo method for the early detection of melanoma and other pigmented skin lesions. It has been shown to improve diagnostic sensitivity for melanoma by 10% to 27%.
  • Clinical Significance of Dysplastic Nevi – BK moles, Clark’s nevi, and atypical nevi are terms that refer to lesions with specific clinical and pathologic characteristics associated with an increased risk for the development of melanoma. These typically become clinically apparent at puberty or adolescence and continue to appear throughout life. Some clinicians have described patients having many nevi as having “dysplastic nevus syndrome,” although the classic definition refers to a patient with a triad of >100 nevi, at least 1 nevus that is ≥8 mm in diameter, and at least 1 nevus with clinically atypical features. The clinical significance of dysplastic nevi is in their association with the development of melanoma, with an age-adjusted incidence of melanoma ∼15 times higher in those patients with dysplastic nevi versus the general population (154 vs 10 per 100,000 person-years).

Melanoma stages – Healthcare professionals use a staging system called the AJCC system to describe how far melanoma has grown into the skin (the thickness) and whether it has spread. The type of treatment you receive will depend on what stage the melanoma has reached.

The melanoma stages can be described as

  • Stage 0 – the melanoma is on the surface of the skin
  • Stage 1A – the melanoma is less than 1mm thick
  • Stage 1B – the melanoma is 1-2mm thick, or less than 1mm thick and the surface of the skin is broken (ulcerated) or its cells are dividing faster than usual
  • Stage 2A – the melanoma is 2-4mm thick, or it’s 1-2mm thick and ulcerated
  • Stage 2B – the melanoma is thicker than 4mm, or it’s 2-4mm thick and ulcerated
  • Stage 2C – the melanoma is thicker than 4mm and ulcerated
  • Stage 3A – the melanoma has spread into 1 to 3 nearby lymph nodes, but they’re not enlarged; the melanoma isn’t ulcerated and hasn’t spread further
  • Stage 3B – the melanoma is ulcerated and has spread into 1 to 3 nearby lymph nodes but they’re not enlarged, or the melanoma isn’t ulcerated and has spread into 1 to 3 nearby lymph nodes and they are enlarged, or the melanoma has spread to small areas of skin or lymphatic channels, but not to nearby lymph nodes
  • Stage 3C – the melanoma is ulcerated and has spread into 1 to 3 nearby lymph nodes and they’re enlarged, or it’s spread into 4 or more lymph nodes nearby
  • Stage 4 – the melanoma cells have spread to other parts of the body, such as the lungs, brain or other areas of the skin;

Treatment of Skin Mole/Melanoma


If you have melanoma skin cancer you’ll be cared for by a team of specialists that should include a dermatologist, a plastic surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a pathologist and a specialist nurse.When helping you decide on your treatment, the team will consider:

  • the type of cancer you have
  • the stage of your cancer (its size and how far it has spread)
  • your general health

Whether it’s during 1 or 2 visits, a dermatologist can safely and easily remove a mole. A dermatologist will use one of these procedures:

  • Surgical excision –  The dermatologist cuts out the entire mole and stitches the skin closed if necessary. Your mole will also be looked at under a microscope by a specially trained doctor. This is done to check for cancer cells. If cancer cells are found, your dermatologist will let you know.
  • Surgical shave – The dermatologist uses a surgical blade to remove the mole. In most cases, a specially trained doctor will examine your mole under a microscope. If cancer cells are found, your dermatologist will let you know.

Your treatment team will recommend what they believe to be the best treatment option, but the final decision will be yours. Before going to the hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out about the advantages and disadvantages of particular treatments.

Treating stage 1 to 2 melanoma

Treating stage 1 melanoma involves surgery to remove the melanoma and a small area of skin around it. This is known as surgical excision.

  • Surgical excision is usually carried out under local anesthetic [rx], which means you’ll be conscious but the area around the melanoma will be numbed, so you won’t feel pain. In some cases, general anesthetic [rx] is used, which means you’ll be unconscious during the procedure.
  • If surgical excision is likely to leave a significant scar, it may be carried out in combination with a skin graft[rx]. However, skin flaps are now more commonly used because the scars are usually much better than those resulting from a skin graft.
  • In most cases, once the melanoma has been removed there’s little possibility of it returning and no further treatment should be needed. Most people (80-90%) are monitored in the clinic for 1 to 5 years and are discharged with no further problems.

Sentinel lymph node biopsy

  • A sentinel lymph node biopsy[rx] is a procedure to test for the spread of cancer. It may be offered to people with stage 1B to 2C melanoma. It’s carried out at the same time as surgical excision. You’ll decide with your doctor whether to have a sentinel lymph node biopsy. If you decide to have the procedure and the results show no spread to nearby lymph nodes, it’s unlikely you’ll have further problems with this melanoma.
  • If the results confirm melanoma has spread to nearby nodes, your specialist will discuss with you whether further surgery is required.
  • Additional surgery involves removing the remaining nodes, which is known as a lymph node dissection or completion lymphadenectomy[rx].

Treating stage 3 melanoma

  • If the melanoma has spread to nearby lymph nodes (stage 3 melanoma), further surgery may be needed to remove them. Stage 3 melanoma may be diagnosed by sentinel node biopsy, or you or a member of your treatment team may have felt a lump in your lymph nodes. The diagnosis of melanoma is usually confirmed using a needle biopsy fine needle aspiration[rx].
  • Removing the affected lymph nodes is done under general anesthetic. The procedure, called a lymph node dissection, can disrupt the lymphatic system, leading to a build-up of fluids in your limbs. This is known as lymphoedema.[rx].

Treating stage 4 melanoma

  • If melanoma comes back or spreads to other organs it’s called stage 4 melanoma. In the past, cure from stage 4 melanoma was very rare but new treatments, such as immunotherapy and targeted treatments, show encouraging results.
  • Treatment for stage 4 melanoma is given in the hope that it can slow cancer’s growth, reduce symptoms, and extend life expectancy. You may be offered surgery to remove other melanomas that have occurred away from the original site.
  • You may also be able to have other treatments to help with your symptoms, such as radiotherapy[rx] and medication. If you have advanced melanoma, you may decide not to have treatment if it’s unlikely to significantly extend your life expectancy, or if you don’t have symptoms that cause pain or discomfort.
  • It’s entirely your decision and your treatment team will respect it. If you decide not to receive treatment, pain relief and nursing care will be made available when you need it. This is called palliative care.

Immunotherapy

  • Immunotherapy is used to treat advanced (stage 4) melanoma, and it’s sometimes offered to people with stage 3 melanoma as part of a clinical trial.
  • Immunotherapy uses medication to help the body’s immune system to find and kill melanoma cells. A number of different medications are available, some of which can be used on their own (monotherapy) or together (combination therapy).

Medications used include:

  • ipilimumab
  • nivolumab
  • pembrolizumab
  • talimogene laherparepvec

Ipilimumab

Ipilimumab is recommended by NICE as a treatment for people with previously treated or untreated advanced melanoma that’s spread or can’t be removed using surgery. It’s given by injection over a 90-minute period, every 3 weeks for a total of 4 doses. Common side effects include diarrhea, rash, itching, fatigue, nausea, vomiting, decreased appetite, and abdominal pain.

  • ipilimumab for previously treated advanced melanoma
  • ipilimumab for previously untreated advanced melanoma

Nivolumab

  • Nivolumab is recommended by NICE for treating advanced cases of melanoma in adults that have spread or can’t be removed using surgery. It’s given directly into a vein (intravenously) over a 60-minute period, every 2 weeks. Treatment is continued for as long as it has a positive effect or until it can no longer be tolerated. Nivolumab can be used either on its own or in combination with ipilimumab.

In clinical trials, the most common side effects were tiredness, rash, itching, diarrhea, and nausea.

  • nivolumab for treating advanced melanoma that has spread or can’t be treated with surgery
  • nivolumab in combination with ipilimumab for treating advanced melanoma[rx]

Pembrolizumab

Pembrolizumab is recommended by NICE to treat advanced melanoma in adults that are spread or can’t be treated with surgery. It’s given by injection for 30 minutes, every 3 weeks. In clinical trials, the most common side effects were diarrhea, nausea, itching, rash, joint pain, and fatigue.

  • pembrolizumab for treating advanced melanoma after disease progression with ipilimumab
  • pembrolizumab for advanced melanoma not previously treated with ipilimumab[rx]

Talimogene laherparepvec

  • Talimogene laherparepvec is recommended by NICE for treating melanoma that’s spread or can’t be removed with surgery, where treatment with other immunotherapies isn’t suitable. It’s injected directly into the skin, sometimes with the help of ultrasound guidance. In clinical trials, the most common side effects were flu-like symptoms, reactions at the injection site and cellulitis[rx] (infection of the deeper layers of skin and underlying tissue). Read the NICE guidance about talimogene laherparepvec for treating melanoma that’s spread and can’t be surgically removed[rx]

Targeted Treatments

Around 40 to 50 in every 100 people with melanoma have changes (mutations) in certain genes, which cause cells to grow and divide too quickly. If gene mutations have been identified, medication can be used to specifically target these gene mutations to slow or stop cancer cells growing. Possible targeted treatments include:

  • vemurafenib
  • dabrafenib
  • trametinib

Vemurafenib

Vemurafenib is a medication that blocks the activity of a cancerous gene mutation known as BRAF V600. It’s recommended by NICE as a treatment for people who’ve tested positive for the mutation and have locally advanced melanoma or melanoma that’s spread. Common side effects include joint pain, tiredness, rash, sensitivity to light, nausea, hair loss[rx] and itching. Vemurafenib can also be used with another medication called cobimetinib for treating people with the BRAF V600 mutation melanoma that’s spread or can’t be removed with surgery.

  • vemurafenib for treating locally advanced or metastatic BRAF V600 mutation-positive melanoma
  • cobimetinib in combination with vemurafenib for treating BRAF V600 mutation-positive melanoma that’s spread or can’t be treated with surgery[rx]

Dabrafenib

  • Dabrafenib also blocks the activity of BRAF V600. It’s recommended by NICE for treating adults with the BRAF V600 mutation who have melanoma that’s spread or can’t be removed with surgery. Common side effects include decreased appetite, headache, cough, nausea, vomiting, diarrhea, rash, and hair loss. [rx[.

Trametinib

  • Trametinib blocks the activity of the abnormal BRAF protein, slowing the growth and spread of cancer. It’s recommended by NICE either for use on its own or with dabrafenib for treating people with melanoma with a BRAF V600 mutation that’s spread or can’t be removed with surgery.
  • Common side effects include tiredness, nausea, headache, chills, diarrhea, rash, join pain, high blood pressure[rx] and vomiting. Read the NICE guidance about trametinib in combination with dabrafenib for treating melanoma that’s spread or can’t be removed with surgery[rx].

Radiotherapy and Chemotherapy

  • You may have radiotherapy[rx] after an operation to remove your lymph nodes, and it can also be used to help relieve the symptoms of advanced melanoma.
  • Controlled doses of radiation are used to kill the cancerous cells. If you have advanced melanoma, you may have a single treatment or a few treatments. Radiotherapy after surgery usually consists of a course of 5 treatments a week (1 a day from Monday to Friday) for a number of weeks. There’s a rest period over the weekend.

Common side effects associated with radiotherapy include:

  • Tiredness
  • Nausea
  • Loss of appetite
  • Hair loss[rx]
  • Sore skin

Many side effects can be prevented or controlled with prescription medicines, so tell your treatment team if you experience any. The side effects of radiotherapy should gradually reduce once treatment has finished. Chemotherapy is now rarely used to treat melanoma. Targeted treatments and immunotherapy (as described above) are the preferred treatment options.

Melanoma vaccines

Research is underway to produce vaccines for melanoma, either to treat advanced melanoma or to be used after surgery in people with a high risk of the melanoma returning. Cancer Research UK has more information about melanoma vaccines[rx].

Home Remedies of Skin Mole/Melanoma



Removing Moles Yourself with Natural Remedies

  • Do not cut or shave off moles at home – While natural remedies for moles are mostly harmless, attempting to cut a mole off yourself can leave a permanent scar or cause a dangerous infection. If the mole contains cancer, some of the cancer cells may stay in the skin and spread. You should also see a doctor before you try any natural remedies for your mole to ensure that it is not cancerous.
  • Know that self-treatment of moles may lead to scarring – It is always best to see a dermatologist if you wish to remove a mole for cosmetic reasons. The treatments listed below have been used for decades, but they are not scientifically proven. Some may irritate your skin or even lead to scarring. If you experience irritation, stop the treatment immediately and call your doctor.
  • Use natural skin whiteners to fade out moles – There are a number of fruits and extracts that have been shown to whiten skin. Though each of these treatments will take several weeks to show an effect, they can be an effective, scar-free way to reduce the appearance of moles, particularly non-raised ones.
  • Lemon Juice – Citrus fruits contain vitamin C, which promotes collagen production (necessary for the creation of new skin cells), is a powerful antioxidant and has been shown to inhibit skin darkening due to UV exposure.  Combine lemon juice with honey and apply to the mole for 15 to 20 minutes, once a day. Wash off with water.

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Warning – Do not expose the mole to sunlight while treating it. The juice in citrus fruits can react with UV light to cause photodermatitis, a painful condition resulting in a rash, blisters or scaly skin.

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  • Asian Pears – Pears contain arbutin – a naturally occurring form of hydroquinone, which has been proven to be an effective tyrosinase inhibitor. Tyrosinase is an enzyme that helps to produce melanin, the pigment that darkens skin, so inhibiting will produce a skin-whitening effect.  The best pear varieties to use are Yaquang, Hongpi, Quingpi, or Guifei. Blend the peel and fruit together along with honey as a binding agent and apply for 15-20 minutes a day, washing off with warm water. Stop if you develop skin irritation.
  • Pineapple – Pineapple fruit contains compounds that act as tyrosinase inhibitors, thereby whitening skin. Blend four slice of pineapple in a food processor along with a half a tablespoon of honey. Apply for 15-20 minutes a day and wash off with warm water.
  • Gooseberry oil, bearberry extract or grapefruit seed extract – These all contain tyrosinase inhibitors that help to whiten skin, but you should be careful when using, as too much may cause an allergic reaction. Mix a few drops of the oil or extract with honey and apply to the mole for 15-20 minutes a day.
Apply garlic to the mole – Garlic contains sulfur-rich juices and enzymes that break down pigment-producing cells and lighten pigmentation. Garlic may help lighten a mole. Cut a clove of garlic in half, place the cut side in contact with the mole, and secure it overnight with a bandage. The mole should begin to disappear within 5 days.

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  • Warning: Garlic can irritate and redden your skin.
  • Apply petroleum jelly to the area around the mole to protect it from the garlic juice.

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Use apple cider vinegar – Clean the mole with warm water, then soak a cotton ball in apple cider vinegar and place it on the mole. You can secure it with a bandage overnight, but if you wish to irritate your skin less, consider placing it on the mole for only 10-15 minutes, four times a day. The mole may fall off after 10 days or so.

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  • Warning – Apple cider vinegar can make the mole worse at first.
  • Using apple cider vinegar may leave scars once the mole is removed.
  • Apply petroleum jelly to protect the skin around the mole.

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Try castor oil or flaxseed oil – Though evidence regarding their effectiveness is inconclusive, both of these oils have long been used to soften and dissolve moles. They may be particularly helpful with raised moles.

  • Castor Oil – Mix just a pinch of baking soda and a few drops of castor oil and apply to the mole twice a day. This method is unlikely to leave scars, but it may take a month or more before your mole starts to fade.
  • Flaxseed Oil – Mix finely ground flax seeds and honey to make a paste. Apply it to the mole for one hour, three times a day. It may take several weeks for the mole to fade.
Apply aloe vera – Use a cotton bandage to apply aloe vera to your mole and wait until it is completely absorbed, then apply more. After several weeks, your mole may fade.

References


Melanocytic Tumor

Constipation; Causes, Symptoms, Diagnosis, Treatment

Constipation refers to bowel movements that are infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

Constipation is a health problem that influences almost 20% of the world’s population[]. It is a bothersome disorder which negatively affects the quality of life and increases the risk of colon cancer[]. There are a wide-range of treatment methods. Lifestyle modification, such as increased fluid intake or exercise, is usually recommended as first-line treatment, but data on the effectiveness of these measures are limited[]. Laxatives are most commonly used for the treatment of constipation, but frequent use of these drugs may lead to some adverse effects[,], alternative treatment measure is, therefore, needed. Soluble fiber absorbs water to become a gelatinous, viscous substance and is fermented by bacteria in the digestive tract. Insoluble fiber has a bulking action[]. Dietary fiber is the product of healthful compounds and has demonstrated some beneficial effect. The increase of dietary fiber intake has been recommended to treat constipation in children and adults[]. In a large-population case-control study, Rome found that dietary fiber intake was independently negatively correlated with chronic constipation, despite the age range and the age at onset of constipation[].

Constipation

Epidemiology of 

Constipation is the most common chronic gastrointestinal disorder in adults. Depending on the definition employed, it occurs in 2% to 20% of the population. It is more common in women, the elderly and children. Specifically constipation with no known cause affects females more often affected than males. The reasons it occurs more frequently in the elderly is felt to be due to an increasing number of health problems as humans age and decreased physical activity.

  • 12% of the population worldwide reports having constipation.
  • Chronic constipation accounts for 3% of all visits annually to pediatric outpatient clinics.
  • Constipation-related health care costs total $6.9 billion in the US annually.
  • More than four million Americans have frequent constipation, accounting for 2.5 million physician visits a year.
  • Around $725 million is spent on laxative products each year in America.

Constipation

 

Causes of Constipation

People’s regular toilet habits can be affected by many things, including.

  • Busy lifestyles
  • Changes of routine, including holidays, starting school
  • Not eating enough fibre
  • Not drinking enough water or fluids
  • Not taking enough exercise, being sedentary
  • Ignoring natural urges to go to the toilet, sometimes due to not being near a toilet you are comfortable using
  • Emotional and psychological problems
  • Health conditions, including Parkinson’s disease, an under-active thyroid gland and depression
  • Age and circumstances
  • Bottle-feeding for babies
  • Some medications, including narcotic-type pain killers such as codeine, iron supplements and some drugs used to control blood pressure.

Causing Secondary Constipation

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Congenital malformations
Structural causes or mechanical obstruction
  •  Colon cancer
  • Benign stricture
  • Rectocele, enterocele, rectal prolapse
  •  Megacolon
  • Fissures
Metabolic
  • Hypothyroidism
  • Hypercalcemia
  • Hypokalaemia
  • Uraemia
  • Coeliac disease
Myopathies
  • Scleroderma
  • Amyloidosis
Neuropathies
  • Spinal injury
  • Myelomeningocele
  • Multiple sclerosis
  • Diabetic neuropathy
  • Cerebrovascular disease
  • Parkinson’s disease
Complications from surgery or irradiation therapy
Depression
Cognitive impairment
Immobility

 

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Constipation

Why Does It Happen?

Some causes of constipation include

  • Antacid medicines containing calcium or aluminum
  • Changes in your usual diet or activities
  • Colon cancer
  • Eating a lot of dairy products
  • Eating disorders
  • Irritable bowel syndrome
  • Neurological conditions such as Parkinson’s disease or multiple sclerosis
  • Not being active
  • Not enough water or fiber in your diet
  • Overuse of laxatives
  • Pregnancy
  • Problems with the nerves and muscles in the digestive system
  • Resisting the urge to have a bowel movement, which some people do because of hemorrhoids
  • Some medications (especially strong pain drugs such as narcotics, antidepressants, or iron pills)
  • Stress
  • An underactive thyroid (called hypothyroidism)

Drugs that Cause constipation prescription drugs that cause constipation include pain relievers like opiates etc.

The drug that causes constipation especially among the elderly include

  • Opioid pain relievers like Morphine, Codeine, etc.
  • Anticholinergic agents like Atropine, Trihexyphenidyl
  • Antispasmodics like dicyclomine
  • Tricyclic antidepressants like amitriptyline
  • Calcium channel blockers used in arrhythmias and high blood pressure such as verapamil
  • Anti-Parkinsonian drugs – Parkinson’s disease itself may cause constipation and the drugs used for this condition including Levodopa cause constipation as well
  • Sympathomimetics like ephedrine and terbutaline. Terbutaline is commonly used on bronchial asthma
  • Antipsychotics like clozapine, thioridazine, chlorpromazine used for psychiatric disorders
  • Diuretics for heart failure like furosemide
  • High blood pressure-lowering agents like methyldopa, clonidine, propranolol, etc.
  • Antihistamines like diphenhydramine
  • Antacids especially calcium and aluminum-containing
  • Calcium supplements
  • Iron supplements
  • Antidiarrheal agents (loperamide, attapulgite)
  • Anticonvulsants e.g. phenytoin, clonazepam
  • Pain relievers or NSAIDs (Nonsteroidal anti-inflammatory drugs) like ibuprofen, aspirin, etc.
  • Miscellaneous compounds including Octreotide, polystyrene resins, cholestyramine (for lowering high blood cholesterol) and oral contraceptives

Symptoms of constipation

Constipation

Constipation symptoms include

  • Hard, compacted poor that is difficult or painful to pass
  • Straining during bowel movements
  • No bowel movements after 3 days
  • Stomach aches that are relieved by bowel movements
  • Bloody stools due to hard poo, piles (hemorrhoids) and anal fissures
  • Leaks of wet, almost diarrhea-like poo between regular bowel movements
  • Complications of constipation
  • Complications of constipation include:
  • Dry, hard poo collecting in the rectum, called fecal impaction.
  • Leakage of liquid stools called fecal incontinence.
  • Straining on the toilet and constipation leading to piles.

Diagnosis of Constipation

In addition to a general physical exam and a digital rectal exam, doctors use the following tests and procedures to diagnose chronic constipation and try to find the cause:

  • Blood tests – Your doctor will look for a systemic condition such as low thyroid (hypothyroidism).
  • Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy) – In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon.
  • Examination of the rectum and entire colon (colonoscopy) – This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube.
  • Evaluation of anal sphincter muscle function (anorectal manometry). In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels.
  • Evaluation of anal sphincter muscle speed (balloon expulsion test) – Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum.
  • Evaluation of how well food moves through the colon (colonic transit study ) – In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over several days and be visible on X-rays.
  • In some cases, you may eat radiocarbon-activated food and a special camera will record its progress (scintigraphy). Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.
  • An X-ray of the rectum during defecation (defecography). During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.
  • MRI defecography. During this procedure, as in barium defecography, a doctor will insert contrast gel into your rectum. You then pass the gel. The MRI scanner can visualize and assess the function of the defecation muscles. This test also can diagnose problems that can cause constipation, such as rectocele or rectal .
  • transit study examination – where you take a short course of special capsules that show up on X-rays; one or more X-rays are taken later on to see how long it takes for the capsules to pass through your digestive system
  • anorectal manometry – where a small device with a balloon at one end is inserted into your rectum and attached to a machine that measures pressure readings from the balloon as you squeeze, relax and push your rectum muscles; this gives an idea of how well the muscles and nerves in and around your rectum are working.

Constipation

Treatment of Constipation

Most cases of constipation are easy to treat at home with diet and exercise. Some cases require doctor recommendations, prescription medicine, or a medical procedure.

At-home treatment includes

Diet – Eating a healthy diet with fiber and drinking plenty of fluids (water is the most helpful) can usually clear up constipation.

  • High fiber foods include beans, dried fruits, fresh fruits and vegetables, whole-grain foods (choose brown rice or whole wheat bread instead of white), flaxseed meal, and powdered products containing psyllium. For example, 3 cups of popped popcorn have a little more than 3 grams of fiber. One cup of oatmeal has 4 grams of fiber. Adding fiber to each meal and snack will help you reach your goal for the day. Fiber supplements are helpful. Processed foods, such as desserts and sugary drinks, only make constipation worse.
  • Men over the age of 50 should get at least 38 grams of fiber per day.
  • Women over 50 should get 25 grams per day.
  • Children ages 1 to 3 should get 19 grams of fiber per day.
  • Children between 4 and 8 years old should get 25 grams per day.
  • Girls between 9 and 18 should get 26 grams of fiber each day. Boys of the same age range should get between 31 and 38 grams of fiber per day.
  • Bowel training – Teach your children to go to the bathroom when they have to. Holding it can lead to constipation. This also may be necessary for your elderly parents, if you are caring for them.
  • Laxatives – This is over-the-counter medicine that helps you have a bowel movement. Laxatives should only be used in rare instances. Do not use them on a regular basis. If you have to use a laxative, bulk-forming laxatives are best. These work naturally to add bulk and water to your stools so they can pass easily. Bulk-forming laxatives can cause some bloating (when your stomach feels full) and gas.

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Anti- Ulcerant

Antiulcer Drugs
Brand Name
(Generic Name)
Possible Common Side Effects Include:
Axid (nitzatidine) Diarrhea, headache, nausea and vomiting, sore
throat
Carafate (sucralfate) Constipation, insomnia, hives, upset stomach,
vomiting
Cytotec (misoprostol) Cramps, diarrhea, nausea, gas, headache,
menstrual disorders (including heavy bleeding
and severe cramping)
Pepcid (famotidine) Constipation or diarrhea, dizziness, fatigue,
fever
Prilosec (omeprazole) Nausea and vomiting, headache, diarrhea,
abdominal pain
Tagamet (cimetidine) Headache, breast development in men, depres-
sion and disorientation
Zantac (ranitidine
hydrochloride)
Headache, constipation or diarrhea, joint pain

Treatment can be include

Type Generic and brand names Forms How fast? Safe to use long-term? Available as a generic?
bulk-forming psyllium (Metamucil, Konsyl), calcium polycarbophil (FiberCon), methylcellulose fiber (Citrucel) powder, granules, liquid, tablet, packet, wafer a few days yes yes
lubricant mineral oil (Fleet Mineral Oil Enema) enema, oral liquid 6 to 8 hours no yes
osmotic magnesium hydroxide (Phillips Milk of Magnesia), magnesium citrate, polyethylene glycol (Miralax), sodium phosphate (Fleet Saline Enema), glycerin (Fleet Glycerin Suppository) enema, suppository, oral liquid 30 minutes or less yes yes
stimulant bisacodyl (Dulcolax), senna/sennoside (Senokot) enema, suppository, oral liquid or capsule 6 to 10 hours no yes
stool softener docusate (Colace, DulcoEase, Surfak)

 

Enema, suppository, oral tablet, capsule, or liquid 1 to 3 days yes yes

 

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Here are prescription drugs used for the treatment of chronic constipation

  • Linaclotide (Linzess) – This drug is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bowel movements occur more often. It is not approved for use in those aged 17 years and younger. The most common side effect of Linzess is diarrhea. Linaclotide is an agonist of guanylate cyclase-C receptors, which stimulates intestinal fluid secretion and transit. In early studies, it has been found to increase bowel movement frequency and loosen stool consistency. A recently published dose range-finding study and results from two Phase III trials in 1272 patients with chronic constipation, show that linaclotide significantly improved bowel function (measured as ≥3 complete SBMs (SCBM) per week, with an increase of ≥1 from baseline for ≥9 of 12 weeks) in up to approximately 20% of patients. The median time to first SBM was 21.9 h (150 μg).Furthermore, abdominal symptoms, global measures of constipation and quality of life were also significantly improved  and there was no evidence of rebound constipation upon treatment cessation. The most common AEs were GI-related, of which diarrhea had the highest incidence.Linaclotide is currently not licensed for use in the EU.
  • Other 5-HT4 agonists – Other enterokinetic agents in development include the 5-HT4 receptor agonists TD-5108 (Phase II), and ATI-7505 (Phase II). A number of other prokinetic 5-HT4 receptor agonists have been developed for GI disorders, which are of considerable therapeutic interest but are in the early stages of development.
  • Lactulose (Cephula, Chronulac, Constulose, Duphalac, Enulose) – Lactulose, a prescription laxative with a variety of brand names, draw water into the bowel to soften and loosen the stool. Side effects include gas, diarrhea, upset stomach, and stomach cramps.
  • Lubiprostone (Amitiza) – Amitiza is approved by the FDA for the treatment of chronic constipation from an unknown cause (not constipation due to another condition or treatment). Amitiza softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food. Some reported side effects of Amitiza include a headache, nausea, diarrhea, abdominal pain, and vomiting.
  • Plecanatide (Trulance)  – Taken once a day, this tablet is a guanylate cyclase-C agonist. It helps stimulate intestinal fluid secretions that help your stool transit through the bowel. It was developed specifically for those suffering from Chronic Idiopathic Constipation. Side effects include diarrhea. It’s not recommended for use in patients younger than 6 years of age because of the dangers of severe dehydration.
  • Polyethylene glycol (Miralax, Glycolax ). This drug is an osmotic laxative and causes water to remain in the stool, which results in softer stools. For those patients who do not tolerate dietary fiber supplements, this medication may be recommended.
  • Prucalopride – Prucalopride is highly selective for the 5-HT4 receptor, unlike cisapride, displaying at least 150-fold selectivity for its therapeutic target receptor. Early studies demonstrated that it decreased colonic transit time in normal and constipated subjects. Three large randomized Phase III controlled trials with a total of 1977 patients (1750 female and 227 male) with severe chronic constipation (defined as ≤2 SCBM/week for a minimum of 6 months with either very hard or hard stools, sensation of incomplete evacuation or straining during defecation for at least 25% of the time) confirmed that, averaged over 12 weeks, bowel function (measured as an increase of ≥1 SBM/week) was significantly improved in up to 69% of patients receiving the recommended dose of 2 mg prucalopride, with a median time of 2.5 h to first SBM.
  • Colchicine – is an alkaloid substance, which is used as an anti-inflammatory agent. It can increase the frequency of bowel movements, where it may be prescribed as a remedy for the treatment of chronic constipation. Alvimopan and methylnaltrexone have been recently suggested as new agents for the treatment of constipation caused by the opioid.
  • Alvimopan – has been recommended for postoperative ileus after surgeries by the Food and Drug Administration (FDA), while FDA indicated that methylnaltrexone could be applied for patients suffering from opioid-induced constipation. However, trials of alvimopan in the confirmed use of methylnaltrexone in in opioid-induced constipation represent seriously dangerous cardiovascular causes with opposite results in terms of efficacy.[] In addition, the efficacy of commercially available synbiotic elements has been previously evaluated for the treatment of functional constipation in males.[]
  • Mineral oil – Do not use this without your doctor’s recommendation. Your doctor may recommend using it if you recently had surgery and should not strain for a bowel movement. Do not use it regularly. It causes your body to lose important vitamins A, D, E and K.
  • Enema – This is a liquid medicine. It is inserted into your anus to help with constipation. It is often used after a surgery or before some medical procedures.
  • Prescription medicine – Your doctor will prescribe a medicine based on the reason for your constipation.
  • Medical procedures – This is done to help remove stool from the intestine.
  • Surgery – This is rare. It might involve removing a damaged intestine for serious reasons.
  • Opioid antagonists – Three mu-opioid antagonists (naloxone, methylnaltrexone, and alvimopan) are currently under evaluation for the treatment of opiate-induced constipation  and postoperative ileus. Although endogenous opioids may play a role in modulating GI function, early reports suggested that opioid antagonists are not effective in idiopathic constipation.

Biofeedback Therapy

Previous studies reported that biofeedback therapy could be effectively efficient by using neuromuscular training, visual, and verbal feedback. It has priority over other therapies such as laxative and sham training.[]

Biofeedback session implicates placing a probe into the anus to give feedback of muscle tension using a computer screen. Biofeedback therapy is an efficient and multidisciplinary approach without the adverse effects of therapy.[] It has been observed that more than 70% of patients with gastrointestinal disorders get rid of symptoms by treating biofeedback therapy.[]

Laxatives

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Bulk laxatives
  • Dietary fiber, psyllium, polycarbophil, methylcellulose, carboxymethylcellulose
Osmotic agents
  • Saline laxatives: Magnesium, sulfate, potassium and phosphate salts
  • Poorly absorbed sugars: Lactulose, sorbitol, mannitol, lactose, glycerine suppositories
  • Polyethylene glycol (PEG): PEG 3350 laxative
Stimulant laxatives
  • Surface-active agents: Docusate, bile salts
  • Diphenylmethane derivatives: Phenolphthalein, bisacodyl, sodium picosulfate
  • Ricinoleic acid: Castor oil
  • Anthraquinones: Senna, cascara sagrada, aloe, rhubarb
  • Emollients
  • Mineral oil
Neuromuscular agents
  • 5-HT4 Agonists: Cisapride, or cisapride, prucalopride, tegaserod
  • Colchicine
  • Prostaglandin agent – Misoprostol
  • Cholinergic agents – Bethanechol, neostigmine
  • Opiate antagonists – Naloxone, naltrexone
Investigational agents
  • Recombinant methionyl human brain-derived neurotrophic factor (r-metHuBDNF), neurotrophin-3
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Bulk Laxatives

Fiber

  • Constipation has been associated with a deficiency of dietary fiber in Western society for decades. A correlation between increasing the daily fiber intake and fecal weight, as well as colonic transit time, has been demonstrated.
  • Dietary fiber appears to be effective in relieving mild to moderate, but not severe constipation. The recommended amount of dietary fiber is 20 to 35 grams per day (g/d) and this can be obtained from whole wheat bread, unrefined cereals, citrus fruits, and vegetables.
  • Insoluble fiber, such as cereal bran, may cause significant abdominal gas and bloating, creating discomfort. In some patients, these agents also delay gastric emptying and depress appetite. To improve the tolerance and adherence you may start with low doses of fiber and increase their dietary fiber intake gradually over the next weeks until ∼20 to 25 g/d.
  • If constipation has not improved, then commercially available fiber supplements should be tried. Patients also must be encouraged to drink water and maintain hydration when increasing fiber intake.

Ispaghula (Psyllium)

  • Ispaghula comes from an Asian plant that has a high water-binding capacity and is fermented in the colon. In an observational study with psyllium, the response to treatment was poor among patients with slow colonic transit, whereas 85% of patients without abnormal physiology improved or became symptom-free.
  • Side effects include delayed gastric emptying and loss of appetite in some patients. Also, there have been some reports of serious acute allergic reactions, cough, and asthma.

Methylcellulose

  • Methylcellulose is a synthetic fiber polymer that is methylated. This results in resistance to bacterial fermentation. Mainly, it absorbs water into the colonic lumen, which increases fecal mass promoting motility and reduction in the colonic transit time.
  • In one study, the patients showed an increase in solid stool mass with 1, 2, and 4 g of methylcellulose per day, but fecal water increased only with the 4-g dose. Despite the fact that bowel frequency was increased, the patients did not report a marked improvement in the consistency or passage of stools.

Calcium Polycarbophil

  • Calcium polycarbophil is a hydrophilic resin that is resistant to bacterial degradation and thus may be less likely to cause gas and bloating. In patients with IBS with features of constipation, calcium polycarbophil seems to improve overall symptoms and passage of stool, but not abdominal pain.

Osmotic Agents

  • In patients unresponsive to bulk agents alone, the addition of other laxatives is often the next step in the management of constipation. There are different forms of laxatives that can be selected based on the patient’s symptoms and preferences.

Poorly Absorbed Ions-H2

Magnesium and Sulfate

  • Magnesium, sulfate, and phosphate ions are poorly absorbed by the gut and thereby create a hyperosmolar intraluminal environment. Magnesium oxide has been considered safe to use on a regular basis in mildly constipated patients. Standard doses of 40 to 80 mmol of magnesium ion usually provoke a bowel movement within 6 hours. Magnesium sulfate is a more potent laxative that tends to produce a large volume of liquid stool and abdominal distention.Tas a result of excessive use.

Sodium sulfate is a component of some bowel lavage solutions for colon cleansing prior to diagnostic and surgical procedures,[ but significant absorption may occur in the jejunum that may cause electrolyte disturbances.

Phosphate

  • Phosphate can be absorbed by the small intestine, and a high dose must be ingested to produce an osmotic laxative effect. Complications have been reported with sodium phosphate and OTC use is no longer available in the United States.
  • Some of the complications reported include hyperphosphatemia, especially in patients with renal insufficiency and acute renal injury if used in large amounts as in bowel preparations. Risk factors include advanced age, dehydration, and the use of angiotensin-converting enzyme inhibitors or nonsteroidal anti-inflammatory drugs.

Poorly Absorbed Sugars

Lactulose

  • Lactulose is a poorly absorbed synthetic disaccharide of galactose and fructose. This nonabsorbable carbohydrate becomes a substrate for colonic bacterial fermentation that produces hydrogen and methane and lowers fecal pH, carbon dioxide, water, and fatty acids.
  • These products are osmotic agents that promote intestinal motility and secretion. The recommended dose of lactulose for adults is 15 to 30 mL once or twice daily. The time to onset of action is between 24 to 72 hours, longer than for other osmotic laxatives.
  • Lactulose increases stool frequency in chronically constipated patients and is dose-dependent because it is fermented by colonic bacteria, gas and bloating usually limit its clinical use.

Sorbitol

  • Sorbitol is a poorly absorbed sugar alcohol that may produce effects similar to lactulose if taken in sufficient dosages. Sorbitol is commonly found as an artificial sweetener. It has been shown that as little as 5 g can cause a rise in breath hydrogen from bacterial fermentation, and 20 g produces diarrhea in about half of normal patients.
  • Sorbitol is as effective as lactulose and less expensive. A randomized, double-blind, crossover trial of lactulose (20 g/d) and sorbitol (21 g/d) showed no difference in regards the frequency of bowel movements and patient preference. Patients using lactulose had more nausea compared with sorbitol. Mannitol is another sugar alcohol that can be used as a laxative.

Polyethylene Glycol

  • Polyethylene glycol (PEG) is an isosmotic laxative that is metabolically inert, which binds to water and keeps water retention inside the lumen. PEG is commonly used in solutions for colon cleansing as polyethylene glycol electrolyte lavage solutions (PEG-ELS) and sulfate-free electrolyte lavage solution (SF-ELS).
  • These solutions have electrolytes added to avoid side effects from dehydration and electrolyte disturbances and have been shown to be safe for preparation for diagnostic colonoscopy, barium x-ray examinations, and colon surgery. Most of these solutions have been shown to be dose-dependent, increasing the number of stools with increasing dosage of PEG. Low-dose PEG has been shown in studies to be more effective than lactulose in the treatment of chronic constipation.
  • The most common adverse effects of PEG include abdominal bloating and cramps. However, there are some case reports of severe pulmonary edema that have been reported with the use of PEG.

Stimulant Laxatives

  • Stimulant laxatives – increase intestinal motility and intestinal secretion. They begin working within hours and often are associated with abdominal cramps. Stimulant laxatives include anthraquinones (e.g., cascara, aloe, senna) and diphenylmethanes (e.g., bisacodyl, sodium picosulfate, phenolphthalein).
  • Castor oil – is used less commonly because of its side-effect profile and poor palatability. The effect of stimulant laxatives is dose-dependent. Low doses prevent absorption of water and sodium, whereas high doses stimulate secretion of sodium, followed by water, into the colonic lumen.
  • Stimulant laxatives – sometimes are abused, especially in patients with an eating disorder, even though at high doses they have only a modest effect on calorie absorption. Although a cathartic colon (i.e., a colon with reduced motility) has been attributed to prolonged use of stimulant laxatives, no animal or human data support this effect. Rather, cathartic colon, as seen on a barium enema examination, is probably a primary motility disorder.

Anthraquinones

  • Anthraquinones, such as cascara, senna, aloe, and frangula, are produced by a variety of plants. The compounds are inactive glycosides that when ingested, pass unabsorbed and unchanged down the small intestine and are hydrolyzed by colonic bacterial glycosidases to yield active molecules.
  • These active metabolites increase the transport of electrolytes into the colonic lumen and stimulate myenteric plexuses to increase intestinal motility. The anthraquinones typically induce defecation 6 to 8 hours after oral dosing.
  • Anthraquinones cause apoptosis of colonic epithelial cells, which they are phagocytosed by macrophages and appear as a lipofuscin-like pigment that darkens the colonic mucosa, a condition termed pseudomelanosis coli. Whether anthraquinone laxatives given over the long term cause adverse functional or structural changes in the intestine is controversial.
  • Animal studies have shown neither damage to the myenteric plexus after long-term administration of sennosides nor a functional defect in motility. A case-control study in which multiple colonic mucosal biopsy specimens were examined by electron microscopy showed no differences in the submucosal plexuses between patients taking an anthraquinone laxative regularly for one year and those not taking one. An association between use of anthraquinones and colon cancer or myenteric nerve damage and the development of cathartic colon has not been established.

Diphenylmethane Derivatives

  • Diphenylmethane compounds include bisacodyl, sodium picosulfate, and phenolphthalein. After oral ingestion, bisacodyl and sodium picosulfate are hydrolyzed to the same active metabolite, but the mode of hydrolysis differs. Bisacodyl is hydrolyzed by intestinal enzymes and thus can act in the small and large intestines. Sodium picosulfate is hydrolyzed by colonic bacteria.
  • Like anthraquinones, the action of sodium picosulfate is confined to the colon, and its activity is unpredictable because its activation depends on the bacterial flora.
  • Like the anthraquinone laxatives, bisacodyl leads to apoptosis of colonic epithelial cells, the remnants of which accumulate in phagocytic macrophages, but these cellular remnants are not pigmented. Aside from these changes, bisacodyl does not appear to cause adverse effects with long-term use.
  • Phenolphthalein inhibits water absorption in the small intestine and colon by effects on eicosanoids and the Na+/K+-ATPase pump present on the surface of enterocytes. The drug undergoes enterohepatic circulation, which may prolong its effects. It has been removed from the U.S. market because it is teratogenic in animals.

Ricinoleic Acid (Bisacodyl and Castor Oil)

  • Castor oil comes from the castor bean. After oral ingestion, it is hydrolyzed by lipase in the small intestine to ricinoleic acid, which inhibits intestinal water absorption and stimulates intestinal motor function by damaging mucosal cells and releasing neurotransmitters. Cramping is a common side effect.
  • Stimulant laxatives, such as bisacodyl and senna exert their primary effects through alteration of electrolyte transport by the intestinal mucosa and generally work within several hours. In his classification, Schiller refers to this class of drugs as “secretagogues and agents with direct effects on the epithelial, nerve, or smooth muscle cells.” Following their use, it is not uncommon for patients to report symptoms of abdominal discomfort and cramping. This grouping includes surface-active agents, diphenylmethane derivatives, ricinoleic acid, and anthraquinones.
  • Although stimulant laxatives may be associated with occasional side effects such as salt overload, hypokalemia, and protein-losing enteropathy, data does not support the theory that they cause a so-called cathartic colon. Melanosis Coli, pigmentation of the colonic mucosal due to the accumulation of apoptotic epithelial cells phagocytosed by macrophages, may develop in patients who chronically ingest anthraquinone-containing stimulant laxatives.
  • Despite prior theories to the contrary, neither anthracoid laxative use nor macroscopic or microscopic melanosis coli are associated with any significant risk for the development of colorectal adenoma or carcinoma.
  • Phenolphthalein, no longer marketed in the United States, has been associated with the fixed-drug eruption, protein-losing enteropathy, Stevens-Johnson syndrome, and lupus reactions.Castor oil, containing ricinoleic acid, alters intestinal water absorption and motor function, and side effects often include cramping and nutrient malabsorption.

Docusate Sodium

  • Docusate sodium is a widely available stool softener and is a detergent agent that stimulates fluid secretion by the small and large intestine. Like most available OTC agents, conflicting evidence supports its use.
  • One study showed no change in the volume of stool output in patients with ileostomy or weight of stool in normal subjects. A small double-blind crossover study showed improvement in bowel frequency in one-third of the studied patients. Other studies showed docusate to be less effective than psyllium for chronic idiopathic constipation.

Emollients

  • Mineral oil is an indigestible lipid compound which provides lubrication and emulsification of the fecal mass. In addition to being unpalatable, long-term use can cause malabsorption of fat-soluble vitamins, seepage, incontinence, and rarely lipoid aspiration pneumonia.

Enemas and Suppositories

  • Enemas general act by causing rectal distention and sometimes irritation of the rectal mucosa. Although generally safe, enemas may cause serious damage to the rectum by misinsertion resulting in trauma to the rectal mucosa.

Phosphate Enemas

  • Commercially available sodium phosphate enemas are hypertonic solutions, which cause stimulation and some degree of macro and microscopic irritation of the rectal mucosa. Like most other OTC agents, there is little convincing evidence of their efficacy, mostly because of the lack of well-designed trials.

Saline, Tap Water, and Soapsuds Enemas

  • Saline, tap water, and soapsuds enemas also cause rectal distention, prompting an evacuation. As a group, they are less irritating to the rectal mucosa if used in small volumes. With larger volumes, water intoxication has been reported with tap water enemas.
  • Similarly, electrolyte disturbances have also been reported with larger volume soapsuds enemas. Saline enemas have been proposed as a survival technique in situations without pure freshwater.

Stimulant Suppositories and Enemas

  • Glycerin and bisacodyl are available without a prescription as suppositories for use in constipation. Glycerin appears to work by stimulating an osmotic effect in the rectum. Bisacodyl exerts its action on neurons in the rectum, prompting defecation. Few if any clinical trials support their use.

Prokinetic Agents (5-HT4 Agonists)

  • Prokinetic agents induce contractions in the gastrointestinal tract. Recently, most attention in the development of prokinetic agents has focused on the 5-HT4 serotonin receptor, given prior toxicities of drugs with other targets (metoclopramide and cisapride in particular).
  • Tegaserod showed particular promise in the treatment of chronic constipation, but was withdrawn from the U. S. market due to observed cardiovascular toxicities; however, it remains available in other parts of the world. Newer 5-HT4 agonists are under development and appear promising as treatments for chronic constipation.[,Unfortunately, prucalopride is not yet available in the United States.
  • TD-5108, also known as velusetrag, is also a full 5-HT4 agonist. It has shown promise in phase II studies as an agent for chronic constipation. Despite positive results of early studies published around 2007, no phase III studies have been published and there may be issues with tachyphylaxis that may limit its utility for chronic constipation.

Peripheral µ-Opioid Antagonists

Methylnaltrexone

  • Methylnaltrexone is a peripheral µ-opioid receptor antagonist that was U.S. Food & Drug Administration- (FDA-) approved in 2008 for opioid-induced constipation in patients with late-stage illness who receive opioids on a continuous basis. Most patients in clinical trials had limited life expectancy. Results are usually brisk, with almost half of patients having a bowel movement within 4 hours of the first dose. In the clinical trials, methylnaltrexone did not appear to precipitate opioid withdrawal.

Alvimopan

  • Alvimopan is FDA approved to hasten bowel recovery after surgery. Like methylnaltrexone, it is also a µ-opioid receptor antagonist. It may also be useful in opioid-induced constipation.

Other Agents

Clostridium Botulinum Toxin Type A (Botox)

  • Clostridium botulinum toxin has been used to relieve outlet dysfunction defecatory disorders. Usually, it is injected into the puborectalis muscle. Controlled trials are lacking and it is not FDA approved for this indication.

Bethanechol

  • Cholinergic agents have been used in the treatment of constipation. Bethanechol appears to be beneficial in patients whose constipation results from tricyclic antidepressants. Use outside of this setting lacks evidence of efficacy. Neostigmine is clearly beneficial in colonic pseudo-obstruction, but given the severity of side effects, its use in chronic constipation would likely be problematic or intolerable.

Colchicine

  • Colchicine is commonly used for constipation in practice. Again though, there is limited evidence in the form of quality clinical trials to support its use. One study did demonstrate increased bowel movement frequency, but patients treated with colchicine had more abdominal pain than controls.
  • Misoprostol is also used in treating chronic constipation, but given that its mechanism is probably similar to lubiprostone and its toxicities are likely greater, its regular clinical use is probably not warranted.

Newer Agents

Linaclotide

  • Linaclotide targets the guanylate cyclase C protein and is minimally absorbed. In clinical trials, it has been shown to be safe, well-tolerated, decrease abdominal pain, accelerate colon transit, and improve bowel function and CSBM. Despite recent high-profile publications demonstrating its efficacy, it is unclear when or if FDA approval will occur.

R-Manhunt-3

  • Another promising approach in the management of chronic constipation is targeting neurotrophins, a family of proteins that may induce nerve growth, nerve transmission, and consequently improve colonic and/or GI tract transit times. Thus far, the only agent studied is R-metHuNT-3 (recombinant human neurotrophic factor 3). It appears to offer improvement in gut transit but suffers from some significant toxicities (injection site reactions and paresthesias).

Alternative Treatment

Defecation Training

  • Defecation training may be helpful, but few specially trained instructors are available. The process involves teaching and supportive listening as well as the encouragement of progress in follow-up sessions. The basics are teaching patients not to suppress the urge to defecate, setting aside time for regular bowel habits, and correct body positioning while defecating (including raising the feet above the floor when using Western-style toilets).

Anorectal Biofeedback

  • Anorectal biofeedback can be similarly beneficial, but finding qualified therapists may be challenging. The process usually involves several sessions performed with either surface electromyogram (EMG) electrodes or an anorectal manometry catheter. Patients are taught coordinated movements to promote successful defecation. The process is usually beneficial—a pooled analysis estimated about two-thirds of patients improved, but insurance coverage usually is an obstacle to its use.

 Home Remedies For Constipation

Triphala powder or churna

  • This consists of three fruits – amla or Indian gooseberry, haritaki (Chebulic Myrobalan) and vibhitaki (Bellirica Myrobalan). It is a great laxative and helps to regulate digestion and bowel movements.

How to use

  • You can either have one teaspoon with warm water or. Mix the powder with honey either before going to bed or early in the morning on an empty stomach.

 Raisins (kishmish)

  • They are packed with fiber and act as great natural laxatives. This remedy also works wonders for pregnant women, without the side-effects of medication. Here are more reasons to eat raisins.

How to use

  • Soak a handful in water overnight.
    Have them first thing in the morning on an empty stomach.

Guavas (abroad or Peru)

  • They have soluble fiber in the pulp and insoluble fiber content in the seeds. They also help with the mucus production in the anus and with peristalsis (a series of contractions within the intestinal lining that helps the passage of food in the stomach). Don’t forget about these health benefits of guavas.

Lemon (nimbu) juice

  • It acts as a cleansing agent for the intestines, the salt content helps in quick and easy passage of stool.
  • This juice also is a great way to detox your body. Here are more reasons to add lemons to your diet.

How to use

  • All you need to do is mix one teaspoon of lemon juice in a glass of warm water.
  • Add a pinch of salt to the solution.
  • Drink this juice on an empty stomach to relieve constipation.

Figs (Anjeer)

  • Either dried or ripe, figs are packed with fiber and act as a great natural laxative.

How to use

  • For relief from constipation, boil a few figs in a glass of milk, drink this mixture at night before bed.
    Make sure the mixture is warm when you drink it.
    Using a whole fruit for this purpose is much better as compared to syrups that are available commercially.

Flaxseeds (Alsi)

  • They are known for their fiber content, and can very well help you when it comes to constipation.

How to use

  • You can mix flaxseeds in your cereal every morning.
    Or just have a handful with warm water early in the morning. More reasons they are great for health.

Castor oil (Arandi ka tel)

  • This has been used for centuries as a sure shot remedy for constipation and has properties that can kill intestinal worms.

How to use

  • If drinking a spoon of castor oil alone is not something you’d like to do, you could add a tablespoon of it in a warm glass of milk.
    Have this mixture at night before bed to relieve constipation. Did you know castor oil is great for your skin too?

Spinach (Palak)

  • This has properties that cleanse, rebuild and renew the intestinal tract. You can also reap in these 10 amazing health benefits of palak.

How to use

  • You can have about 100 ml of spinach juice mixed with an equal quantity of water twice daily.
    This home remedy is the most effective method to cure even the most stubborn cases of constipation.

Oranges

  • They are not only a great source of vitamin C but also have a large amount of fiber content.

How to use

  • Eating two oranges every day, once in the morning and once in the evening can provide great relief from constipation.
    Eat them without peeling off the white threads for added effect. Here’s how oranges keep you healthy.

Seed Mixtures

  • This is a great source of fiber and can help relieve constipation. This mixture not only provides the necessary fiber content to relieve constipation but it also helps in rejuvenating the intestinal walls.

How to use

  • -2-3 sunflower seeds, a few flaxseeds, til or sesame seeds and almonds ground together to a fine powder can help relieve constipation.
    -Have one tablespoon of this mixture every day, for a week.
    -You can add it to your salad or cereal every morning.

Diet tips to avoid constipation

  • In order to avoid and cure constipation, it is essential that you maintain healthy food habits. Here are a few changes you could make in your diet to cure constipation:
  • Avoid foods that contain white flour-like maida, white sugar, and other processed foods.
  • Eat light regular meals, and make sure you eat at least 3-4 hours before you go to bed. Regular meals not only keep constipation at bay.
  • Include fruits and vegetables into your daily diet.
  • Adding condiments like jeera, Haldi, and ajwain in your food while cooking it is a great way to help digestion.
  • Drink at least eight glasses of water every day. Make sure you have a glass of warm water every morning and before you go to bed.
  • Constipation is an entirely curable and manageable condition, all you need to do is keep some of these home remedies in mind and you should be well on your way to a happy morning.

Can constipation be prevented or avoided?

There are things you can do to reduce constipation. This includes:

  • Add more fiber to your diet – Adults should eat between 20-35 grams of fiber each day. Foods, such as beans, whole grains, fruits, and vegetables are high in fiber.
  • Drink more water – Being dehydrated causes your stool to dry out. This makes having a bowel movement more difficult and painful.
  • Don’t wait – When you have the urge to have a bowel movement, don’t hold it in. This causes the stool to build up.
  • Get physical – exercise is helpful in keeping your bowel movements regular.
  • Beware of medicines – Certain prescription medicines (especially pain medicines) can slow your digestive system. This causes constipation.
  • Talk to your doctor about how to prepare for this if you need these medicines.
  • Try warm liquids, especially in the morning.
  • Add fruits and vegetables to your diet.
  • Eat prunes and bran cereal.
  • If needed, use a very mild over-the-counter stool softener like docusate or a laxative like magnesium hydroxide. Don’t use laxatives for more than 2 weeks without calling your doctor. If you overdo it, your symptoms may get worse.
  • Talk to your doctor if you are being treated for certain diseases that are related to constipation. He or she may have additional guidance for lowering your risks.

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Laxatives to avoid or use with caution for elderly patients

LAXATIVE PRECAUTIONS
  • Docusate
• Lacks evidence for prevention and treatment of constipation (ie, no harm, but ineffective)
  • Magnesium
• Avoid in individuals with cardiac or renal dysfunction
  • Mineral oil
• Oral mineral oil should be avoided for older adults owing to concerns about aspiration (safer alternatives are available)
  • Soapsuds enema
• Risk of colonic mucosa irritation
  • Sodium phosphate enema
• As a purgative, avoid owing to serious electrolyte, renal, cardiovascular, and neurological concerns
• As a laxative, avoid in individuals with dehydration, renal impairment, cardiac dysfunction, or electrolyte disturbances
  • picosulfate, magnesium oxide, and citric acid
• Risk of electrolyte imbalance
• Avoid for patients with renal impairment (creatinine clearance < 30 mL/min)
  • Polyethylene glycol 3350 with electrolytes
• Avoid if the patient has impaired gag reflex, is prone to aspiration or regurgitation, is semiconscious, has a risk of electrolyte imbalance, has severe renal dysfunction (creatinine clearance < 30 mL/min), or has congestive heart failure

 

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References

Shoulder Dislocation; Causes, Symptom, Diagnosis, Treatment,

Shoulder dislocation occurs when the head of the humerus (upper arm bone) pops out of the shallow shoulder socket of the scapula (called the glenoid). This can happen when a strong force pulls the shoulder upward or outward, or from an extreme external rotation of the humerus. Glenohumeral dislocations are generally classified by the direction of dislocation of the humerus.

Shoulder joint dislocation is the most common joint dislocation in the emergency department (8 to 17 cases/100 000 inhabitants/year). In 95% of cases, the upper end of the humerus is pushed out of the joint socket in a forward direction, usually as a result of a low-energy accident. The shoulder joint has the greatest range of motion of all the joints in the human body; for this reason it is the most unstable joint.Once a dislocation has occurred, the shoulder is more susceptible to re-dislocation. In the literature, recurrence has been reported in 85% to 92% of cases.

shoulder-dislocation-anatomy

Dislocation can be full or partial:

  • Partial dislocation (also called subluxation) — the head of the humerus slips out of the socket momentarily and then snaps back into place
  • Full dislocation — the head of the humerus comes completely out of the socket

Shoulder dislocations can also be associated with fractures—one can have a fracture and dislocation at the same time. Nerves and blood vessels can sometimes be injured with a severe shoulder dislocation, requiring immediate medical attention.

Alternative Names of Shoulder dislocation

Shoulder dislocation; Shoulder subluxation; Shoulder reduction; Glenohumeral joint dislocation.

Anatomy

The shoulder is a ball and socket joint. The “ball” at the top of your arm bone (humerus) fits into the “socket” (glenoid), which is part of the shoulder blade. The joint is held in place (stabilised) by the soft tissues, which surround it and wrap around it. This stability is provided by a combination of structures and factors.

  • The glenoid and glenoid labrum – the shape and depth of the socket provide some stability and the socket is deepened by a rim of cartilage around its edge – called the labrums
  • The joint capsule provides a loose soft tissue covering around the joint.
  • The ligaments. These are strap-like structures which attach between the ball and the socket – helping to hold them in place.
  • The rotator cuff muscles and tendons. The rotator cuff muscles fan out from the shoulder blade and narrow to become tendons – attaching onto the “ball”. A fraction of a second before you lift your arm, these muscles and their tendons contract to keep the ball centred in the socket.
  • Additional stability is provided by the negative pressure of the joint capsule and also suction effect of the labrum which acts a bit like a plunger – sucking the ball into the socket.
  • Further stability is provided by proprioception and control. This is the ability of the brain to know the position of the shoulder joint and to make subtle adjustments.
  • The position of the shoulder blade is also important. The socket is located on the top / outside border of the shoulder blade. If the position of the shoulder blade is altered by pain / injury / bad posture / habit then this can compromise the ability of the ball to maintain its position in the socket.
shoulder dislocations

Type of Shoulder dislocation

Shoulder dislocations are usually divided according to the direction in which the humerus exits the joint:

  • anterior > 95%
    • subcoracoid (majority)
    • subglenoid (1/3)
    • subclavicular (rare)
  • posterior 2-4% 2
  • inferior (luxatio erecta) < 1%

Types of Dislocation

Anterior dislocation – is the most common, accounting for up to 97% of all shoulder dislocations.

  • Mechanism of injury is usually a blow to an abducted, externally rotated and extended extremity.
  • It may also occur with posterior humerus force or fall on an outstretched arm.
  • On exam, the arm is usually abducted and externally rotated, and the acromion appears prominent
  • There are associated injuries in up 40% of anterior dislocations including nerve damage, or tears and fractures associated with the labrum, glenoid fossa, and/or humeral head.

Posterior dislocations –  account for 2% to 4% of shoulder dislocations.

  • Usually, the injury is caused by a hit to the anterior shoulder and axial loading of the adducted internally rotated arm.
  • It may also be a result of violent muscle contractions (seizures, electrocution).
  • On exam, the arm is usually held in adduction, and internal rotation and patient is unable to rotate externally.
  • Higher risk of associated injuries such as fractures of surgical neck or tuberosity, reverse Hill-Sachs lesions (also called a McLaughlin lesion which is an impaction fracture of anteromedial aspect of humeral head), and injuries of the labrum or rotator cuff.

Inferior dislocations –  (also known as luxatio erecta) are the most uncommon type (less than 1%).

  • Usually caused by hyperabduction or with axial loading on the abducted arm.
  • On exam, the arm is held above and behind the head and patient is unable to adduct arm.
  • Often associated with nerve injury, rotator cuff injury, tears in the internal capsule, and the highest incidence of axillary nerve and artery injury of all shoulder injuries.

Anterior Dislocation

Anterior Dislocation

With an anterior dislocation, the head of the humerus is driven forward from inside the glenoid cavity to a place under the coracoid process. This type of dislocation is sometimes referred to as a subcoracoid dislocation. The joint capsule is usually avulsed (torn away) from the margin of the glenoid cavity.

Anterior Dislocation2

Anterior shoulder dislocation can also be the result of a detached labrum. When both the labrum and the capsule along the anterior margin of the glenoid cavity are avulsed, the injury is called a Bankart lesion. Compression fracture of the humeral head from the force of hitting the hard glenoid is called a Hill-Sach’s lesion. Three-fourths of the patients with a Bankart lesion will also have a Hill-Sach’s lesion.

Posterior and Inferior Dislocations

http://rxharun.com/pnterior Dislocation

When the shoulder dislocates posteriorly, the head of the humerus moves backward behind the glenoid. An inferior dislocation describes the position of the humeral head down below the glenoid cavity. Posterior and inferior shoulder dislocations only account for about five to 10 per cent of all shoulder dislocations. Most shoulder dislocations are in the anterior direction.

inferior Dislocation

A Bankart lesion is the most common injury sustained with traumatic dislocation, but other injuries can occur. These may alter the surgery and rehabilitation. These injuries can usually be diagnosed on an MR-Arthrogram or CT-Arthrogram.

These injuries are

  • ALPSA lesion – (Anterior Labral Periosteal Sleeve Avulsion) a displacedBankart tear, where the labrum has displaced around the glenoid neck. This is associated with a higher risk of recurrent instability than an undisplacedBankart tear. – ALPSA lesion at arthroscopy
  • HAGL tear – (Humeral Avulsion of Glenohumeral ligament)
  • Bony Bankartt – a fragment of bone breaks off with the Bankart tear – Bony Bankart at arthroscopy
  • Hill-Sachs lesion – a dent in the back of the humeral head which occurs during the dislocation as the humeral head impacts against the front of the glenoid.
  • SLAP Tear – a tear at the top of the labrum

http://rxharun.com/inferior Dislocation

Causes of Shoulder Dislocation

Shoulder dislocation can be caused by

  • Falling on an outstretched arm
  • A direct blow to the shoulder area, such as inan automobile accident
  • Forceful throwing, lifting, or hitting
  • Force applied to an outstretched arm, such as in a football tackle

Symptoms of Shoulder Dislocation

Symptoms of a dislocated shoulder include

  • Pain, often severe
  • Instability and weakness in the shoulder area
  • Inability to move the shoulder
  • Swelling
  • Bruising
  • Shoulder contour appears abnormal
  • Numbness and tingling around the shoulder or in the arm or fingers
  • Severe shoulder pain
  • Limited motion of the shoulder
  • A distortion in the contour of the shoulder — In an anterior dislocation, the side silhouette of the shoulder has an abnormal squared-off appearance instead of its typical sloping, rounded contour. In a posterior dislocation, the front of the shoulder may look abnormally flat.
  • A hard knob under the skin near the shoulder — This knob is the top of the humerus that has popped out of its socket.
  • Shoulder bruising or abrasions if an impact has caused your injury

Diagnosis of Shoulder dislocation

Clinically important fractures occur in about 25% of dislocations.

  • Fractures of tuberosity, surgical neck fractures may occur and should not be reduced in emergency department
  • Bankart lesion develops when the glenoid labrum is disrupted with or without the addition of avulsed bone fragment (bony Bankart). Soft Bankart lesions involving the inferior anterior labrum are more common.
  • Hill-Sachs deformity is a compression fracture of the posterolateral humeral head primarily with anterior dislocations.
  • Reverse Hill-Sachs lesions seen in posterior dislocations (also called a McLaughlin lesion) which is an impaction fracture of the anteromedial aspect of the humeral head.

Reduction of the Dislocated Shoulder

  • Often conscious sedation with fentanyl, midazolam, ketamine, etomidate, or propofol used. This is done with continuous monitoring with capnography. If conscious sedation not needed, an intraarticular injection of 10 cc of local lidocaine or similar anesthetic may be helpful.

Contraindications to a reduction in ED

Anterior Dislocation

  • Fractures of the humeral neck can lead to avascular necrosis
  • Subclavicular and/or intrathoracic dislocations include a subacute dislocation in an elderly patient and an associated surgical neck fracture
  • Avoid multiple attempts in injuries that include neurovascular compromise (including brachial plexus involvement, axillary nerve, a musculocutaneous nerve, etc.).  If prompt reduction cannot occur without further injury, may need surgical help.
  • The suspected arterial injury may need urgent angiography first.

Posterior Dislocation

  • Delayed presentation to the emergency department (more than 6 weeks)
  • Multipart or displaced fracture/dislocations

Inferior Dislocation

  • Humeral neck or shaft fractures should be done in a surgical setting
  • Any potential of vascular injury

Initial exam will serve to rule out any other problems, like a shoulder fracture, and generally includes:

  • Taking your medical history – This includes asking questions about how the injury occurred, and whether you have ever dislocated your shoulder in the past. It can also include questions about whether you have other medical problems, and if you take any medications.
  • Physical exam – The orthopedist will examine your shoulder and arm to evaluate your pain and sensitivity, strength, range of motion.

Imaging tests – Your orthopedist may want to examine the bones and joints themselves using a variety of imaging techniques, including

  •  X-ray, which can show the dislocation and also help determine if you have any broken bones
  • MRI, which uses powerful magnets and computer technology to create a picture of your muscles, tissues, and nerves to show if you have any tissue damage.
  • Electromyography – This procedure measures electrical activity in your muscles and can help show if you have any nerve damage.
  • Report checklist

In addition to reporting the presence of a dislocation a number of features and associated findings should be sought and commented upon direction of dislocation associated fractures/injuries

  • Hill-Sachs lesion
  • bony Bankart lesion
  • proximal humeral fracture
  • clavicular fracture
  • acromioclavicular joint disruption
  • acromial fracture

It is also important to remember to scrutinise the ribs and portion of the lungs and mediastinum included in the film for unexpected findings. Think about the soft tissue structures that might be injured, particularly the neurovascular bundle with inferior dislocations.

Treatment

Treatment includes

  • Closed reduction — The doctor will move the head of the humerus back into the shoulder joint socket by applying traction to your arm. You will be given pain medication before this procedure begins.

Reduction methods

Hippocratic method

  • The clinician holds the patient’s affected arm by the wrist and applies traction at a 45° angle.
  • At the same time, they provide countertraction by placing a foot on the patient’s chest wall or by having an assistant wrap a sheet around the patient’s torso.

External rotation method

  • The patient is in a supine position on the bed.
  • The affected arm is adducted and flexed to 90° at the elbow.
  • The arm is then slowly externally rotated.
  • The shoulder should be reduced before reaching the coronal plane.

Stimson’s technique

  • The patient is placed in a prone position on the bed.
  • The affected shoulder is supported and the arm is left to hang over the edge of the bed.
  • A weight is attached to the elbow/wrist. It is usual to begin with about 2 kg. Up to 10 kg may be applied.
  • Gravity stretches the muscles and reduction occurs.
  • Gentle internal/external humeral rotation may be applied.
  • This method may take 15 to 20 minutes.
  • There is now some evidence that this technique may be slightly less effective than Milch’s reduction technique.

Kocher’s method

  • This is not frequently used because there is an increased rate of complications (risk of fracture of the humeral neck or shaft).
  • Bend the arm at the elbow and press it against the body.
  • Next, rotate the arm outwards until you can feel resistance.
  • Lift the externally rotated upper part of the arm in the sagittal plane as far as possible forwards.
  • Finally, turn the arm inwards slowly.

Immediate reduction

  • If the doctor witnesses an anterior dislocation of shoulder, perhaps during sport, and if they are satisfied that there is no significant risk of fracture, rapid reduction may be considered. This provides quick pain relief and requires less force.
  • Local analgesia may be obtained by injecting 20 ml of 1% lidocaine into the joint.
  • The manoeuvre involves initial slight abduction and internal de-rotation of the affected arm. This can be done without applying a great deal of traction.
  • The shoulder is then immobilised in a sling..
  • Immobilization—After the reduction, you will need to wear a sling or a device called a shoulder immobilizer to keep the shoulder from moving. The shoulder is generally immobilized for about four weeks, and full recovery takes several months.
  • Rest — It is important to rest your shoulder and not put any strain on the joint area.
  • Ice and heat — Apply ice or a cold pack to your shoulder for 15-20 minutes, four times a day, for the first two days. After the third day, use a heating pad for 20 minutes or less might help relief muscle soreness. This helps reduce pain and swelling as well. Wrap the ice or cold pack in a towel. Do not apply the ice directly to your skin.
  • Rehabilitation exercises — After removal of the shoulder sling, begin exercises to restore strength and range of motion in your shoulder as recommended by your healthcare professional.

Medications

The goal of treatment is to decrease pain and increase mobility.

Reduction techniques for anterior shoulder dislocation

Scapular Manipulation  (80% to 100% successful)

  • Upright or prone
  • In the upright position, the patient is sitting up, may rest unaffected shoulder against the upright head of the bed
  • Stand behind the patient and use one thumb over the tip of the scapula and push medially while pushing acromion inferiorly with the other thumb
  • Assistant simultaneously provided traction by grabbing patient’s wrist with one hand and flexed elbow with other hand and pushing down on the elbow
  • The reduction may be subtle, without obvious “clunk.”
  • Reduced risk of associated fractures

External Rotation Technique

The external rotation technique reduces anterior glenohumeral dislocation by overcoming spasm of the internal rotators of the humerus, unwinding the joint capsule, and enabling the external rotators of the rotator cuff to pull the humerus posteriorly.

  • Easy and can do alone
  • With patient supine, elbow flexed to 90 degrees, elbow held with one hand, and wrist is held with another hand
  • Slowly, have patient allow the arm to fall to the side, externally rotating forearm. The patient pauses with pain and allows muscles to relax. Over 5 to 10 minutes, the arm externally rotates, and reduction occurs
  • Reduction usually occurs with arm externally rotated between 70 to 110 degrees

Cunningham Technique

  • Patient is seated with examiner seated in front of the patient, and the patient places an ipsilateral hand on top of examiner’s shoulder
  • The clinician rests one arm in patient’s elbow crease and uses the other hand to massage the patient’s biceps, deltoid, and trapezius muscles
  • Have patient relax and instruct to pull their shoulder blades together and straighten their back
  • Popular technique now since rarely conscious sedation needed

Milch Technique  (add Milch technique if external rotation unsuccessful)

  • Patient is supine, fingers over the shoulder with thumb in axilla to stabilize
  • Arm is externally rotated and then abducted over the patient’s head while maintaining external rotation with simultaneously placing direct pressure over the humeral head

Stimson Technique

  • No assistant needed and no need for conscious sedation
  • Patient is prone with the affected arm hanging off the side of the bed with 5 lb to  15 lb of weight
  • Reduction is usually achieved within 30 minutes

Traction Countertraction

  • A sheet is wrapped under the axilla, and one assistant provides continuous traction at the wrist or elbow while the other provides countertraction with the sheet from the opposite side

Spaso Technique

  • Patient is supine while examiner grasps wrist or distal forearm and lifts vertically with gentle vertical traction and external rotation

Fares Technique

  • Patient is supine with upper extremity at their side
  • The examiner holds patient’s wrist and gently pulls the arm to provide traction
  • The arm is abducted while continuously moving arm in anteriorly and posteriorly in small oscillating movements (about 10 cm)
  • If shoulder has not reduced by 90 degrees of abduction, add external reduction

Fulcrum Technique

  • Patient is supine or sitting, and a rolled towel or sheet is placed in the axilla
  • The distal humerus is adducted with simultaneous posterolateral force on the humeral head
  • Requires increased force, may have increased complications

Kocher’s and Hippocratic Techniqueoot placed in patient’s axilla before traction) no longer recommended due to a higher risk of complications

Posterior Shoulder Reduction

  • The patient is in the supine position. An assistant applies anterior pressure to the humeral head while examiner applies axial traction to the humerus with internal and external rotation of the humerus

Disposition After Shoulder Reduction

  • Place patient in a sling
  • Neurovascular exam
  • Post-reduction imaging
  • Follow-up with an orthopedic surgeon

Reduction Process for Rehabilitation

PHASE I – Joint Reduction. Check Neurovascular Integrity

  • The most urgent matter for a recently dislocated shoulder is to ensure that your nerves or blood supply are not compromised. If your shoulder did not relocate itself naturally, it important to promptly head to hospital for an emergency X-ray to exclude fractures. You will then have your shoulder reduced to its normal position by the emergency doctors.

PHASE II – Pain Relief. Minimise Swelling & Injury Protection

  • Managing your pain. Pain will accompany shoulder movement in the early days. Overstretching the injured tissues should be avoided for between two to six weeks. You will usually be prescribed a shoulder sling to support and immobilise your shoulder. Manage your inflammation via ice therapy and rest to deload the inflammed structures.
  • Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These may include: ice, electrotherapy, acupuncture, deloading taping techniques, soft tissue massage and temporary use of a sling to off-load the injured shoulder ligaments.

PHASE III – Maintain & Restore Muscle Control & Strength

  • It is important to maintain the strength of your shoulder’s rotator cuff muscles and scapular (shoulder blade) stabilisers. Researchers have discovered the importance of your rotator cuff muscles to dynamically stabilise your shoulder joint.
  • It is also vital to address your shoulder blade stability, since your scapular is the stable platform that attaches your arm to your chest wall. It is an important base that if it is not functioning correctly, will allow your shoulder blade to slide into a position that could predispose you to future dislocations.
  • Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.PhysioWorks has developed both a “Rotator Cuff Strengthening” and a “Scapular Stabilisation Program” to assist their patients to regain normal shoulder muscle control. Please ask your physio for their advice.

PHASE IV – Restoring Normal ROM & Posture

  • As your pain and inflammation settles and your ligaments start to heal, your physiotherapist will turn their attention to restoring your normal joint range of motion, muscle length, neural tissue mobility and resting muscle tension.
  • Regaining full shoulder motion in the early phase is not a priority to avoid overstretching the healing shoulder ligaments and capsule. Treatment may include joint mobilisation and alignment techniques, massage, muscle stretches and neurodynamic exercises, plus acupuncture, trigger point therapy or dry needling. Your physiotherapist is an expert in the techniques that will work best for you and avoid predisposing you to a future dislocation.

PHASE V – Restoring Full Function

  • During this stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their shoulders that will determine what specific treatment goals you need to achieve. For some it be simply to carry the shopping. Others may wish to throw or pitch a ball, serve or bowl with high speed or return to a labour-intensive activity.

Your physiotherapist will tailor your shoulder rehabilitation to help you achieve your own functional goals.

PHASE VI – Preventing a Recurrent Shoulder Dislocation

  • Shoulder dislocation and subluxation have a tendency to return in poorly rehabilitated shoulders. In addition to your muscle control, your physiotherapist will assess your shoulder biomechanics and start correcting any deficiencies. It may be as simple as providing your will rotator cuff exercises or some scapular or posture exercises to address any biomechanical faults in your upper limb. Your physiotherapist will guide you.
  • Fine tuning your shoulder stability can be further enhanced by proprioception, co-contraction, speed and agility drills with the ultimate goal of safely returning to your previous sporting or leisure activities!

Surgery

MRI of the shoulder after dislocation with Hill-Sachs lesion and labral Bankart’s lesion.

  • A systematic review of published literature concerning dislocation of the shoulder has indicated that young adults engaged in highly demanding sports or job activities should be considered for operative intervention to achieve an optimal outcome. Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion and/or to tighten the shoulder capsule.
  • Arthroscopic stabilization surgery has evolved from the Bankart repair, a time-honored surgical treatment for recurrent anterior instability of the shoulder. However, the failure rate following Bankart repair has been shown to increase markedly in patients with significant bone loss from the glenoid (socket). In such cases, improved results have been reported with some form of bone augmentation of the glenoid such as the
  • Although posterior dislocation is much less common, instability following it is no less challenging and, again, some form of bone augmentation may be required to control instability.
  • There remains those situations characterized by multidirectional instability, which have failed to respond satisfactorily to rehabilitation, falling under the AMBRI classification previously noted. This is usually due to an overstretched and redundant capsule which no longer offers stability or support. Traditionally, this has responded well to a ‘reefing’ procedure known as inferior capsular shift.
  • More recently, the procedure has been carried out as an arthroscopic procedure, rather than open surgery, again with comparable results. Most recently, the procedure has been carried out using radio frequency technology to shrink the redundant shoulder capsule, although the long-term results of this development are currently unproven

Home Treatment

Cold Compress

Cold compresses are highly beneficial in alleviating shoulder pain. The cold temperature helps numb the area, which in turn reduces inflammation and pain.

  • Put some ice cubes in a plastic bag and wrap the bag in a thin towel.
  • Place it on the affected area for 10 to 15 minutes.
  • Repeat a few times daily for a few days.

You can also soak a towel in cold water and apply it on the shoulder.

Note: Do not place ice directly on the skin. It can cause frostbite.

Hot Compress

Just like cold compresses, hot compresses also help treat shoulder pain, inflammation and swelling. It is best to use hot compresses after 48 hours of the injury occurring. Hot compresses also help relieve the pain of stressed out muscles.

  • Fill a hot water bag with hot water and apply it on the aching shoulder for 10 to 15 minutes while you lie down comfortably. Repeat a few times a day until you get complete relief.
  • Also, you can stand in the shower and run warm to slightly hot water on your shoulder for 5 to 10 minutes. Try to stand still for this time. You can enjoy a hot shower twice daily.

Compression

  • Compression means putting even pressure on the painful area to help reduce the swelling. A compression wrap will give ample support to your shoulder and make you feel more comfortable.
  • You can compress the affected area with an elastic bandage or a warm wrap, which you can easily buy from the market. Wrap the affected area for a few days or until the pain and swelling are gone. Also, keep your shoulder elevated with the help of pillows to promote healing.

Note: Avoid wrapping it too tightly, which can lead to poor circulation and worsen the condition.

Epsom Salt Bath

Epsom salt, made up of magnesium sulfate, can help reduce shoulder pain. It helps improve blood circulation and relax stressed shoulder muscles. It also helps relieve stress from the entire body.

  • Fill your bathtub with warm or tolerably hot water.
  • Add 2 cups of Epsom salt and stir thoroughly.
  • Soak in this water with your shoulder submerged for 20 to 25 minutes.
  • Do this up to 3 times a week.

Massage

Massage is another good way to reduce shoulder pain. A gentle massage will help your shoulder muscles release stress and tension. In addition, it will improve blood circulation and reduce swelling and stiffness.

Get the massage done by someone who can do a good massage to your shoulder. For massaging, you can use olive, coconut, sesame or mustard oil.

  • Warm the oil slightly and apply it on the shoulder.
  • Gently squeeze the shoulder muscles and apply pressure as well to relieve pain and encourage blood flow.
  • Massage for about 10 minutes, then put a warm towel on the affected area for best results.
  • Do massage therapy a few times daily until the pain subsides.

Note: Do not massage the injured area if it causes pain.

Turmeric

Turmeric is a good remedy to relieve pain in your shoulder. The curcumin in turmeric contains antioxidant as well as anti-inflammatory properties that help reduce pain and swelling.

  • Make a paste by mixing 2 tablespoons of turmeric powder and 1 or more tablespoons of coconut oil. Rub this paste over the sore muscles and let it dry. Rinse it off with warm water. Repeat twice daily until the pain is gone.
  • Add 1 teaspoon of turmeric powder to 1 cup of milk and boil it. Sweeten with honey and drink it twice daily to promote healing.
  • You can also take 250 to 500 mg turmeric capsules up to 3 times daily. Consult your doctor for the correct dosage.

Note: Avoid excessive intake of turmeric if you take blood-thinning medicine.

 Apple Cider Vinegar

Rx

Rx

When it comes to treating shoulder pain, another effective household ingredient is apple cider vinegar. It has anti-inflammatory as well as alkalizing properties that can help reduce pain and inflammation.

  • Add 2 cups of raw, unfiltered apple cider vinegar to a bathtub of warm water. Soak in this water for 20 to 30 minutes. Enjoy this relaxing bath once daily for a few days.
  • You can also drink a glass of warm water mixed with 1 tablespoon of raw, unfiltered apple cider vinegar and a little honey twice daily for a week to promote quick recovery.

Ginger

Rx

Rx

Ginger contains antioxidant and anti-inflammatory properties that help reduce pain and inflammation of any kind, including shoulder pain. In addition, it improves blood circulation that promotes quick healing.

  • Drink 2 to 3 cups of ginger tea daily. To make the tea, simmer 1 tablespoon of thinly sliced ginger in 1½ to 2 cups of water for 10 minutes. Strain, add honey and drink it.
  • You can also take ginger supplements after consulting your doctor

Lavender Oil

Rx

Rx

Lavender oil is an excellent essential oil that can relax tired muscles. This aids in reducing pain as well as inflammation.

  • Add a few drops of lavender essential oil to hot or warm bathwater. Soak your entire body in this soothing bath for 30 minutes. Do this once daily to relax your sore shoulder muscles.
  • Mix a few drops of lavender essential oil in 1 to 2 tablespoons of warm olive oil. Use it to massage the tense and aching shoulder muscles for 10 minutes, twice daily for a few days.

Alfalfa

Rx

Rx

Alfalfa is another herbal remedy that can relieve pain and swelling. It ensures smooth blood flow throughout the body, in turn reducing inflammation and swelling.

  • Drink 1 or 2 cups of warm alfalfa tea for a few days to treat shoulder pain. To make the tea, add 1 teaspoon of dried alfalfa leaves to a cup of hot water. Steep for 5 minutes, strain and drink it.
  • You can also take alfalfa supplements, but consult your doctor first.

Additional Tips

  • Rest the affected area as much as possible for a few days to promote healing.
  • Keep the affected area elevated with the help of a few pillows to reduce swelling and pain.
  • Maintain good posture to help your shoulder muscles heal quickly.
  • When experiencing shoulder pain, keep your elbow at your side in order to give your shoulder a break.
  • You can even try some simple neck stretching exercises to treat the problem.
  • Use a thicker pillow while sleeping to give enough support to your neck and shoulder.
  • Try acupressure or acupuncture for quick recovery.
  • Practice some light stretching exercises for the area to treat shoulder pain. You can use a number of different stretching methods. If unsure, consult an expert.
  • Drink a few glasses of warm lemon water daily to prevent mineral deposits in the joints that can cause pain in your shoulder and other body parts.
  • You can even apply a gel containing 0.0125 percent capsaicin topically on the affected area to reduce pain.
  • Do not smoke or use other tobacco products, as they can slow down the healing process.

Axillary nerve damage.

  • Brachial plexus, radial and other nerve damage.
  • Axillary artery damage (more likely if brachial plexus injury is present – look for axillary haematoma, a cool limb and absent or reduced pulses).
  • Associated fracture (30% of cases) – eg, humeral head, greater tuberosity, clavicle, acromion.
  • Recurrent shoulder dislocation.
  • Anatomical lesions
  • Bankart’s lesion – avulsion of the antero-inferior glenoid labrum at its attachment to the antero-inferior glenohumeral ligament complex. There is rupture of the joint capsule and inferior glenohumeral ligament injury.
  • Hill-Sachs lesion –  a posterolateral humeral head indentation fracture can occur as the soft base of the humeral head impacts against the relatively hard anterior glenoid. Occurs in 35-40% of anterior dislocations and up to 80% of recurrent dislocations.

 References

stroke

Snoring; Causes, Symptoms, Diagnosis, Treatment

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. In some cases, the sound may be soft, but in most cases, it can be loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea(OSA). Research suggests that snoring is one of the factors of sleep deprivation.

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, with or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction with contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity.

snoring

Snoring occurs when the muscles of the airway relax too much during sleep and vibrate (creating noise) when air we breathe passes in and out. Most people will snore at some time, however loud or chronic snoring can disrupt sleep-quality and disturb others. Particularly when loud, it is often associated with other sleep-related breathing disorders, such as obstructive sleep apnoea (OSA).

Anatomy of Snoring

HOW you snore reveals WHY you snore
Type of snoring What it may indicate
Closed-mouth snoring May indicate a problem with your tongue
Open-mouth snoring May be related to the tissues in your throat
Snoring when sleeping on your back Probably mild snoring—improved sleep habits and lifestyle changes may be effective cures
Snoring in all sleep positions Can mean your snoring is more severe and may require a more comprehensive treatment

snoring-causes

Common Causes of Snoring

  • Allergies
  • Eating too much at night
  • Nasal congestion
  • Deformity of the nose
  • Consumption of alcohol close to bed-time, especially if the amount is large
  • Being overweight or obese
  • Pregnancy
  • Swelling of the muscular part of the roof of the mouth
  • Swollen adenoids or tonsils, especially in children
  • Medications, including sleeping tablets
  • Sleep position – sleeping on your back may cause your throat muscles and tongue to relax; the tongue is then more likely to fall back and compress the airway, causing snoring or making snoring louder.
  • Age – As you reach middle age and beyond, your throat becomes narrower, and the muscle tone in your throat decreases. While you can’t do anything about growing older, lifestyle changes, new bedtime routines, and throat exercises can all help to prevent snoring.
  • Being overweight or out of shape – Fatty tissue and poor muscle tone contribute to snoring. Even if you’re not overweight in general, carrying excess weight just around your neck or throat can cause snoring. Exercising and losing weight can sometimes be all it takes to end your snoring.
  • The way you’re built – Men have narrower air passages than women and are more likely to snore. A narrow throat, a cleft palate, enlarged adenoids, and other physical attributes that contribute to snoring are often hereditary. Again, while you have no control over your build or gender, you can control your snoring with the right lifestyle changes, bedtime routines, and throat exercises.
  • Nasal and sinus problems – Blocked airways or a stuffy nose make inhalation difficult and create a vacuum in the throat, leading to snoring.
  • Alcohol, smoking, and medications – Alcohol intake, smoking, and certain medications, such as tranquilizers like lorazepam (Ativan) and diazepam (Valium), can increase muscle relaxation leading to more snoring.
  • Sleep posture – Sleeping flat on your back causes the flesh of your throat to relax and block the airway. Changing your sleep position can help.

Structural factors related to craniofacial bony anatomy that predisposes patients with OSA to pharyngeal collapse during sleep, e.g

  • Retrognathia and micrognathia
  • Maxillo-Mandibular hypoplasia
  • Adenotonsillar hypertrophy, particularly in children and young adults
  • High, arched palate (particularly in women)

Nonstructural risk factors for OSA include

  • Central fat distribution
  • Male sex
  • Age
  • Postmenopausal state
  • Alcohol use
  • Sedative use
  • Other conditions associated with the development of OSA are as follows: Hypothyroidism, Stroke, and Acromegaly.

Smoking and alcohol consumption are often considered as risk factors for sleep apnea despite the limited evidence, especially in females.

It is well-known that alcohol consumption before going to bed worsens sleep apnea in males and that smoking is related to snoring in males and females.

snoring-causes

An overnight sleep study can be performed to assess the nature and severity of snoring, and to check for other sleep-disorders that often accompany snoring, especially obstructive sleep apnoea (OSA).

Symptoms of Snoring

Obstructive Sleep Apnea (OSA) symptoms begin insidiously and are often present for years before the patient is referred for evaluation.

Nocturnal symptoms may include:

  • Frequent loud snoring, witnessed apneas, restless sleep, nocturia and mouth breathing associated with the presence of obstructive SDB.
  • The hallmark of OSA are the witnessed apneas during sleep.

Daytime symptoms may include:

  • Nonrestorative sleep (e.g., “waking up as tired as when they went to bed”)
  • Morning headache, dry or a sore throat
  • Excessive daytime sleepiness (EDS) that usually begins during quiet activities
  • Daytime fatigue/tiredness
  • Cognitive deficits; memory and intellectual impairment
  • Sexual dysfunction, including impotence and decreased libido.
  • Disruptive snoring: A history of disruptive snoring has 71% sensitivity in predicting sleep-disordered breathing (SDB).
  • Disruptive snoring and witnessed apneas: These factors taken together have 94% specificity for SDB.

Physical exam findings may include:

  • Obesity – Body mass index (BMI) greater than 30 kg/m
  • Large neck circumference – Greater than 43 cm (17 in) in men and 37 cm (15 in) in women
  • Abnormal (increased) Mallampati score (Mallampati score assessment (originally designed for quantifying different intubation) is a simple and fast method for assessing upper airway dimensions)
  • Enlarged, or “kissing,” tonsils (3+ to 4+)
  • Retrognathia or micrognathia, macroglossia
  • Large degree of overjet
  • High-arched hard palate
  • Systemic arterial hypertension, present in approximately 50% of patients with OSA

Clinical assessment of tonsillar size (Brodsky score) is a weak predictor of presence or severity of obstructive SDB. During an evaluation, other differential diagnoses must be considered before labeling as sleep apnea.

Causes of nocturnal dyspnea include bronchial asthma, gastroesophageal reflux disease, and panic disorder. EDS might be a result of poor sleep hygiene, alcohol or drug abuse, atypical depression, and narcolepsy. Nocturia is prevalent and increases sharply with age. It might be caused by urological and other medical conditions such as hypertrophic benign prostate, diabetes mellitus, congestive heart failure, renal disease, diabetes insipidus and intake of diuretic medication.

Treatment of Snoring

All patients with OSA should be counseled about the potential benefits of therapy and the hazards of going without treatment.

Non Pharmacological Measure including Diet, Devices and Surgery.

Pharmacological

  • Treatment depends in part on the severity of the sleep-disordered breathing (SDB). People with mild apnea have a wider variety of options, while people with moderate-to-severe apnea should be treated with nasal continuous positive airway pressure (CPAP).
  • CPAP treatment is indicated for all OSA patients with an RDI of 30 or more events per hour, regardless of symptoms, based on the increased risk of hypertension.
  • Treatment with CPAP is indicated for patients with an RDI of five to 30 events per hour for documented cardiovascular diseases to include hypertension, ischemic heart disease or stroke.
  • A randomized clinical trial shows significant improvement in all sleep-related symptoms, including snoring, witnessed apnoeas, choking, nightmares, daytime hypersomnolence (all p<0.001) and nocturia (p=0.049), in the CPAP group. In elderly patients with severe sleep apnea, CPAP treatment achieves an improvement in all domains of quality of life measured by QSQ, including day-time and night-time symptoms and social and emotional domains.
  • Effective CPAP is defined as the pressure level at which all apneas, hypopneas, respiratory-effort related arousals and snoring events are abolished. This pressure level could be maintained constantly throughout the night (Standard CPAP) or it could be automatically adjusted by the CPAP-device according to the patient needs (Auto-CPAP).
  • In patients with mild-to-severe obstructive sleep apnea who refuse or reject nasal CPAP therapy or who cannot tolerate CPAP due to persistent massive nasal mask air leakage or discomfort, BiPAP therapy should be tried next. If this therapy fails or is rejected, Oral Appliances should be considered.
  • Adequate adherence to PAP is defined as more than 4.5 hours of PAP use per night on a routine basis. Maximal improvement in neurocognitive symptoms can require as long as two months of PAP treatment.

Oral appliances

  • Oral appliances are considered an alternative to CPAP for treating OSA. Mandibular advancement devices/tongue retaining devices reduce sleep-disordered breathing and subjective daytime sleepiness, improve the quality of life compared with control treatments and are recommended in the treatment of patients with mild to moderate OSA.
  • General and behavioral measures, such as weight loss, avoidance of alcohol for four to six hours before bedtime, and sleeping on one’s side rather than on the stomach or back, are elements of conservative nonsurgical treatment.
  • Because obesity is a major predictive factor for OSA, weight reduction reduces the risk of OSA. The best data suggest that a 10% reduction in weight leads to a 26% reduction in the respiratory disturbance index (RDI). Patients with sleep-disordered breathing should be advised to have sufficient sleep and appropriate sleep hygiene.

Sleep hygiene instructions

  • Restricting caffeine after lunch
  • Restriction of other drinks or foods with activating properties (e.g. coke, tea, chocolate)
  • No alcohol intake in the evening
  • Restriction of smoking especially close to bedtime
  • Regular physical activity
  • Reduction of noises in the bedroom
  • Instructions to make the bed comfortable and to keep the bedroom dark during the night
  • Proper ventilation of the bedroom

Positional treatment aims at avoiding the supine horizontal posture while sleeping. This method might be effective in patients with positional OSA. Tennis ball attached to the back of a night-shirt, a variety of straps and vests with foam attachments, auditory alarms aimed at training patients to refrain from sleeping in the supine posture are a number of devices used for postural therapy.

Surgery: Upper airway surgery and Barriatric Surgery for weight loss.

Medications

  • Dronabinol – Nonselective agonist of cannabinoids type I and type II receptor reduces central apneas and reduction in AHI index in small studies but still need further safety data to be estabilshed treatment.
  • Modafinil –  is approved by the US Food and Drug Administration (FDA) for use in patients who have residual daytime sleepiness despite optimal use of CPAP. The most improvement has been seen in patients who have taken modafinil at doses of 200-400 mg/d. The mechanism of action of modafinil in wakefulness is unknown. It has wake-promoting actions similar to sympathomimetic agents.
  • Armodafinil – the R-enantiomer of modafinil, is also now FDA approved for use in these patients. Patients in whom noninvasive medical therapy (e.g., CPAP, BiPAP, OAS) fails should be offered surgical options.

Surgery

  • Various surgical techniques are available for treatment of OSA. Their aim is to permanently increase upper airway patency and decrease pharyngeal resistance. Surgery may be applied as a first-line therapy in selected patients with mild OSA who have surgically correctible anatomical abnormalities contributing to upper airway collapse during sleep.
  • Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in selected patients, and potential benefits should be weighed against the risk of long-term side-effects.
  • Hypoglossal nerve stimulation for the treatment of OSA may be a safe and effective alternative for improving OSA outcomes in individuals with moderate to severe OSA who have difficulties with CPAP therapy.
  • The most appropriate treatment for snoring varies according to the severity of snoring, presence of sleep apnoea, age, body-weight, degree of daytime sleepiness, alcohol-consumption, medical history and the anatomy of the upper airway. A Sleep Physician is a doctor who specialises in treating patients with snoring and other sleep-disorders, and who is qualified to help sufferers make an informed decision about which treatment is the most appropriate.

 Theravent

  • Theravent Snoring Therapy is available in Australia for patients with snoring (but no obstructive sleep apnoea).  The treatment involves small adhesive devices that cover the nostrils.  Similar to Provent Therapy, the unique valve system is designed to eliminate snoring by increasing the pressure inside the airway.
  • Theravent is an effective treatment for many patients with troublesome snoring, particularly when combined with other conservative snoring treatments (including lateral sleep and weight-reduction).

Exclusively Lateral Sleep

  • Exclusively lateral sleep can be an effective, non-invasive treatment of snoring and obstructive sleep apnoea.  It achieves this by preventing the tongue, soft palate and uvula from falling backward under the effect of gravity, thereby causing the pharyngeal airway to be restricted. This, in turn, results in an increased speed of air-flow through the narrowed airway, causing an increase in soft-tissue vibration and resultant snoring.  A variety of simple measures can be implemented to encourage exclusively lateral sleep, such as the use of a bolster pillow placed lengthwise in the bed (to lean against) or pinning tennis balls (or the like) to the back of a pajama top.  As the tennis ball causes discomfort to the wearer when supine, it typically causes the wearer to turn back to a lateral position.  Within a few weeks, most people learn the habit of sleeping laterally and will no longer require tennis balls or similar measures.  Exclusively lateral sleep is limited however in its effectiveness, particularly in sufferers with severe obstructive sleep apnoea.  In this case alternative treatments are required.

Night Shift Device

snoring-causes

  • Night Shift is a new lateral sleep position aid that assists patients to sleep exclusively on their side.  Many patients have obstructive sleep apnoea that is significantly worse (or only present) when sleeping on their back (the supine position).   The device accurately monitors sleep-position and vibrates when supine sleep is detected, helping many patients with position-related airway disorders to avoid other OSA treatments. It records positional data and snoring volumes that can be downloaded, either to provide you with information on your sleep, or to provide to your Sleep Physician to monitor the progress of your treatment.
  • Night Shift can also be used in conjunction with other OSA treatments, including Provent Therapy.  Patients who require CPAP can use Night Shift as well to lower their nightly CPAP setting.
  • For ethical reasons, we do not sell Night Shift or any other treatment device, but our doctors may recommend a trial based on the results of your sleep study.

Weight-loss

  • Weight loss will generally decrease the severity of snoring, although not all people who snore are overweight, but weight gain will typically make existing snoring even worse.  Losing even a little weight can reduce fatty tissue in the back of the throat and decrease snoring. In some patients, weight loss may not cure snoring, but can significantly reduce its loudness

Cessation of Tobacco Smoking

  • In addition to causing cancer and being a major health risk, tobacco smoke causes the walls of airways to retain fluid and swell (this is called oedema). This causes the airway to narrow, worsening snoring (and sleep apnoea). Smokers are 4 to 5 times more likely than non-smokers to suffer from snoring and obstructive sleep apnoea. Nicotine also contributes to insomnia and poor sleep-habits.

Mandibular Advancement Splint (MAS)

  • A Mandibular Advancement Splint is a small device (a type of dental splint) which is placed in the mouth during sleep, causing the lower jaw and tongue to be held more forward than usual. This in turn opens the pharyngeal airway, resulting in a lower rate of air-flow.
  • This minimises vibration of the tissues at the back of the pharynx, thereby reducing the volume of snoring. However, there are a number of problems which can occur for users of a MAS, including a build-up of excessive amounts of saliva, discomfort of jaws and teeth, problems with the gums and other oral tissues with certain types of MAS, particularly if fitted incorrectly and in a significant percentage of patients, permanent repositioning of the teeth and an altered bite over a period of years.

Continuous Positive Airway Pressure (CPAP)

  • As for obstructive sleep apnoea (OSA), CPAP is currently the most effective treatment for simple snoring. CPAP involves the use of a compact air pump to deliver a continuous flow of pressurized air (via a mask) to an individual’s airway. This pressurised air acts as a pneumatic splint and prevents the airway from collapsing, which in turn causes snoring to cease. Each individual’s pressure-requirement differs, depending on a variety of factors, including weight and severity of snoring. These and other details of

Nasal Steroids and Allergy Treatments

  • Naso-pharyngeal congestion from allergies can also contribute to a narrowing of the airways.  Nasal congestion limits the amount of air a person can breathe through their nose while asleep.  This can be caused by the presence of an allergen in an individual’s immediate environment, resulting in an inflammatory response and mucosal swelling, which blocks the nose.
  • Mouth-breathing is then the only available means to ensure that sufficient oxygen is delivered to the body. Nasal steroids can be an effective way to combat the underlying allergic reaction, eg, with prescription agents such as ‘Nasonex’.  Certain over-the-counter nasal steroids are also available from pharmacies.

Non-Steroidal Over-The-Counter Nasal Sprays and Other Anti-Allergy Treatments

  • Other over-the-counter treatments may also be beneficial in patients prone to nasal allergies or troublesome nasal congestion at night-time.  The most common cause of nasal congestion is temporary swelling of nasal passages due to colds or allergic reactions to pollen, dust, mould, animals or some foods.
  • These can cause the lining of the nasal membrane to become inflamed, and mucus to thicken and become acidic. There are a number of over-the-counter nasal sprays that can be helpful in the short term, eg, FESS Nasal Spray, a non-medicated saline nasal spray.
  • Nasal sprays like Afrin, Neo-Synephrine, NasalCrom (Cromyln) and anti-histamines can also be useful as decongestants. However the use of such sprays for more than 72 hours can cause a rebound, negative effect.  Allergy desensitization treatments will sometimes be recommended by a Sleep Physician, Allergist or General Practitioner.

snoring-causes

ENT Interventions and Surgery and Other Procedures on the Soft Palate

  • When narrowing is due to structural abnormality, ENT surgery can be very helpful as a means of opening the nasal passages, thereby improving nasal air-flow and eliminating the sufferer’s need for mouth-breathing.

Surgical procedures which have been used in the hope of reducing snoring include uvulopalatopharyngectomy (UPPP), radio frequency uvulopalatopharyngectomy (RFUPPP) and laser-assisted uvuloplasty (LUAP). These treatments tend to be painful and expensive, and they often fail to cure snoring, especially when this is loud.  They have no place as a treatment for snorers who also suffer from moderate or severe OSA (and in fact, can complicate later treatment of OSA with CPAP).

  • Injection snoreplasty is a nonsurgical treatment for snoring whereby the soft palate is injected in front of the uvula with a hardening agent. This creates an inflammatory reaction and results in scar tissue, which in turn stiffens the soft palate and ultimately reduces the amount of palatal tissue ‘flutter’.
  • When this is the cause of snoring, the treatment can result in reduced snoring volume. Unfortunately, a number of other pharyngeal tissues can vibrate and cause snoring and this technique cannot assist when this is the case. Also, this is presently a new treatment, with limited long-term evidence of its effectiveness.

External Nasal Strips

  • Nasal strips such as ‘Breathe Right’ appear to reduce snoring in some patients through opening the nasal passages, but there are no published scientific studies which definitely prove that these strips do in fact assist significantly with snoring.  These strips probably have their main place in the 5-10% of individuals whose nostrils collapse during inspiration.

Nocturnal Sedatives and Alcohol

  • Nocturnal sedatives (such as sleeping pills) and alcohol (especially in large quantities) can cause narrowing of the pharynx as a result of relaxation of pharyngeal muscles, with a resulting increase in soft-tissue vibration and snoring.  Reducing the intake of these agents commonly therefore helps to reduce snoring volume.

Bedtime remedies to help you stop snoring

  • Change your sleeping position – Elevating your head four inches may ease breathing and encourage your tongue and jaw to move forward. There are specifically designed pillows available to help prevent snoring by making sure your neck muscles are not crimped.
  • Sleep on your side instead of your back – Try attaching a tennis ball to the back of a pajama top or T-shirt (you can sew a sock to the back of your top then put a tennis ball inside). If you roll over onto your back, the discomfort of the tennis ball will cause you to turn back onto your side. Alternatively, wedge a pillow stuffed with tennis balls behind your back. After a while, sleeping on your side will become a habit and you can dispense with the tennis balls.
  • Try an anti-snoring mouth appliance – These devices, which resemble an athlete’s mouth guard, help open your airway by bringing your lower jaw and/or your tongue forward during sleep. While a dentist-made appliance can be expensive, cheaper do-it-yourself kits are also available.
  • Clear nasal passages – If you have a stuffy nose, rinse sinuses with saline before bed. Using a Neti pot, nasal decongestant, or nasal strips can also help you breathe more easily while sleeping. If you have allergies, reduce dust mites and pet dander in your bedroom or use an allergy medication.
  • Keep bedroom air moist – Dry air can irritate membranes in the nose and throat, so if swollen nasal tissues are the problem, a humidifier may help.

Self-help strategies for snoring

  • There are so many bizarre anti-snoring devices available on the market today, with more being added all the time, that finding the right solution for your snoring can seem like a daunting task.
  • Unfortunately, many of these devices are not backed up by research, or they work by simply keeping you awake at night. There are, however, plenty of proven techniques that can help eliminate snoring.
  • Not every remedy is right for every person, though, so putting a stop to your snoring may require patience, lifestyle changes, and a willingness to experiment with different solutions.

Bedtime remedies to help you stop snoring

  • Change your sleeping position – Elevating your head four inches may ease breathing and encourage your tongue and jaw to move forward. There are specifically designed pillows available to help prevent snoring by making sure your neck muscles are not crimped.
  • Sleep on your side instead of your back – Try attaching a tennis ball to the back of a pajama top or T-shirt (you can sew a sock to the back of your top then put a tennis ball inside). If you roll over onto your back, the discomfort of the tennis ball will cause you to turn back onto your side. Alternatively, wedge a pillow stuffed with tennis balls behind your back. After a while, sleeping on your side will become a habit and you can dispense with the tennis balls.
  • Try an anti-snoring mouth appliance – These devices, which resemble an athlete’s mouth guard, help open your airway by bringing your lower jaw and/or your tongue forward during sleep. While a dentist-made appliance can be expensive, cheaper do-it-yourself kits are also available.
  • Clear nasal passages – If you have a stuffy nose, rinse sinuses with saline before bed. Using a Neti pot, nasal decongestant, or nasal strips can also help you breathe more easily while sleeping. If you have allergies, reduce dust mites and pet dander in your bedroom or use an allergy medication.
  • Keep bedroom air moist – Dry air can irritate membranes in the nose and throat, so if swollen nasal tissues are the problem, a humidifier may help.

Lifestyle changes to help you stop snoring

  • Lose weight – Losing even a little bit of weight can reduce fatty tissue in the back of the throat and decrease, or even stop, snoring.
  • Quit smoking – If you smoke, your chances of snoring are high. Smoking irritates the membranes in the nose and throat which can block the airways and cause snoring. While quitting is easier said than done, it can bring quick snoring relief.
  • Avoid alcohol, sleeping pills, and sedatives – because they relax the muscles in the throat and interfere with breathing. Also talk to your doctor about any prescription medications you’re taking, as some encourage a deeper level of sleep which can make snoring worse.
  • Be careful what you eat before bed – Research shows that eating large meals or consuming certain foods such as dairy or soymilk right before bedtime can make snoring worse. Placing a household ban on the following snore-hazards right before bedtime can make for quieter nights.

Six anti-snoring throat exercises

  • Exercise in general can reduce snoring, even if it doesn’t lead to weight loss. That’s because when you tone various muscles in your body, such as your arms, legs, and abs, this leads to toning the muscles in your throat, which in turn can lead to less snoring. There are also specific exercises you can do to strengthen the muscles in your throat.

Studies show that by pronouncing certain vowel sounds and curling the tongue in specific ways, muscles in the upper respiratory tract are strengthened and therefore reduce snoring. The following exercises can help

  • Repeat each vowel (a-e-i-o-u) out loud for three minutes a few times a day.
  • Place the tip of your tongue behind your top front teeth. Slide your tongue backwards for three minutes a day.
  • Close your mouth and purse your lips. Hold for 30 seconds.
  • With your mouth open, move your jaw to the right and hold for 30 seconds. Repeat on the left side.
  • With your mouth open, contract the muscle at the back of your throat repeatedly for 30 seconds. Tip: Look in the mirror to see the uvula (“the hanging ball”) move up and down.
  • For a more fun exercise, simply spend some time singing. Singing can increase muscle control in the throat and soft palate, reducing snoring caused by lax muscles.

References

Hormone Imbalance; Symptoms, Diagnosis, Treatment

Hormone imbalance are your body’s chemical messengers. Produced in the endocrine glands, these powerful chemicals travel around your bloodstream telling tissues and organs what to do. They help control many of your body’s major processes, including metabolism and reproduction.

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When the word “hormones” is uttered, visions of raging menopausal women come to mind for most. That’s so sad. Hormonal changes affect everyone from birth to death, yet we seem to have a very negative association with that word.

For women, the most pronounced changes come in their 40s and 50s, but can been seen as early as their mid-30s. Many more women are having hormonal symptoms earlier, which has a lot to do with not only our lifestyle and diet, but also the pollution, toxins and xenoestrogens (synthetic chemicals that act as estrogen in our bodies) that we’re exposed to every day.

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Causes of a hormone imbalance

There are many possible causes for a hormonal imbalance. Causes differ depending on which hormones or glands are affected. Common causes of hormonal imbalance include:

  • diabetes
  • hypothyroidism, or underactive thyroid
  • hyperthyroidism, or overactive thyroid
  • hypogonadism
  • Cushing syndrome
  • thyroiditis
  • hyperfunctioning thyroid nodules
  • hormone therapy
  • tumors (benign or cancerous)
  • congenital adrenal hyperplasia
  • eating disorders
  • medications
  • stress
  • adrenal insufficiency
  • pituitary tumor
  • injury or trauma
  • cancer treatments

Causes unique to women

Many causes of hormonal imbalance in women are related to reproductive hormones. Common causes include:

  • menopause
  • pregnancy
  • breastfeeding
  • PCOS
  • premature menopause
  • hormone drugs like birth control pills
  • primary ovarian insufficiency

Some of the most common symptoms of hormone imbalance are

Persistent weight gain.

  • Yes, there are lifestyle, diet and physical activity components to maintaining a healthy weight, but that isn’t the end of the story. Many women have underlying hormonal imbalances that make it difficult to maintain a healthy weight. Unaddressed or emerging insulin resistance is one of the most common; small changes in diet — such as eliminating processed foods, sugars and wheat — step in the right direction.

Belly fat and loss of muscle mass

  • When your endocrine system is under stress there’s an underproduction of certain hormones and an overproduction of others (mainly cortisol). This makes your body store fat for future use, making an increase in belly fat a clue to adrenal fatigue.

Low libido.

  • One of the most noticeable symptoms of hormonal imbalance is low libido, which starts with disturbed sleep. Without quality sleep, our sex hormone production can diminish.

Fatigue

  • Can’t make it past mid-morning without some sort of pick-me-up? How about that mid-afternoon crash? It isn’t normal to feel sluggish, scattered or mentally foggy. Easy dietary changes, such as eliminating wheat and most grains, will help stabilize your blood sugar.
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Anxiety, irritability and depression

  • Not feeling like yourself? This isn’t the time for pharmaceuticals. Anxiety and depression are clues that you have an imbalance, toxicity, are overworked, stressed out, and most likely aren’t nourishing your body the way it needs. Listen to your inner voice and take the actions necessary to meet your needs.

Insomnia and poor sleep patterns

  • This starts the cycle of physical stress and increases cortisol levels, which directly causes many hormonal imbalances. There isn’t one area of your life that insomnia doesn’t touch.

Sweating

  • For many women, night sweats and hot flashes are the first uncomfortable sign that something is amiss. This isn’t the time to start hormone replacement therapy, but begin a food journal by jotting down what you eat and drink, how you feel physically, and any emotions that come up after. Many times our emotions are the trigger that increases internal temperature. The next time you feel the flashes coming on, stop and think about the thoughts swirling around in your mind.

Digestion problems.

  • Gas, bloating and slow digestion are common hormonal problems that aren’t usually associated with hormonal imbalances but may be associated with eating bad foods, not chewing your food and eating too much. When you don’t have optimal digestion, your body is starving because of poor nutrient extraction.

Cravings.

  • After eating way more than you should have, or having gone through half a bottle of wine, do you look back and ask yourself why? Common causes of cravings and excess eating are adrenal fatigue, insulin resistance, and other hormonal imbalances. Again, minimizing sugars, alcohol, dairy and wheat — although difficult — not only will help control cravings, but your digestive issues as well.
  • Please note that many of these symptoms can be linked to other physical problems, and a simple blood test can tell you if there are other underlying concerns.

With consistent effort applied to improve diet and digestive health, stress management, improved sleep and consistent physical activity, true holistic health is attainable.

Common hormonal conditions affecting both men and women could cause any of the following symptoms

  • weight gain
  • fatigue
  • increased sensitivity to cold or heat
  • constipation or more frequent bowel movements
  • dry skin
  • puffy face
  • unexplained weight loss (sometimes sudden)
  • increased or decreased heart rate
  • muscle weakness
  • frequent urination
  • increased thirst
  • muscle aches, tenderness, and stiffness
  • pain, stiffness, or swelling in your joints
  • thinning hair or fine, brittle hair
  • increased hunger
  • depression
  • decreased sex drive
  • nervousness, anxiety, or irritability
  • blurred vision
  • sweating
  • infertility
  • a fatty hump between the shoulders
  • rounded face
  • purple or pink stretch marks

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Do You Struggle with Out-of-Balance Sex Hormones?

When female patients suspect sex hormones might be out of whack, I ask them to self-evaluate using this quiz:

  • I have premenstrual syndrome.
  • I have monthly weight fluctuation.
  • I have edema, swelling, puffiness, or water retention.
  • I feel bloated.
  • I have headaches.
  • I have mood swings.
  • I have tender, enlarged breasts.
  • I am depressed.
  • I feel unable to cope with ordinary demands.
  • I have backaches, joint, or muscle pain.
  • I have premenstrual food cravings (especially sugar or salt).
  • I have irregular cycles, heavy bleeding, or light bleeding.
  • I am infertile.
  • I use birth-control pills or other hormones.
  • I have premenstrual migraines.
  • I have breast cysts or lumps or fibrocystic breasts.
  • I have a family history of breast, ovarian, or uterine cancer.
  • I have uterine fibroids.
  • I have peri-menopausal symptoms (hot flashes, mood swings, headaches, irregular cycles, heavy bleeding, fluid retention, breast tenderness, vaginal dryness, brain fog, muscle and joint pain, low sex drive, weight gain).
  • I have hot flashes.
  • I feel anxious.
  • I have night sweats.
  • I have insomnia.
  • I have lost my sex drive.
  • I have dry skin, hair, and/ or vagina.
  • I have heart palpitations.
  • I have trouble with memory or concentration.
  • I have bloating or weight gain around the middle.
  • I have facial hair.
  • I have been exposed to pesticides or heavy metals (in the food, water, and/ or air).
  • Score one point for every time you answered “yes,” and then check out how you scored using the scale below:

0 to 9 – You may have a mild sex hormone imbalance.

10 to 14 – You may have a moderate sex hormone imbalance.

15 or more – You may have a severe sex hormone imbalance.

Now that you have determined the severity of your imbalance, let’s talk about the one thing you can do today to begin treating your symptoms.

Hormonal Changes During Stress

In response to stress, the level of various hormones changes. Reactions to stress are associated with enhanced secretion of a number of hormones including glucocorticoids, catecholamines, growth hormone and prolactin, the effect of which is to increase mobilization of energy sources and adapt the individual to its new circumstance.

Cortisol

Activation of the pituitary-adrenal axis is a prominent neuroendocrine response to stress, promoting survival. Stimulation of this axis results in hypothalamic secretion of corticotrophin-releasing factor (CRF). CRF then stimulates the pituitary to adrenocorticotropin (ACTH), 8-lipotropin and 3-endorphin. Plasma levels of these hormones can increase two- to fivefold during stress in humans.[] The paraventricular nucleus of the hypothalamus is responsible for the integrated response to stress.[] Norepinephrine, serotonin and acetylcholine mediate much of the neurogenic stimulation of CRF production.[]

Catecholamines

  • Stimulation of the pituitary-adrenal axis is associated with the release of catecholamines. This leads to increased cardiac output, skeletal muscle blood flow, sodium retention, reduced intestinal motility, cutaneous vasoconstriction, increased glucose, bronchiolar dilatation and behavioral activation.[] Timio et al.,[] have reported increased activation of the adrenosympathetic system during occupational stress.

Vasopressin

  • Acute stress leads to the rapid release of vasopressin from the paraventricular nucleus of the hypothalamus along with corticotrophin releasing hormone CRH. Vasopressin can stimulate secretion of ACTH from the pituitary by acting on the V1b receptor, potentiating the effect of CRH. During chronic stress with corticotroph responsiveness, there is a preferential expression of hypothalamic vasopressin over CRH.[]

Gonadotropins

  • In stress, there is suppression of circulating gonadotropins and gonadal steroid hormones leading to disruption of the normal menstrual cycle.[] Prolonged exposure to stress can lead to complete impairment of reproductive function.[] Gonadotrophin-releasing hormone GnRH drive to the pituitary is decreased, probably due to increased endogenous CRH secretion.

Thyroid Hormones

  • Thyroid function is usually down-regulated during stressful conditions. T3 and T4 levels decrease with stress. Stress inhibits the thyroid-stimulating hormone (TSH) secretion through the action of glucocorticoids on the central nervous system.[]

Growth Hormone

  • The growth hormone (GH) level is increased during acute physical stress. The level can increase up to two- to tenfold. Because of its insulin-antagonistic effect, GH may enhance metabolic activity. In psychological stress, however, GH responses are rarely seen.[] Rather there is GH secretory defect with prolonged psychosocial stress.[]

Prolactin

  • Depending on the local regulatory environment at the time of stress, prolactin level can either increase or decrease. Vasopressin and peptide histidine isoleucine may be involved in the secretion of prolactin during stress.[] However, the teleological significance of the change in the prolactin level is uncertain. It may affect the immune system or some aspect of homeostasis.

Insulin

  • Insulin may decrease during stress. This along with an increase in its antagonistic hormones can contribute to stress-induced hyperglycemia.[]

Stress as a Precipitating Factor/Cause of Endocrine Disorders

Hyperthyroidism

  • Genetic factors such as HLA (Human leukocyte antigen) and CTLA-4 (Cytotoxic T lymphocyte antigen – 4) determine the susceptibility to GD.[] Stress may lead to immunologic perturbations and may affect the immune response to TSH receptor through modulation of hormones, neurotransmitters and cytokines. A defect of antigen-specific suppressor T-lymphocytes has been proposed to be partially responsible for the initiation of GD.[] Stress may result in a defect in the immunologic surveillance leading to production of TSH receptor antibodies.[] In genetically susceptible individuals stress favors the development of GD by shifting the Th1-Th2 immune balance away from Th1 towards Th2.[] This shifting may affect the onset or course of GD.
  • However, there are many studies which failed to show any relationship between stress and GD. No significant difference was seen in the number and nature of stressful life events up to six months before the onset of thyrotoxicosis between patients with thyrotoxicosis and nontoxic goiters in the study by Gray and Hoffenberg.[] Chiovato et al., could not find past or present Graves′ hyperthyroidism in patients with panic disorder.[]

Diabetes Mellitus

  • Severe stress may be a risk factor for diabetes. Children aged five to nine years with stress were significantly more likely to be diabetic.[] However, recent-onset Type 1 diabetics, 15-34 years old reported no major stress factors within the year before diagnosis.[] Thus stress in early life may be a risk factor for diabetes, but not in young adults.

Gonadal dysfunction

  • In females, stress can lead to anovulation, amennorhea and other menstrual irregularities. Among newly incarcerated women with stress 9% had amenorrhea and 33% had menstrual irregularity.[]
  • In males, there can be decreased sperm count, motility and altered morphology.[] Ejaculatory disorders, impotence and oligospermia may be associated with psychological factors in male infertility.[]

Psychosocial dwarfism

  • This is an extreme form of failure to thrive and may be associated with dramatic behavioral abnormalities. Defective GH secretion has been reported with a stimulation test. Reversal of GH insufficiency within three weeks of removal from the hostile environment has been reported.[] Munoz-Hoyos et al. observed a conspicuous reduction in the levels of neuroendocrine markers (melatonin, serotonin, β-endorphins and ACTH) in children suffering from affective deficiency, a diminution which was even more noticeable in the children presenting delayed growth. The organic incapability of confronting stress on a genetic basis, and/or the fact of repeated stresses, from the exhaustion of the homeostatic mechanisms, could make some groups of patients liable to suffer depressive symptoms associated with a wide range of deleterious consequences in the endocrine system leading to delayed growth.[]

Obesity

  • Mental stress leads to chronic activation of the neuroendocrine systems. Cortisol favors central fat deposition, a decrease in the adipostatic signal leptin and an increase in the orexigenic signal ghrelin, inducing increased appetite and food intake. This phenomenon contributes to the current epidemic of obesity. The “stress” genes which have been selected under pressure in ancient environments may have not adapted to the rapid environmental changes of today.[]

The Right Diet Becomes Your Number-One Reset Button

Balancing your hormones is a process, and sometimes it has little twists and turns. But by sticking with it, you can become vital, happy, alert, brilliant, and thriving.

Your diet is the foundation that helps balance your sex hormones.

  • The first step involves removing the bad stuff. We know that sugar, caffeine, alcohol, stress, and lack of exercise all contribute to worsened PMS and all hormonal imbalances – including menopause.
  • Imbalances in your hormones are triggered by bad food. If you eat sugar, you’ll produce more insulin, more estrogen, and more testosterone. Any type of flour and sugar can lead to these imbalances.  Dairy and gluten are often triggers for inflammation and hormonal imbalances. Xenobiotics or environmental chemicals like pesticides in our food can act like powerful hormone disruptors and trigger our own hormones to go out of balance. If you are interested to know how these toxins disrupt our hormones then read Our Stolen Future by Theo Colburn.
  • Dairy is one of the biggest triggers of hormonal imbalances because of all the hormones found naturally in milk and because of the hormones and antibiotics added to milk. Even organic milk can come from pregnant cows, jacking up hormone levels. In fact, dairy has over 60 hormones that can contribute to imbalances. Dairy and gluten are among the most common food sensitivities that you might benefit from eliminating from your diet.
  • After removing the bad stuff, you will want to replace it with good stuff. Eat a whole, real, unprocessed, organic, mostly plant-based diet with organic or sustainably raised animal products. When you focus on this type of diet, you minimize intake of xenoestrogens, hormones, and antibiotics. Taking simple steps like choosing organic food and drinking filtered water can hugely impact hormone balance.
  • You might consider doing my , which will naturally help reset your hormones by eliminating sugary, processed foods and food sensitivities while focusing on organic, whole, unprocessed foods. To reset female hormones, focus on specific hormone-balancing foods. Increase certain foods like flaxseeds, cruciferous veggies, good fats, and traditional organic non-GMO whole soy foods (tofu, tempeh, miso, natto, and edamame). Add 1 to 2 tablespoons of ground flaxseeds a day to your diet.

Other Strategies to Balance Your Sex Hormones

Diet aside, there’s a lot you can do to balance your sex hormones without resorting to medication.

  • Supplement smartly. Fish oil and additional vitamin D and B vitamins help balance estrogen. Take these in addition to a good multivitamin and mineral with sufficient calcium and magnesium. Probiotics, antioxidants and phytonutrients (vitamin E, resveratrol, curcumin, n-actetyl cysteine, green tea, selenium), and the anti-inflammatory omega-6 fat (GLA or gamma linoleic acid) can help balance sex hormones. You can find these and other hormone-balancing supplements in my store.
  • Exercise. When you exercise, you have less PMS and other problems. Find something that you love to do. Running, long walks, weight training, dance, or any other form of movement that you enjoy.
  • Reduce stress. Chronic stress can trigger or exacerbate hormonal imbalances. The key here becomes finding something that works for you to reduce stress. That might include meditation, yoga, tapping, therapy, or finding a creative or expressive outlet. My UltraCalm CD helps melt away stress, anxiety, and tension.
  • Sleep well. Insufficient sleep can adversely impact PMS, menopause, and other conditions. Getting eight hours of quality, uninterrupted sleep every night is one of the best things I can think of to balance hormonal levels.
  • Reduce or eliminate alcohol. Alcohol – yes, even red wine – jacks up estrogen and increases chances of cancer.

How to Do Hormone Replacement Therapy Safely

  • For more than three decades, women were the subject of widespread experimentation founded on absent or weak evidence, creating unnecessary harm through increases in uterine, breast, and ovarian cancer, as well as heart attacks and strokes. These methods provide a temporary solution to intractable (and often transient) menopausal symptoms.
  • Despite potential drawbacks, there are some cases in which hormone replacement and medications are helpful and even necessary for women whose symptoms are unmanageable. Occasionally, despite lifestyle therapies – diet, exercise, stress reduction, nutrient supplementation, and herbs – hormone therapy can be lifesaving (as well as mood- and brain-saving).
  • Only a physician knowledgeable and experienced with bio-identical hormone therapy should prescribe them. I recommend if you go that direction, talk with a knowledgeable functional practitioner who could discuss the pros and cons of hormone therapy so you make the most informed decision.

If you believe hormone replacement therapy might be necessary for you, please discuss the pros and cons with your Functional Medicine practitioner.

References

Magnesium Deficiency

Oxytocin Hormone; The Love Hormone to Enjoy Yours Conjugal life

Oxytocin is a powerful hormone that acts as a neurotransmitter in the brain. It regulates social interaction and sexual reproduction, playing a role in behaviors from maternal-infant bonding and milk release to empathy, generosity, and orgasm. When we hug or kiss a loved one, oxytocin levels increase; hence, oxytocin is often called “the love hormone.” In fact, the hormone plays a huge role in all pair bonding. The hormone is greatly stimulated during sex, birth, and breastfeeding. Oxytocin is the hormone that underlies trust. It is also an antidote to depressive feelings.

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Oxytocin is a hormone secreted by the posterior lobe of the pituitary gland, a pea-sized structure at the base of the brain.

It’s sometimes known as the “cuddle hormone” or the “love hormone,” because it is released when people snuggle up or bond socially. Even playing with your dog can cause an oxytocin surge, according to a 2009 study published in the journal Hormones and Behavior. But these monikers may be misleading.

Oxytocin can also intensify memories of bonding gone bad, such as in cases where men have poor relationships with their mothers. It can also make people less accepting of people they see as outsiders. In other words, whether oxytocin makes you feel cuddly or suspicious of others   environment.

 

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Oxytocin is a particularly important hormone for women. “Oxytocin is a peptide produced in the brain that was first recognized for its role in the birth process, and also in nursing,” said Larry Young, a behavioral neuroscientist at Emory University in Atlanta, Georgia.

The hormone causes uterine contractions during labor and helps shrink the uterus after delivery. When an infant suckles at his or her mother’s breast, the stimulation causes a release of oxytocin, which, in turn, orders the body to “let down” milk for the baby to drink.

Oxytocin also promotes mother-child bonding. Studies show that “female rats find pups to be aversive if [the females are] virgins,” Young told Live Science. “But once they give birth, the brain is transformed, so they find the pups irresistible,” he said. And similar findings are seen in humans.

A 2007 study published in the journal Psychological Science found that the higher a mom’s oxytocin levels in the first trimester of pregnancy, the more likely she was to engage in bonding behaviors such as singing to or bathing her baby.

Although maternal bonding may not always be hardwired — after all, human females can adopt babies and take care of them — oxytocin released during pregnancy “does seem to have a role in motivation and feelings of connectedness to a baby,” Young said. Studies also show that interacting with a baby causes the infant’s own oxytocin levels to increase, he added.

In men, as in women, oxytocin facilitates bonding. Dads who got a boost of oxytocin via a nasal spray played more closely with their 5-month-old babies than dads who didn’t get the hormone zap, a 2012 study found. (There is another hormone, called vasopressin, which plays a stronger role in men.)

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Another study found that men in relationships given a burst of oxytocin spray stood farther away from an attractive woman than men who weren’t given any oxytocin. Single men didn’t see any effect from the hormone, suggesting oxytocin may work as a fidelity booster for guys who are already bonded with another woman.

This anti-social effect of a social hormone brings some nuance to the story of oxytocin. In one study, researchers found that Dutch students given a snort of the hormone became more positive about fictional Dutch characters, but were more negative about characters with Arab or German names. The finding suggests that oxytocin’s social bonding effects are targeted at whomever a person perceives as part of their in-group, the researchers reported in January 2011 in the journal PNAS.

In another study, published in PNAS in 2010, men were given a dose of oxytocin and asked to write about their mothers. Those with secure relationships described their moms as more caring after the hormone dose. Those with troubled relationships actually saw their mothers as less caring. The hormone may help with the formation of social memories, according to the study researchers, so a whiff strengthens previous associations, whether good or bad.

“My view of what oxytocin is doing in the brain is making social information more salient,” Young said. “It connects brain areas involved in processing social information — whether it’s sights, faces, sounds or smells — and helps link those areas to the brain’s reward system.”

Oxytocin nose sprays also have been considered for use in treating autism. The neurological disorder is marked by struggles with social functioning, so a small 2013 study published in the journal PNAS gave a dose to children and teens with autism and asked the participants to identify emotions based on pictures of people’s eyes.

The participants weren’t any better at identifying the emotions after the oxytocin burst, but the regions of their brains associated with social interaction became more active. The increased processing could mean that a burst of oxytocin might help cement behavioral therapy for kids with the disorder.

“When you think about using oxytocin to treat diseases like autism, you want to make sure you do it in a context where the social information is positive,” Young said.

Use of oxytocin sprays outside of a medical context is far murkier, however. The sprays sold online without a prescription promise stress relief and social ease, but they are not regulated by the Food and Drug Administration (FDA). That means that nothing is known about their efficacy, side effects, or even whether they contain any oxytocin.

There are no long-term studies on the side effects of the legitimate oxytocin sprays used in hormone research; most studies give people one dose of the hormone only. Pitocin, a synthetic version of oxytocin given intravenously to stimulate labor, has side effects that include nausea, vomiting and stomach pain.

Some  Interesting Effects of Oxytocin

Intro

Intro

Oxytocin the so-called “love hormone” is being increasingly shown to trigger a wide variety of physical and psychological effects in both women and men.

The hormone’s influence on our behavior and physiology originates in the brain, where it’s produced by the by a structure called the hypothalamus, and then transfers to the pituitary gland which releases into the bloodstream.. Like antennas picking up a signal, oxytocin receptors are found on cells throughout the body. Levels of the hormone tend to be higher during both stressful and socially bonding experiences, according to the American Psychological Association.

“It’s like a hormone of attachment, you might say,” said Carol Rinkleib Ellison, a clinical psychologist in private practice in Loomis, California and former assistant clinical psychiatry professor at the University of California, San Francisco. “It creates feelings of calm and closeness.”

Thought scientists have long known about oxytocin’s rolein breastfeeding and childbirth, “We’re just learning more about it now,” Ellison said.

A stream of studies in the last decade have focused on oxytocin’s effects on body and mind. Here’s a look at what we’ve learned.

<strong>Oxytocin promotes attachment</strong>

Oxytocin promotes attachment

Pregnant women with higher levels of oxytocin during their first trimester bonded more strongly with their babies after they were born, according to a 2007 study in the journal Psychological Science. And compared with other women, women with higher levels throughout their pregnancy and in the first month after birth reported engaging in more behaviors such as singing, feeding and bathing their infants in specific ways that promoted an exclusive relationship between the two, the study found.

<strong>Oxytocin solidifies relationships</strong>

Oxytocin solidifies relationships

Comparing urine levels of oxytocin and a related hormone called vasopressin in biological and adoptive children who lived in Russian and Romanian orphanages, researchers found that oxytocin rose in biological children after having contact with their mothers. The study, published in 2005 in the journal Proceedings of the National Academy of Sciences, showed that oxytocin levels remained static in the adoptive children in the same situation, suggesting a physiological basis for why some adoptive.

 

<strong>Oxytocin eases stress</strong>

Oxytocin eases stress

Research done on prairie voles showed that those separated from their siblings exhibited signs of anxiety, stress and depression that abated after they were injected with oxytocin. The study, presented at a 2007 meeting of the Society for Neuroscience, indicated the hormone’s effects were more evident under stressful situations.

<strong>Oxytocin crystallizes emotional memories</strong>

Oxytocin crystallizes emotional memories

A November study in the journal Proceedings of the National Academy of Sciences supported researchers’ theory that oxytocin would amplify men’s early memories of their mothers. In a group of 31 men, those who inhaled a synthetic version of the hormone found the hormone intensified fond memories of their mothers if their relationships had been positive. Those whose ties with their mom’s had frayed downgraded their opinions after inhaling oxytocin, the study showed.

<strong>Oxytocin facilitates childbirth and breastfeeding</strong>

Sexual Dysfunction; Causes, Symptoms, Diagnosis, Treatment

Sexual dysfunction (or sexual malfunction or sexual disorder) is difficulty experienced by an individual or a couple during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal or orgasm. According to the DSM-5, sexual dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum of 6 months (excluding substance or medication-induced sexual dysfunction). Sexual dysfunctions can have a profound impact on an individual’s perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Sexual function is an essential component of life, both in species propagation as well as the quality of life. Sexual dysfunction can lead to reduced quality of life and potentially procreative advancement. Male sexual dysfunction, especially erectile dysfunction, has been extensively studied and effective therapies are available for men with this disorder. However, female sexual dysfunction (FSD) is more complicated and significantly less is understood in comparison to male sexual dysfunction. Therefore, the present review focuses on therapies available or in development as well as challenges faced by investigators in the study of FSD. Other recent reviews articles may be useful for understanding additional aspects of FSD [].

Types of Sexual Dysfunction

The spectrum of sexual dysfunction encompasses:

  • Decreased sexual desire—persistent or recurrent deficiency or absence of desire for sexual activity giving rise to marked distress and interpersonal difficulty;
  • Sexual aversion disorder—persistent or recurrent aversion and avoidance of all genital sexual contact leading to marked distress and interpersonal difficulty;
  • Difficulty in erection—recurrent or persistent, partial or complete failure to attain or maintain an erection until the completion of the sex act;
  • Difficulty in achieving orgasm—persistent or recurrent delay in or absence of orgasm, following a normal sexual excitement phase;
  • Premature ejaculation—persistent or recurrent ejaculation with minimal sexual stimulation, before, on or shortly after penetration and before the person wishes it, which causes marked distress.[]

Sexual dysfunction generally is classified into four categories

  • Desire disorders —lack of sexual desire or interest in sex
  • Arousal disorders —inability to become physically aroused or excited during sexual activity
  • Orgasm disorders —delay or absence of orgasm (climax)
  • Pain disorders — pain during intercourse

List of disorders of Sexual Dysfunction

DSM

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders lists the following sexual dysfunctions:

  • Hypoactive sexual desire disorder (see also asexuality, which is not classified as a disorder)
  • Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse)
  • Female sexual arousal disorder (failure of normal lubricating arousal response)
  • Male erectile disorder
  • Female orgasmic disorder
  • Male orgasmic disorder
  • Premature ejaculation
  • Dyspareunia
  • Vaginismus

Additional DSM sexual disorders that are not sexual dysfunctions include:

  • Paraphilias
  • PTSD due to genital mutilation or childhood sexual abuse

Other sexual problems of Sexual Dysfunction 

  • Sexual dissatisfaction (non-specific)
  • Lack of sexual desire
  • Anorgasmia
  • Impotence
  • Sexually transmitted diseases
  • Delay or absence of ejaculation, despite adequate stimulation
  • Inability to control the timing of ejaculation
  • Inability to relax vaginal muscles enough to allow intercourse
  • Inadequate vaginal lubrication preceding and during intercourse
  • Burning pain on the vulva or in the vagina with contact to those areas
  • Unhappiness or confusion related to sexual orientation
  • Transsexual and transgender people may have sexual problems before or after surgery.
  • Persistent sexual arousal syndrome
  • Sexual addiction
  • Hypersexuality
  • All forms of Female genital cutting
  • Post-orgasmic diseases, such as Dhat syndrome, post-coital tristesse (PCT), postorgasmic illness syndrome (POIS), and sexual headache.

Causes Sexual Dysfunction

Physical causes — Many physical and/or medical conditions can cause problems with sexual function. These conditions include diabetes, heart, and vascular (blood vessel) disease, neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure, and alcoholism and drug abuse. Physical causes refer to health conditions that contribute to sexual problems or the inability to achieve satisfaction. Some of the most common physical causes for sexual disorders include:

  • Neurological disorders like multiple sclerosis
  • Fatigue, frequent headaches or chronic pain
  • Urinary or bowel difficulties
  • Surgery, especially in the pelvic area
  • Diseases like arthritis, diabetes or high blood pressure
  • Use of certain medication or recreational drugs
  • Injuries

Psychological causes — These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt, concerns about body image, and the effects of past sexual trauma.

  • Heart disease
  • Clogged blood vessels (atherosclerosis)
  • High cholesterol
  • High blood pressure
  • Diabetes
  • Obesity
  • Metabolic syndrome — a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
  • Parkinson’s disease
  • Multiple sclerosis
  • Certain prescription medications
  • Tobacco use
  • Peyronie’s disease — development of scar tissue inside the penis
  • Alcoholism and other forms of substance abuse
  • Sleep disorders
  • Treatments for prostate cancer or enlarged prostate
  • Surgeries or injuries that affect the pelvic area or spinal cord
  • Depression, anxiety or other mental health conditions
  • Stress
  • Relationship problems due to stress, poor communication or other concerns
  • Sexual trauma or abuse in the past
  • Anxiety disorder and attacks
  • Poor self-image and lack of confidence

Medications

  • Certain medications can cause changes in the level of experienced sexual desire through “non-specific effects on general well-being, energy level, and mood”. Declining levels of sexual desire have been linked to the use of anti-hypertension medication and many psychiatric medications; such as antipsychotic medications, tricyclic anti-depressants, monoamine-oxidase (MAO) inhibitors, and sedative drugs.
  • However, the most severe decreases in sexual desire relating to psychiatric medication occur due to the use of selective serotonin reuptake inhibitors (SSRIs). In women specifically, the use of anticoagulants, cardiovascular medications, medications to control cholesterol, and medications for hypertension contributed to low levels of desire.

Hormone

  • Sexual desire is said to be influenced by androgens in men and by androgens and estrogens in women. Many studies associate the sex hormone, testosterone with sexual desire. Testosterone is mainly synthesized in the testes in men and in the ovaries in women. Another hormone thought to influence sexual desire is oxytocin.
  • Exogenous administration of moderate amounts of oxytocin has been found to stimulate females to desire and seek out sexual activity. In women, oxytocin levels are at their highest during sexual activity. In males, the frequency of ejaculations affects the libido. If the gap between ejaculations extends toward a week, there will be a stronger desire for sexual activity.

Interventions

There are a few medical interventions that can be done on individuals who feel sexually bored, experience performance anxiety, or are unable to orgasm. For everyday life, a 2013 fact sheet by the Association for Reproductive Health Professionals recommends:

  • Erotic literature
  • Recalling instances when feeling sexy and sexual (The patient is instructed to recall her physical appearance, the setting, the smells in the air, the music she was hearing, and the foods she was eating at that time and use these as ‘cues’ for feeling sexual now)

Social and Religious Views of Sexual Dysfunction

  • The views on sexual desire and on how sexual desire should be expressed vary significantly between different societies and religions. Various ideologies range from sexual repression to hedonism. Lawson various forms sexual activity, such as homosexual acts and sex outside marriage vary by countries. Some cultures seek to restrict sexual acts to marriage.
  • In some societies, there is a double standard regarding the male and female expression of sexual desire. Female genital mutilation is practiced in some regions of the world in an attempt to prevent women to act on their sexual desire and engage in “illicit” sex.

Symptoms of Sexual Dysfunction

  • The total absence of sexual desire or a low sex drive
  • An inability to get aroused or maintain arousal for the duration of sexual activity
  • Recurrent ejaculation with minimal sexual stimulation
  • Inadequate lubrication in spite of sexual excitement
  • Not achieving an orgasm, after going through the normal excitement phase
  • Pain while having intercourse
Sexual dysfunction

Rx

Vaginal Dryness

  • Why It’s Happening Vaginal dryness can result from hormonal changes that occur during breastfeeding or menopause. In fact, a study of 1,000 postmenopausal women published in January 2010 in the journal Menopause found that half of the postmenopausal women experience vaginal dryness.

Low Desire

  • Why It’s Happening As hormones decline in the years leading up to menopause, your libido can go south, too. But low desire isn’t just a problem for older women: Half of females ages 30 to 50 have also suffered from a lack of lust, according to a national survey of 1,000 women. Low libido can result from a number of issues, including medical problems like diabetes and low blood pressure, and psychological issues like depression or simply being unhappy in your relationship. Certain medications, like antidepressants, can also be libido killers, as can hormonal contraceptives, according to a study published in June 2010 in The Journal of Sexual Medicine.
  • What You Can Do – There’s no one-stop solution to boost libido, so talk to your doctor, who can help you get to the root of the problem. If the issue is emotional or psychological, they may recommend seeing a therapist. “A traditional or sexual therapist can help couples evolve from having the same old conversation patterns, life habits, and sexual habits to having a sexual relationship that’s fulfilling, invigorating, and romantic,” says Worley.

Painful Sex

Sexual dysfunction

Rx

  • Why It’s Happening As many as 30 percents of women report pain during sex, Pain can be caused by vaginal dryness, or it may be an indication of a medical problem, like ovarian cysts or endometriosis, according to The American Congress of Obstetricians and Gynecologists. Painful sex can also be related to vaginismus, a condition in which the vagina tightens involuntarily when penetrated.
  • What You Can Do – Talk to your healthcare provider to rule out medical issues like ovarian cysts, endometriosis, or vaginismus. If those aren’t the problem, your doctor may recommend pelvic floor physical therapy, medication, or surgery to treat the cause of pain, says Worley. “It’s important to understand that the first treatment doesn’t always work, and sometimes multiple attempts at treatment are needed before you find success,” he says.

Arousal Problems

  • Why It’s Happening The inability to become aroused may be due to a number of reasons, such as anxiety or inadequate stimulation (aka, you need more foreplay). If you experience dryness or pain during sex, it can also be harder to become turned on. Hormonal changes due to menopause or a partner’s sexual issues (like erectile dysfunction or premature ejaculation) can also make it more difficult to get in the mood.
  • What You Can Do – Work with your healthcare provider to ID the underlying reason you can’t become aroused, recommends Worly. He or she can help connect you with the right form of treatment to correct the problem, whether that’s seeking out sexual therapy, a medication (like hormones), or treatment for your partner’s problem, he says.

Trouble Reaching Orgasm

  • Why It’s Happening – About 5 percent of perimenopausal women experience orgasm problems,” says Worly. Aside from hormone changes, an inability to reach orgasm may also be due to anxiety, insufficient foreplay, certain medications, and chronic diseases.
  • What You Can Do – Just like other forms of sexual dysfunction, it’s key to talk to your doctor to address the underlying problem before trying to treat it. In the meantime, try being more mindful while you’re getting it on by paying attention to the sensations as they happen.  suggests that being mindful during sex can make it easier to achieve orgasm. It may also be useful to add a vibrator to your sexual repertoire, says Worley. “Vibrators are now sold at most pharmacies, both in the store and online, so it’s possible to buy them discreetly from the comfort of your home,” he notes.

Diagnosis of Sexual Dysfunction

  • Physical exam This might include careful examination of your penis and testicles and checking your nerves for sensation.
  • Blood tests – A sample of your blood might be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels, and other health conditions.
  • Urine tests (urinalysis) Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions.
  • Ultrasound – This test is usually performed by a specialist in an office. It involves using a wand-like device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems. This test is sometimes done in combination with an injection of medications into the penis to stimulate blood flow and produce an erection.
  • Psychological exam Your doctor might ask questions to screen for depression and other possible psychological causes of erectile dysfunction.

Treatment of Sexual Dysfunction

Most types of sexual dysfunction can be corrected by treating the underlying physical or psychological problems. Other treatment strategies include:

  • Medication — When a medication is the cause of the dysfunction, a change in the medication may help. Men and women with hormone deficiencies may benefit from hormone shots, pills, or creams. For men, drugs, including sildenafil, tadalafil, vardenafil, and avanafil may help improve sexual function by increasing blood flow to the penis.
  • PDE5 Inhibitors – Increasing blood delivery to the genitals with the development of the first marked PDE5 inhibitor, sildenafil revolutionized the treatment of erectile dysfunction in men. The physiological mechanism responsible for relaxation of smooth muscle of cavernous tissue (both male and female) is initiated with the release of nitric oxide (NO) from adjacent nerve endings and/or endothelial cells upon mental and sensory stimuli via spinal reflex [].
  • Prostaglandins – Prostaglandins (PG) are found in virtually all tissues and organs. They are autocrine and paracrine lipid molecules, which are quickly metabolized, and participate in a variety of physiological events, including blood flow regulation. Specifically, the PG isoform PGE1 (signaling through its EP2 receptor) causes smooth muscle relaxation in the vaginal, uterine, as well as penile smooth muscle []. PGE1/EP2 activation leads to increases in cAMP resulting in activation of protein kinase A, which causes smooth muscle relaxation. Prostaglandins have been used in male sexual dysfunction, especially erectile dysfunction (administered through penile injection), for some time and have displayed positive outcomes for certain women with genital sexual arousal disorder, most likely through increasing vaginal secretion and arterial smooth muscle relaxation [].
  • Nitric Oxide Donor and Combination Therapy – It is well established that the production of NO is essential in vascular relaxation to numerous stimuli. PDE5 inhibitors augment NO-initiated dilation by propagating the downstream mediator, cGMP, through the activation of guanylate cyclase. Thus, activation of the NO-NO synthase (NOS) system is a potential site for pharmacological intervention. Pacher et al., demonstrated the topical application of a NO donor, DS1, a linear polyethyleneimine-nitric oxide/nucleophile adduct, increased vaginal blood flow in anesthetized rats [].
  • Vasoactive Intestinal Peptide – Vasoactive intestinal peptide (VIP) is a polypeptide hormone containing 28 amino acid residues and is produced in many areas of the human body. VIP has potent vasorelexant effects and has been suggested to contribute to vaginal blood flow control []. Like many peptidic therapies, oral administration of VIP is complicated by low bioavailability and high rate of clearance. Therefore, an alternative approach using an inhibitor of neutral endopeptidase (NEP), the primary enzyme responsible for the degradation of VIP, has been in development under the assumption that inhibition of NEP will lead to more VIP in the circulation, which can increase clitoral and vaginal blood flow when sexually stimulated [].
  • Testosterone – The use of testosterone to treat FSD has delivered mixed results. A primary concern in testosterone therapy is the long-term side effects including: hirsutism, acne and masculinization []. Given the results following the Woman’s Health Initiative, replacement therapy with estrogen and progestin revealed elevation in coronary heart disease, stroke and thrombosis formation [], a certain amount of caution must be taken in the treatment of FSD with hormones.
  • Estrogen – Estrogen plays a vital role in the regulation of female sexual function. Alterations in estradiol levels can result in vaginal wall smooth muscle atrophy and increased vaginal canal acidity, ultimately leading to discomfort and stress []. The findings from the Woman’s Health Initiative raised concerns on estrogen replacement therapy, however, the benefits of estrogen in normal function are well accepted. Estrogen plays a vital role in the regulation of female sexual function. Alterations in estradiol levels can result in vaginal wall smooth muscle atrophy and increased vaginal canal acidity, ultimately leading to discomfort and stress [].
  • Centrally Mediated Stimulation – The sexual response for men and women is distinct. Regarding treatment of male ED, PDE5 inhibitors have proven to be very successful, whereas in FSD similar achievements have not been made. Treating FSD through central acting mediators has recently received more attention. This area of investigation has gained momentum by recent publication demonstrating that several hypothalamic nuclei are activated in rodent sexual response []. Therefore, central regulation/activation of the female sexual response could mark an alternative approach for treating FSD.
  • Nitric Oxide Donor and Combination Therapy – It is well established that the production of NO is essential in vascular relaxation to numerous stimuli. PDE5 inhibitors augment NO-initiated dilation by propagating the downstream mediator, cGMP, through the activation of guanylate cyclase. Thus, activation of the NO-NO synthase (NOS) system is a potential site for pharmacological intervention. Pacher et al., demonstrated the topical application of a NO donor, DS1, a linear polyethylenimine-nitric oxide/nucleophile adduct, increased vaginal blood flow in anesthetized rats [].
  • Centrally Mediated Stimulation – The sexual response for men and women is distinct. Regarding treatment of male ED, PDE5 inhibitors have proven to be very successful, whereas in FSD similar achievements have not been made. Treating FSD through central acting mediators has recently received more attention. This area of investigation has gained momentum by recent publication demonstrating that several hypothalamic nuclei are activated in rodent sexual response []. Therefore, central regulation/activation of the female sexual response could mark an alternative approach for treating FSD.
  • Vasoactive Intestinal Peptide – Vasoactive intestinal peptide (VIP) is a polypeptide hormone containing 28 amino acid residues and is produced in many areas of the human body. VIP has potent vasorelexant effects and has been suggested to contribute to vaginal blood flow control []. Like many peptidic therapies, oral administration of VIP is complicated by low bioavailability and high rate of clearance. Therefore, an alternative approach using an inhibitor of neutral endopeptidase (NEP), the primary enzyme responsible for the degradation of VIP, has been in development under the assumption that inhibition of NEP will lead to more VIP in the circulation, which can increase clitoral and vaginal blood flow when sexually stimulated [].
  • Mechanical aids — Aids such as vacuum devices and penile implants may help men with erectile dysfunction (the inability to achieve or maintain an erection). A vacuum device (Eros) is also approved for use in women, but can be costly. Dilators may help women who experience narrowing of the vagina.
  • Sex therapy — Sex therapists can be very helpful to couples experiencing a sexual problem that cannot be addressed by their primary clinician. Therapists are often good marital counselors, as well. For the couple who wants to begin enjoying their sexual relationship, it is well worth the time and effort to work with a trained professional.
  • Behavioral treatments — These involve various techniques, including insights into harmful behaviors in the relationship, or techniques such as self-stimulation for treatment of problems with arousal and/or orgasm.
  • Psychotherapy — Therapy with a trained counselor can help a person address sexual trauma from the past, feelings of anxiety, fear, or guilt, and poor body image, all of which may have an impact on current sexual function.
  • Education and communication — Education about sex and sexual behaviors and responses may help an individual overcome his or her anxieties about sexual function. Open dialogue with your partner about your needs and concerns also helps to overcome many barriers to a healthy sex life.
  • Providing education – Education about human anatomy, sexual function, and the normal changes associated with aging, as well as sexual behaviors and appropriate responses, may help a woman overcome her anxieties about sexual function and performance.
  • Enhancing stimulation – This may include the use of erotic materials (videos or books), masturbation, and changes in sexual routines.
  • Providing distraction techniques – Erotic or non-erotic fantasies; exercises with intercourse; music, videos, or television can be used to increase relaxation and eliminate anxiety.
  • Encouraging non-coital behaviors – Non-coital behaviors (a physically stimulating activity that does not include intercourse), such as sensual massage, can be used to promote comfort and increase communication between partners.
  • Minimizing pain Using sexual positions that allow the woman to control the depth of penetration may help relieve some pain. Vaginal lubricants can help reduce pain caused by friction, and a warm bath before intercourse can help increase relaxation.
  • Alprostadil self-injection With this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil and phentolamine. Often these combination medications are known as bimix (if two medications are included) or trimix (if three are included).
  • Alprostadil urethral suppository –  Alprostadil intraurethral (Muse) therapy involves placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a special applicator to insert the suppository into your penile urethra. The erection usually starts within 10 minutes and, when effective, lasts between 30 and 60 minutes. Side effects can include pain, minor bleeding in the urethra and formation of fibrous tissue inside your penis.
  • Penile implants – This treatment involves surgically placing devices into both sides of the penis. These implants consist of either inflatable or malleable (bendable) rods. Inflatable devices allow you to control when and how long you have an erection. The malleable rods keep your penis firm but bendable.
  • Exercise – Recent studies have found that exercise, especially moderate to vigorous aerobic activity, can improve erectile dysfunction. However, benefits might be less in some men, including those with established heart disease or other significant medical conditions.
  • Psychological counseling – If your erectile dysfunction is caused by stress, anxiety or depression — or the condition is creating stress and relationship tension — your doctor might suggest that you, or you and your partner, visit a psychologist or counselor.

Testosterone replacement – Some men have erectile dysfunction that might be complicated by low levels of the hormone testosterone. In this case, testosterone replacement therapy might be recommended as the first step or given in combination with other therapies that are flollowing..

  • Androgen therapy
  • Estrogen therapy
  • Phosphodiesterase inhibitors
  • Testosterone replacement therapy
  • Tibolone

Potential and Current Therapeutic Options Available for the Treatment of Female Sexual Dysfunction

General Target Product Brand, Company Mechanism of Action
Peripheral Vaginal/Clitoral Blood flow
  • PDE5 inhibitors
Sildenafil
Tadalafil
Vardenafil
(Viagra®, Pfizer)
(Cialis®, Lilly)
(Levitra®, Bayer)
An external file that holds a picture, illustration, etc. Object name is nihms256271ig1.jpg cGMP availability; mediates vascular smooth muscle (VSM) relaxation
  • Prostaglandin
Alprostadil (Femprox®, NexMed)
(Alista®, Vivus)
Binds to EP2 receptor;
An external file that holds a picture, illustration, etc. Object name is nihms256271ig1.jpg cAMP and mediates VSM relaxation
  • Nitric oxide
L-arginine-
yohimbine
L-arginine
(NMI-870®, NitroMed)
(ArginMax®, The Daily Wellness Co.)
An external file that holds a picture, illustration, etc. Object name is nihms256271ig1.jpg NO production; augments
cGMP availability; mediates VSM relaxation
  • VIP
Candoxatril (Candoxatrilat®, Pfizer) Inhibits degradation of VIP;
An external file that holds a picture, illustration, etc. Object name is nihms256271ig1.jpg VSM relaxation
Hormonal
  • Estrogen
Estradiol (Vagifem®, Upjohn)
(Premarin®, Wyeth)
Improves vaginal dryness and irritation
  • Testosterone
Testosterone
Testosterone
Testosterone
(Intrensa®, Watson)
(Tostrelle®, Cellegy)
(Androsorb®, Novavax)
An external file that holds a picture, illustration, etc. Object name is nihms256271ig1.jpg sexual activity, libido and pleasure
  • Synthetic
Tibolone (Livial®, Organon) Improves vaginal dryness and overall sexual function
CNS
  • Dopaminergic agonist
Apomorphine
Bupropion
(Uprima®, Tap)
(Wellbutrin XL®, GlaxoSmithKline)
Binds to D receptors; increases sexual responsiveness
  • Synthetic α-melanocortin- stimulating hormone
Bremelanotide (PT-141®, Palatin) Binds to MC4 receptors; contributes to VSM relaxation

The specific management involves the following stages

  • Helping the woman develop more positive attitudes towards her genitals – After fully describing the female sexual anatomy, the therapist needs to encourage the woman to examine herself with a hand mirror on several occasions. Extremely negative attitudes (especially concerning the appearance of the genitals, or the desirability of examining them) may become apparent during this stage, possibly leading to failure to carry out the homework. Some women find it easier to examine themselves in the presence of the partners; others may only get started if the therapist helps them do this first in the clinic. If this is necessary a medically qualified female therapist is to be involved.
  • Pelvic muscle exercises – These are intended to help the woman gain some control over the muscles surrounding the entrance to the vagina. If she is unsure whether or not she can contract her vaginal muscles she may be asked to try to stop the flow of urine when she next goes to the toilet. The woman can later check that she is using the correct muscles by placing her finger at the entrance to her vagina where she needs to be able to feel the muscle contractions. Subsequently, she is advised to practice firmly contracting these muscles for an agreed number of times (e.g. 10) several times a day.
  • Vaginal penetration – Once the woman has become comfortable with the external genital anatomy she is advised to explore the inside of her vagina with her fingers. This is partly to encourage familiarity and partly to initiate vaginal penetration. Negative attitudes may also become apparent at this stage (e.g. concerning the texture of the vagina, its cleanliness, fear of causing damage, and whether it is ‘right’ to do this sort of thing). The rationale for any of these objections is to be explored. At a later stage, the woman might try using two fingers and moving them around. Once she is comfortable inserting a finger herself, her partner needs to begin to do this under her guidance during their homework sessions. A lotion (e.g. K-Y or baby lotion) can make this easier. Graded vaginal dilators can be used. However, clinical experience has shown that the use of fingers is just as effective.
  • Vaginal containment – When vaginal containment is attempted the pelvic muscle exercises and the lotion are used to assist in relaxing the vaginal muscles and making penetration easier. This is often a difficult stage and the therapist, therefore, needs to encourage the woman to gain confidence from all the progress made so far. Persisting concerns about possible pain may need to be explored, including how the woman might ensure that she retains control during this stage.
  • Movements during containment – Once containment is well established the couple is asked to introduce movement during containment, with preferable women starting the movements first. With this, the general programme of sex therapy is completed and now the treatment needs to include superimposition of treatment for specific sexual dysfunctions.
  • Steps in the management of vaginismus – Treatment is to be individualized for each woman and/or partner, whenever possible with their input. The psychological issue, as well as interpersonal issues,s need to be addressed first. The sex education needs to focus on clarifying normal sexuality and reducing negative attitude for sex. Besides the use of general relaxation exercises, the relaxation procedure needs to focus on teaching the women to relax muscles around the inner thigh and pelvic area. The specific behavioural management is to be followed.

Other oral erectogenic agents

  • Trazodone – One of the earliest drugs used in erectile dysfunction was trazodone. Trazodone and its active metabolite have an antagonistic effect on 5HT2C receptors and may also have adrenoceptor antagonistic action. Available data suggest that trazodone is more efficacious than placebo in mixed and psychogenic erectile dysfunction.
  • Yohimbine – It is a α2-adrenergic blocker. Before introduction of sildenafil, yohimbine was the most widely used oral medication for management of erectile dysfunction. Available evidence suggests that it is more efficacious than placebo.
  • Apomorphine  Apomorphine is a dopamine agonist (D1 & D2 receptors) and its sublingual form (Apo-SL) is a new central initiator of erection and has been found to be effective in various types of erectile dysfunction.. Recent studies show that sublingual apomorphine has a safe cardiovascular profile and thus making it a new treatment option for patients with concomitant disease including cardiovascular disease and diabetes mellitus.
  • Phentolamine – Oral phentolamine mesylate, is a competitive inhibitor of α- adrenergic receptor. It also has the advantage of lack of interaction with nitrates and hence has been suggested as an alternative to the treatment of erectile dysfunction in patients with the cardiac illness.
  • L-arginine L-arginine is the precursor of Nitric Oxide (NO) and has been shown to improve erections in 40% of patients.

Remedies for Sexual 

Some of the most commonly recommended home remedies for improving sexual disorders include:

  • A mixture of milk (250 ml) , to which drumstick flowers (10 to 15 grams) have been added
  • A combination of pistachios, dried dates, quince seeds and almonds, which have all been blended together.
  • Eating 100 grams of dried dates on a regular basis
  • Herbs, such as kava-kava, ginko biloba, chives, diffusa, arginine, lepidium meyenii and damiana
  • Natural therapies, like full body massages and hot baths.
  • Aromatherapy using essential oils like clary sage, rose, jasmine and lavendar
  • Chewing on a few pieces of garlic or increasing the amount of garlic consumed through meals

In case the sexual disorder is a result of a medical condition, then it may be necessary to first address that. Medical treatment may also be used in case home remedies do not prove to be very effective. Some of the medication or therapies suggested for curing sexual disorders in men and women include:

Diet for Sexual Disorders

Given below are some of the food items that should be included in a diet for better sexual health:

  • Alfalfa sprouts
  • Avocado
  • Garlic
  • Ginger
  • Nuts
  • Olive oil
  • Onions
  • Salmon

Similarly, there are certain foods that may aggravate sexual disorders and therefore should be strictly avoided by individuals who do have problems or are undergoing treatment. Some of the foods that should be consumed in limited quantities or preferably not at all include:

  • Red meat
  • Caffeinated beverages like tea, coffee and aerated drinks
  • Alcohol
  • Sweets and sugary items
  • Starchy food, such as processed or packaged items

There are some alternate health care practitioners who refer to Vitamin E as the sex vitamin as it helps in the production of sex hormones. They believe it improves sexual attraction, desire and moods. Hence, increasing the intake of these vitamins can reduce sexual disorders considerably.

References

Sexual dysfunction

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