Metorrhagia

Metrorrhagia refers to vaginal bleeding among premenopausal women that is not synchronized with their menstrual period.

The word Menopause literally means the physiological cessation of menstrual cycles, from the Greek roots 'meno-' (month) and 'pausis' (a pause, a cessation). However, in reality menopause is not simply a matter of the permanent stopping of periods, it is a phenomenon which involves the shutting down of the whole of a woman's reproductive functioning. The root cause of menopause is not what is happening to the uterus, the whole process of menopause is triggered by the faltering and shutting down of the ovaries. This process usually normally occurs more or less in midlife.

Clinically speaking, menopause is referred to with a date: the date of the day after a woman's last period ever finishes.

The normal age range for last period ever is between age 45 to 55, with the peak being at about age 51. An "early menopause" is defined as last period ever at an age between 40 to 45. Age 55 to 60 for last period ever is described as a "late menopause". Last period ever prior to age 40 is considered a "premature menopause", and this is not viewed as being due to normal causes.

In common everyday parlance however, the word "menopause" is most often used to refer to the menopause transition years, also known as the change of life or the climacteric. This time of life is also sometimes known as perimenopause, (literally meaning around menopause).

"Perimenopause" refers to the years both before and after the last period ever, when many women find that they undergo symptoms of hormonal change and fluctuation, such as hot flashes, mood changes, insomnia, etc.

The term "premenopause" refers to the years leading up to last period ever, and the term "postmenopause" refers to the years after last period ever.

A woman who still has her uterus can only be declared to be in post-menopause once she has gone 12 full months with no flow at all, not even any spotting. At that point she is one year into post-menopause. The reason for this delay in declaring a woman post-menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased.

In women who have no uterus and therefore have no periods, post-menopause can be determined by a blood test which can reveal the very high levels of FSH or Follicle Stimulating Hormone typical of post-menopausal women.

The ovaries are the essential organs; they are endocrine glands and produce hormones. Because of this, removal of the uterus, hysterectomy, does not itself cause menopause, although pelvic surgery can sometimes precipitate a somewhat earlier menopause perhaps because of a compromised blood supply to the ovaries. Removing the ovaries however, causes an immediate and powerful surgical menopause, even if the uterus is left intact.

Menopause does also exist in some of the other few mammal species that experience menstrual cycles, such as rhesus monkeys and some cetaceans.

Overview
Menopause occurs as the ovaries begin to fail to be able to produce an egg or ovum each and every month, which in turn after a number of years, leads to the somewhat chaotic shutting down of the whole reproductive system. The break-up of the pattern of the menstrual cycle causes the reproductive hormones to fall out of phase with one another and this causes extreme and unpredictable fluctuations in the levels of several reproductive hormones. After a number of years of erratic functioning, the ovaries stop producing estrogens, progestin and testosterone, and the entire reproductive system gradually shuts down.


Age of onset

The average onset of menopause is 51 years, but some women reach menopause at a younger age, especially if they have had cancer or another serious illness, and have undergone chemotherapy.

Premature menopause (or premature ovarian failure) is defined as last period ever occurring before the age of 40; it occurs in 1% of women. Causes of premature menopause include autoimmune disorders, thyroid disease, and diabetes mellitus. Premature menopause is diagnosed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH); the levels of these hormones will be higher if menopause has occurred. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.


Menopause in other species

Unlike humans, other mammals rarely experience menopause. This may simply be due to their comparatively shorter lifespans. However, recent studies have shown menopause to exist in gorillas, with an average age of 44 at onset.

The Grandmother hypothesis considers that the menopause arose in human evolution, because later life infertility could actually confer an evolutionary advantage by causing women to divert their attention away from any new offspring, in order to free up time to help with the care of her existing children and grandchildren.


Perimenopause

Perimenopause refers to the time preceding and immediately after menopause, during which the production of hormones such as estrogen and progesterone diminish and become more irregular, often with wide and unpredictable fluctuations in levels. During this period, fertility diminishes. When twelve months have passed without any menstruation, a woman is considered to be one year into postmenopause.

Symptoms of perimenopause can begin as early as age 35, although most women become aware of them about 10 years later than this. Perimenopause, the menopause transition time, can last for a few months, for several years, or for 10 years or even longer. In this respect it resembles adolescence, a similar process that surrounds puberty. In fact menopause has been compared to "puberty in reverse." The actual duration of perimenopause in any individual woman cannot be predicted in advance or during the process.

Not every woman suffers symptoms during perimenopause. About one third of all women get no noticeable symptoms other than their periods becoming erratic and then stopping. Another one third of women have moderate symptoms. The remaining one third of women have very strong symptoms which tend to have a longer duration. The tendency to have a very strong perimenopause may be inherited in some cases.

One piece of recent research has appeared to show that melatonin supplementation in perimenopausal women can produce a highly significant improvement in thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing the depression associated with the menopause.


Etiology

A natural or physiological menopause is that which occurs as a part of a woman's normal aging process. However, menopause can be surgically induced by bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), which is often done in conjunction with hysterectomy; the resulting cessation of menses as a result of reproductive organ removal is sometimes called "surgical menopause".

The cessation of menses that is not due to surgical removal of the reproductive organs, is the result of the eventual atresia of almost all oocytes in the ovaries. This causes an increase in circulating FSH and LH levels as there are a decreased number of oocytes responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the post-menopausal symptoms of hot flashes, insomnia, osteoporosis, atherosclerosis, vaginal atrophy and depression.

Cigarette smoking has been found to decrease the age at menopause by as much as one year, and women who have undergone hysterectomy with ovary conservation go through menopause 3.7 years earlier than average. However, premature menopause (before the age of 40) is generally idiopathic.


Symptoms
As the body adapts to the changing levels of natural hormones, vasomotor symptoms such as hot flashes and palpitations, psychological symptoms such as depression, anxiety, irritability, mood swings and lack of concentration, and atrophic symptoms such as vaginal dryness and urgency of urination appear. Together with these symptoms, the woman may also have increasingly erratic menstrual periods.

The clinical features of menopause are caused by lessening amounts of estrogen, progesterone, and testosterone in the woman's body.

Vasomotor instability

hot flashes, hot flushes, including night sweats
sleep disturbances
Urogenital atrophy

itching
dryness
bleeding
watery discharge
urinary frequency
urinary urgency
urinary incontinence
Skeletal

osteoporosis
joint pain, muscle pain
back pain
Skin, soft tissue

breast atrophy
skin thinning
decreased elasticity
Psychological

mood disturbance
irritability
fatigue
memory loss
depression
Sexual

decreased libido
vaginal dryness
problems reaching orgasm
dyspareunia
A cohort study found that menopause was associated with hot flushes; joint pain and muscle pain; and depressed mood. Menopause was not associated with poor sleep, decreased libido, and vaginal dryness.


Treatment of symptoms
While menopause is a natural stage of life, some symptoms may be alleviated through medical treatments. Hormone therapy (HT) provides the best relief, but certain forms appear to pose significant health risks. Some drugs afford limited relief from hot flashes. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HT or other therapies outweigh the risks. Until more becomes known, women who elect to use hormone replacement therapy are generally well advised to take the lowest effective dose of HRT for the shortest period possible and to investigate whether certain forms may pose fewer dangers of clots or cancer than others.

Hormone therapy
In addition to relief from hot flashes, hormone therapy (HT) remains an effective treatment for osteoporosis. In HT, estrogens, progesterone or other hormones are administered to compensate for the body's own insufficiency to produce them. There are several types of therapies, with various side effects.

Conjugated equine estrogens
Conjugated equine estrogens contain estrogen molecules conjugated to hydrophilic side groups (e.g. sulfate) and are produced from Equidae-animals (horses).

Adverse effects
Women had been advised for many years that hormone therapy after menopause might reduce their risk of heart disease and various aspects of aging. However, a large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HT with conjugated equine estrogens (Premarin), whether or not used in combination with a progestin (Premarin plus Provera), had a slightly increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease sufficient to justify stopping the study.

After these results were reported in 2002, the number of prescriptions written for Premarin and PremPro in the United States dropped almost in half, as many women discontinued HT altogether. The sharp drop in prescriptions for Premarin and PremPro following the mid-2002 announcement of their dangers was followed by large and successively greater drops in new breast cancer diagnoses at six months, one year, and 18 months after that announcement, for a cumulative 15% drop by the end of 2003. Surprisingly, no similar drop in Canada's breast cancer rates was observed during the same period, though prescriptions of PremPro and Premarin were reduced in Canada as well. Studies designed to track the further progression of this trend after 2003 are underway, as well as to determine if the drop is related to the reduced use of

Metorrhagia

Swollen Ear Lymph Node Sore Neck Sore Underarms

Lymph nodes are components of the lymphatic system. They are sometimes informally called lymph glands but, as they do not secrete substances, such terminology is not entirely accurate.

Definition Lymph nodes are filters or traps for foreign particles and contain white blood cells.

Function
Lymph nodes act as filters, with an internal honeycomb of reticular connective tissue filled with lymphocytes that collect and destroy bacteria and viruses. When the body is fighting an infection, lymphocytes multiply rapidly and produce a characteristic swelling of the lymph nodes.


Structure
The lymph node is surrounded by a fibrous capsule, and inside the lymph node the fibrous capsule extends to form trabeculae. Thin reticular fibers form a supporting meshwork inside the node.

The concave side of the lymph node is called the hilum. The artery and vein attach at the hilum and allows blood to enter and leave the organ, respectively.

The parenchyma of the lymph node is divided into an outer cortex and an inner medulla.


Cortex
In the cortex, the subcapsular sinus drains to cortical sinusoids.

The outer cortex and inner cortex have very different properties:

Location Name/description Predominant lymphocyte Has nodules?
outer cortex nodular cortex B cells yes
deep cortex juxtamedullary cortex or paracortex T cells no

The cortex is absent at the hilum.

It is made out of the fluid from the blood called plasma


Medulla
There are two named structures in the medulla:

The medullary cords are cords of lymphatic tissue, and include plasma cells and T cells
The medullary sinuses (or sinusoids) are vessel-like spaces separating the medullary cords. Lymph flows to the medullary sinuses from cortical sinuses, and into efferent lymphatic vessels. Medullary sinuses contain histiocytes (immobile macrophages) and reticular cells.

Shape and size

Human lymph nodes are bean-shaped and range in size from a few millimeters to about 1-2 cm in their normal state. They may become enlarged due to a tumor or infection. White blood cells are located within honeycomb structures of the lymph nodes. Lymph nodes are enlarged when the body is infected due to enhanced production of some cells and division of activated T and B cells. In some cases they may feel enlarged due to past infections; although one may be healthy, one may still feel them residually enlarged.


Lymphatic circulation
Lymph circulates to the lymph node via afferent lymphatic vessels and drains into the node just beneath the capsule in a space called the subcapsular sinus. The subcapsular sinus drains into trabecular sinuses and finally into medullary sinuses. The sinus space is criss-crossed by the pseudopods of macrophages which act to trap foreign particles and filter the lymph. The medullary sinuses converge at the hilum and lymph then leaves the lymph node via the efferent lymphatic vessel.

Lymphocytes, both B cells and T cells, constantly circulate through the lymph nodes. They enter the lymph node via the bloodstream and cross the wall of blood vessels by the process of diapedesis.

The B cells migrate to the nodular cortex and medulla.
The T cells migrate to the deep cortex.
When a lymphocyte recognizes an antigen, B cells become activated and migrate to germinal centers (by definition, a "secondary nodule" has a germinal center, while a "primary nodule" does not). When antibody-producing plasma cells are formed, they migrate to the medullary cords. Stimulation of the lymphocytes by antigens can accelerate the migration process to about 10 times normal, resulting in characteristic swelling of the lymph nodes.

The spleen and tonsils are large lymphoid organs that serve similar functions to lymph nodes, though the spleen filters blood cells rather than bacteria or viruses.


Distribution

Regional lymph tissueHumans have approximately 500-600 lymph nodes distributed throughout the body, with clusters found in the underarms, groin, neck, chest, and abdomen.


Lymph nodes of the human head and neck
Cervical lymph nodes
Anterior cervical: These nodes, both superficial and deep, lie above and beneath the sternocleidomastoid muscles. They drain the internal structures of the throat as well as part of the posterior pharynx, tonsils, and thyroid gland.
Posterior cervical: These nodes extend in a line posterior to the sternocleidomastoids but in front of the trapezius, from the level of the Mastoid portion of the temporal bone to the clavicle. They are frequently enlarged during upper respiratory infections.
Tonsillar: (sub mandibular) These nodes are located just below the angle of the mandible. They drain the tonsillar and posterior pharyngeal regions.
Sub-mandibular: These nodes run along the underside of the jaw on either side. They drain the structures in the floor of the mouth.
Sub-mental: These nodes are just below the chin. They drain the teeth and intra-oral cavity.
Supraclavicular: These nodes are in the hollow above the clavicle, just lateral to where it joins the sternum. They drain a part of the thoracic cavity and abdomen. Virchow's node is a left supraclavicular lymph node which receives the lymph drainage from most of the body (especially the abdomen) via the thoracic duct and is thus an early site of metastasis for various malignancies.

Lymph nodes of the arm
These drain the whole of the arm, and are divided into two groups, superficial and deep. The superficial nodes are supplied by lymphatics which are present throughout the arm, but are particularly rich on the palm and flexor aspects of the digits.

Superficial lymph glands of the arm:
supratrochlear glands: Situated above the medial epicondyle of the humerus, medial to the basilic vein, they drain the C7 and C8 dermatomes.
deltoideopectoral glands: Situated between the pectoralis major and deltoid muscles inferior to the clavicle.
Deep lymph glands of the arm: These comprise the axillary glands, which are 20-30 individual glands and can be subdivided into:
lateral glands
anterior or pectoral glands
posterior or subscapular glands
central or intermediate glands
medial or subclavicular glands

Swollen Ear Lymph Node sore neck Sore Underarms

Historectomy

A hysterectomy (from the Greek word histera, meaning "womb") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). In 2005, there were 617,000 hysterectomies performed in the USA. During a hysterectomy, in the last decade, an average of 73% of surgeons removed ovaries and fallopian tubes during the same operation, a procedure known technically as bilateral salpingo-oophorectomy and less formally as ovariohysterectomy.

This surgery is exclusively performed on those who are chromosonally female. Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes their hormonal levels considerably, so the surgery is normally recommended for only a few specific diseases and circumstances:

Certain types of reproductive system cancers (uterine, cervical, ovarian);
As a prophylactic treatment for those with either a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from such cancers;
Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta accreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive postpartum bleeding;
Female to male transsexuals, a.k.a. "transmen", as part of their gender transition.
Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids that leaves the uterus intact, has been performed for over a century.

The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age. According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of genetic females can be expected to have a hysterectomy by age 60. There are currently an estimate of 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.

Both the uterus and the ovaries have important life-long functions in the maintenance of a woman's health, and there is never an age or a time when the uterus and ovaries are not essential to health and well-being. Additionally, the removal of otherwise healthy ovaries is a form of castration because it involves removal of the female gonads, which many opponents and even some supporters of hysterectomy do not support.

Indications
Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (overgrowth of the uterine lining), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); or uterine artery embolization. In mild cases, no treatment is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4cm, and fibroids located in other parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.

Technique
Most hysterectomies in the United States and in most parts of the world are done via laparotomy, sometimes called the "open technique" or "open hysterectomy". The abdominal wall is sliced open, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4-6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.

An increasing number of uterine removals not involving removal of the ovaries are done through the cervix ("supracervical"), reducing the size of the incision and the recovery time as well. In this technique, the uterus is accessed either via the vaginal canal or through an incision inside the navel (or sometimes both, depending on the uterine problem being addressed by the surgery). The uterus itself is detached at the top of the cervical neck and pulled back through the vaginal canal (or out through the navel incision if fibroids or other indications prevent it from being able to pass through the cervix) , after which the cervical neck is stitched shut. This provides the patient with a comparatively normal-length vagina which helps provide some support to the bladder, as well as a significantly decreased recovery time. The main drawback with supracervical hysterectomy is the increased risk of cervical prolapse due to the removal of the much stronger uterus (which would normally support the organs around it to prevent prolapse). This surgery also does not eliminate the possibility of cervical cancer, since the cervix itself is left in place; those who have undergone this procedure must still have regular PAP smears to check for cervical cancer.

The newest technique is robotic-assisted laparoscopic hysterectomy. Instead of a large incision, a few tiny incisions are made through which thin instruments are passed. This new technique significantly reduces scarring, pain, healing time, blood loss, and duration of hospital stay when compared to open technique.


Benefits
Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy. In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only HRT to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT.

The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.

One of the conditions most cited by women who have complex pelvic and reproductive issues is pain. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome. Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder.

Risks and side effects
The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal systems. Although sometimes referred to as surgical menopause, that is incorrect and misleading because it implies that its effects are the same as with natural menopause. In fact, those who are naturally menopausal have the benefit of the functions of their uterus and ovaries (which continue to produce small amounts of hormones even after natural menopause), while those who undergo hysterectomy and/or removal of the ovaries have a permanent loss of their functions.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.

Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.

Those who have undergone a hysterectomy with both ovaries conserved typically have reduced testosterone levels as compared to those left intact. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.

An ectopic pregnancy,can be developed.

Alternatives
Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation.

Gender transitioning
Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of Transman (sometimes called "female-to-male" or "FTM") gender reassignment surgery. Some in the transman community prefer to have this operation along with testosterone therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition. Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy) to avoid undergoing multiple separate operations. Many FTM never complete "bottom surgery" for a number of reasons, and instead choose to have their breasts and reproductive organs removed to eliminate all outward appearances of their femininity.

Historectomy

Acidreflex

Gastroesophageal Reflux Disease (GERD; or GORD when spelling œsophageal, the BrE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia.

Symptoms

Adults
Heartburn is the major symptom of acid in the esophagus, characterized by burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) — inflammatory changes in the esophageal lining (mucosa) — strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those findings. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains, nausea or sinusitis. GERD complications include stricture formation, Barrett's esophagus, esophageal ulcers, and possibly even lead to esophageal cancer, especially in adults over 60 years old.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for developing GERD.

Children
GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.

It is estimated that of the approximately 8 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life. Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition.

Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children that have had heartburn that does not seem to go away, or any other GERD symptoms for a while, should talk to their parents and visit their doctor.

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia or difficulty swallowingA detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24 hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Biopsies can be performed during gastroscopy and these may show:

Edema and basal hyperplasia (non-specific inflammatory changes)
Lymphocytic inflammation (non-specific)
Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
Eosinophilic inflammation (usually due to reflux)
Goblet cell intestinal metaplasia or Barretts esophagus.
Elongation of the papillae
Thinning of the squamous cell layer
Dysplasia or pre-cancer.
Carcinoma.

Pathophysiology
GERD is caused by a failure of the Anti-Reflux Barrier (ARB) and its primary component, the GastroEsophageal valve (GEV). The understanding of the GEV has continued to progress in recent years, and more focus is currently being placed on the GEV, rather than the Lower Esophageal Sphincter (LES), as the largest contributor to the ARB. Researchers have shown the GEV's robust nature and have shown that the intact GEV alone is highly competent to stop reflux. For example, in cadavers, where no muscle tone or LES pressure is present, the stomach ruptures when filled with water before reflux can occur. This shows the GEV's power to stop reflux even in the absence of any LES pressure.

In healthy patients, the "Angle of His," the angle at which the esophagus enters the stomach, is intact creating a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where it can cause burning and inflammation of sensitive esophageal tissue.

Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open and the stomach contents are churned up into the esophagus. However, there is still enough acidity to irritate the esophagus.

Factors that can contribute to GERD are:

Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors
Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
Hypercalcemia, which can increase gastrin production, leading to increased acidity
Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
Gallstones which can impede the flow of bile into the Duodenum which can affect the ability to neutralize gastric acid
GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to laryngopharyngeal reflux and ulcers of the vocal cords.

Treatment
The rubric "lifestyle modifications" is the term physicians use when recommending non-drug GERD treatments. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were supported by evidence.

Foods
Certain foods and lifestyle are considered to promote gastroesophageal reflux:

Coffee, alcohol, and excessive amounts of Vitamin C supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. Calcium containing antacids are in this group. (Although a study published in 2006 by Stanford University researchers disputes the effect of coffee, acidic, spicy foods etc. as a myth.)
Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.
Having more but smaller meals also reduces GERD risk, as it means there is less food in the stomach at any one time.
Eating shortly before bedtime (For clinical purposes, this usually means 2-3 hours before going to bed).
Large meals.
Soda or pop (regular or diet).
Chocolate and peppermint.
Acidic foods, such as oranges and tomatoes
Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
Milk and milk-based products contain calcium and fat, and should be avoided before bedtime.
However, directly following this list of foods is not 100% accurate for some have a more serious GERD case than others. Thus, it is up to each individual to decide which foods bother them and which ones do not. But practical advice offered by many sources is to avoid food for at least two (2) hours before bedtime and, also, not lying down after meals.

Positional therapy
Sleeping on one's left side has been shown to drastically reduce nighttime reflux episodes in patients.

Elevation to the head of the bed is the next easiest to do. When combining drug therapy, food avoidance before bedtime, and elevation of the head of the bed, over 95% of patients will have complete relief[citation needed]. Additional conservative measures may be considered if there is incomplete relief. Another approach is to apply all conservative measures for maximum response. A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies

Elevating the head of the bed can be done by using various items: plastic or wooden bed risers that support bed posts or legs, a bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) in order to be at least minimally effective to prevent the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain, thus foam based mattresses are to be preferred. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.

Drug treatment
A number of drugs are registered for GERD treatment, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can interfere with the function of other drugs:

Proton pump inhibitors are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).
Alginic acid (Gaviscon) may coat the mucosa as well as increase pH and decrease reflux. A meta-analysis of randomized controlled trials suggests alginic acid may be the most effective of non-prescription treatments with a number needed to treat of 4.
Gastric H2 receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a number needed to treat of eight (8).
Prokinetics strengthen the LES and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.
Sucralfate (Carafate®) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.

Posture and GERD
In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there is no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms. A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies [6].

Surgical treatment
The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

Endoluminal Fundoplication
In June 2006 EndoGastric Solutions introduced EsophyX ELF in the Europe Union as an alternative to surgical and pharmaceutical approaches for GERD treatment. EsophyX ELF is intended to deliver similar benefits as the time-proven laparoscopic fundoplication procedures, by reducing hiatal hernia, recreating the Angle of His, and creating a GastroEsophageal Valve (GEV). The key differences are that EsophyX ELF is an endoscopic non-invasive procedure that is performed transorally (through the mouth), does not require incisions, and does not dissect any part of the natural anatomy.

Previous endoluminal treatments focused predominantly on the LES. However, failure to effectively treat reflux long-term with endoluminal therapies that focused only on the Lower Esophageal Sphincter (LES) combined with the fact that surgical approaches like Nissen fundoplication recreate the GEV and have excellent long-term efficacy, has led to an awareness that the GEV is probably the most powerful component of the Anti-Reflux Barrier. The device has been designed to deploy multiple tissue fasteners to create a robust and durable valve and is intended to restore the geometry of the GastroEsophageal Junction and recreate the natural, unidirectional valve mechanism necessary to prevent GERD. EsophyX ELF has not been cleared by the US FDA and is not yet available in the U.S.

Other treatments
In 2000 , the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long term outcomes of both procedures compared to a Nissen fundoplication are still being determined.

Subsequently the NDO Surgical Plicator was FDA cleared for the endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The Plicator is currently marketed by NDO Surgical, Inc.

Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

Barrett's esophagus
Barrett's esophagus, a type of dysplasia, is a precursor high-grade dysplasia, which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.

Acidreflex

Eatin Disorders

An eating disorder is a complex compulsion to eat in a way which disturbs physical, mental, and psychological health. The eating may be excessive (compulsive over-eating); to limited (restricting); may include normal eating punctuated with episodes of purging; may include cycles of binging and purging; or may encompass the ingesting of non-foods. The most heard about eating disorders are Anorexia nervosa and Bulimia nervosa. The most widely and rapidly spreading eating disorder is compulsive overeating or Binge eating disorder. These are also the three most common eating disorders. All three have severe consequences to a person's immediate and long-term health and can cause death. There are numerous theories as to the causes and mechanisms leading to eating disorders.

Types
Anorexia nervosa
Starvation diet
Binge eating disorder
Bulimia nervosa
Diabulimia
Eating disorder not otherwise specified
Orthorexia
Hyperphagia
Rumination
Pica
Night eating syndrome
Eating disorders are characterized by an abnormal obsession with food and weight. Eating disorders are much more noticed in women than in men. This can be attributed to the fact that society is seen to put an emphasis on woman to be thin, and men to be 'bulked up'. This can lead to pressure on woman to be 'picture perfect', and an eating disorder prevails as a result of stress of not being able to reach unattainable goals related to this 'picture perfect' ideal. Also, it can be due to the fact that men are less likely to seek help.

Patients with eating disorders may also have a comorbid diagnosis of, mood disorder, severe mental depression, Obsessive compulsive disorder, Body dysmorphic disorder, Bipolar disorder, self-harm personality disorders and substance abuse disorders. Sexual abuse is also frequently reported among those with eating disorders. Women with eating disorders show poorer eating self-efficacy, psychological distress, disinhibition, low self-esteem, less helpful coping strategies, more frequent sensations of hunger, and less cognitive restraint when compared to control groups.

Some psychologists also classify a syndrome called orthorexia as an eating disorder, or, more properly, "disordered eating" - the person is overly obsessed with the consumption of what they see as the 'right' foods for them, to the point that their nutrition and quality of life suffers (although due to cultural and political factors which influence food choices, this idea is considered controversial by some). In addition, some individuals have food phobias about what they can and cannot eat, which can be characterized as an eating disorder. The UK broadcaster BBC Three have shown a series called Freaky Eaters that deals with such topics.

Somewhat qualitatively different from those conditions previously mentioned is pica, or the habitual ingestion of inedibles, such as dirt, wood, hair, etc.

The American Psychiatric Association recognizes eating disorders.

Causes and mechanisms
Environmental factors have a large influence on developing eating disorders but more research is being performed on hormonal imbalances, brain lesions and their effects on eating disorders. Research has shown that many people who suffer from an eating disorder are highly correlated with having depression and obsessive compulsive disorder. Depressed, obsessive compulsive and bulimic patients were found to have lower than normal serotonin levels. Neurotransmitters, such as serotonin, dopamine, and norepinephrine, are released as you eat.

Researchers have also found low cholecystokinin levels in bulimics. Cholecystokinin is a hormone that causes one to feel full and decreases eating. People who are lacking this hormone are more likely to lack feeling satisfaction while eating which can lead to binge eating. Another explanation researchers found for over eating is abnormalities in the neuromodulator peptides, neuropeptide Y and peptide YY. Both of these peptides increase eating and work with another peptide called leptin. Leptin is released by fat cells and is known to decrease eating. Research found the majority of people who overate produced normal amounts of leptin but they might have complications with the blood-brain barrier preventing an optimal amount to reach the brain.

Cortisol is a hormone released by the adrenal cortex which promotes blood sugar and increases metabolism. High levels of cortisol were found in people with eating disorders. This imbalance may be caused by a problem in or around the hypothalamus. A study in London at Maudsley Hospital found that anorexics were found to have a large variation of serotonin receptors and a high level of serotonin.

Many of these chemicals and hormones are associated with the hypothalamus in the brain.Damage to the hypothalamus can result in abnormalities in temperature regulation, eating, drinking, sexual behavior, fighting, and activity level. Uher & Treasure (2005) performed a study researching brain lesions effects on eating disorders. They evaluated 54 formally published cases of eating disorders and brain damage. They found many correlations between eating disorders and damage to the hypothalamus. People with brain lesions in the hypothalamus had abnormal eating behaviors; unprovoked and self induced vomiting, over concern with becoming fat, cheating with eating, frequent sleepiness, depression, obsessive compulsive behavior and diabetes insipidus

Addiction
The same personality factors that place individuals at risk for substance abuse are often found in individuals with eating disorders. With addiction and eating disorders there is a need to discharge affective experience through action rather than feeling or being able to talk about them, an inability to regulate tension, the need for immediate gratification, poor impulsive control, and a fragile sense of self. Often in those with eating disorders and substance abuse problems drugs or alcohol is used in attempts to avoid binge eating. Similarly, those with eating disorders may deny their problem or attempt to keep it a secret, much like addicts try to conceal their drug and alcohol usage. Similar to genetic components of addiction, there is a large genetic component to body type.

Developmental etiology
Research from a family systems perspective indicates that eating disorders stem from both the adolescent's difficulty in separating from over-controlling parents, and disturbed patterns of communication. When parents are critical and unaffectionate, their children are more prone to becoming self-destructive and self-critical, and have difficulty developing the skills to engage in self-care giving behaviors. Such developmental failures in early relationships with others, particularly maternal empathy, impairs the development of an internal sense of self and leads to an over-dependence on the environment. When coping strategies have not been developed in the family system, food and drugs serve as a substitute.

Eatin Disorders

Decompression Surgery

Decompression sickness (DCS), the diver’s disease, the bends, or caisson disease is the name given to a variety of symptoms suffered by a person exposed to a reduction in the pressure surrounding their body. It is a type of diving hazard and dysbarism.

Introduction
Decompression sickness can happen in these situations:

A diver ascends rapidly from a dive or does not carry out decompression stops after a long or deep dive.
An unpressurized aircraft flies upwards.
The cabin pressurization system of an aircraft fails.
Divers flying in any aircraft shortly after diving. Pressurized aircraft are not risk-free since the cabin pressure is not maintained at sea-level pressure. Commercial aircraft cabin pressure is often maintained to about 8,000 feet above sea level.
A worker comes out of a pressurized caisson or out of a mine, which has been pressurized to keep water out.
An astronaut exits a space vehicle to perform a space-walk or extra-vehicular activity where the pressure in his spacesuit is lower than the pressure in the vehicle.

This surfacing diver must enter a recompression chamber to avoid the bends.These situations cause inert gases, generally nitrogen, which are normally dissolved in body fluids and tissues, to come out of physical solution (i.e., outgas) and form gas bubbles.

According to Henry’s Law, when the pressure of a gas over a liquid is decreased, the amount of gas dissolved in that liquid will also decrease. One of the best practical demonstrations of this law is offered by opening a soft drink can or bottle. When you remove the cap from the bottle, you can clearly hear gas escaping and see bubbles forming in the soda. This is carbon dioxide gas coming out of solution as a result of the pressure inside the container reducing to atmospheric pressure.

Similarly, nitrogen is an inert gas normally stored throughout the human body, such as tissues and fluids, in physical solution. When the body is exposed to decreased pressures, such as when flying an un-pressurized aircraft to altitude or during a scuba ascent through water, the nitrogen dissolved in the body outgases. If nitrogen is forced to come out of solution too quickly, bubbles form in parts of the body causing the signs and symptoms of the "bends" which can be itching skin and rashes, joint pain, sensory system failure, paralysis, and death.

An air embolism, caused by other processes, can have many of the same symptoms as DCS. The two conditions are grouped together under the name decompression illness or DCI.


History
Wikisource has an original article from the 1911 Encyclopædia Britannica about:
Caisson Disease1841: First documented case of decompression sickness, reported by a mining engineer who observed pain and muscle cramps among coal miners working in mine shafts air-pressurized to keep water out.
1867: The submarine pioneer Julius H. Kroehl died of decompression sickness during experimental dives with the Sub Marine Explorer.
1869: An early case resulting from diving activities while wearing an air-pumped helmet.
1872: Washington Roebling suffered from caisson disease while working as the chief engineer on the Brooklyn Bridge. (He took charge after his father John Augustus Roebling died of tetanus.) Washington's wife Emily helped manage the construction of the bridge, after his sickness confined him to his home in Brooklyn. He battled the after-effects of the disease for the rest of his life.

Predisposing factors
Magnitude of the pressure reduction: A large pressure reduction is more likely to cause DCS than a small one. For example, the ambient pressure halves by ascending during a dive from 10 metres / 33 feet (2 bar) to the surface (1 bar), or by flying from sea level (1 bar) to an altitude of 16,000 feet / 5,000 metres (0.5 bar) in an un-pressurized aircraft. Diving and then flying shortly afterwards increases the pressure reduction as does diving at high altitude.
Repetitive exposures: Repetitive dives or ascents to altitudes above 18,000 feet within a short period of time (a few hours) also increase the risk of developing altitude DCS.
Rate of ascent: The faster the ascent, the greater the risk of developing altitude DCS. An individual exposed to a rapid decompression (high rate of ascent) above 18,000 feet has a greater risk of altitude DCS than being exposed to the same altitude but at a lower rate of ascent.
Time at altitude: The longer the duration of the flight to altitudes of 18,000 feet and above, the greater the risk of altitude DCS.
Age: There are some reports indicating a higher risk of altitude DCS with increasing age.
Previous injury: There is some indication that recent joint or limb injuries may predispose individuals to developing "the bends."
Ambient temperature: There is some evidence suggesting that individual exposure to very cold ambient temperatures may increase the risk of altitude DCS.
Body Type: Typically, a person who has a high body fat content is at greater risk of altitude DCS. Due to poor blood supply, nitrogen is stored in greater amounts in fat tissues. Although fat represents only 15 percent of a normal adult body, it stores over half of the total amount of nitrogen (about 1 litre) normally dissolved in the body.
Exercise: When a person is physically active, or performing strenuous activity before or after a dive (such as rowing to and from a dive site), there is greater risk of DCS.
Rate of Air Consumption: If you tend to consume more air than what may be considered "normal" for scuba diving, you will certainly be more susceptible to DCS if you skirt the no-decompression limits.
Alcohol consumption/dehydration: While conventional wisdom would have one believe that the after effects of alcohol consumption increase the susceptibility to DCS through increased dehydration and decreased motor coordination/mental acuity, one study concluded that alcohol consumption did not increase the risk of DCS. The high surface tension of water is generally regarded as helpful in controlling bubble size, hence staying hydrated is recommended by most experts.
Patent foramen ovale: A hole between the atrial chambers of the heart in the fetus is normally closed by a flap with the first breaths at birth. In up to 20 percent of adults the flap does not seal, however, allowing blood through the hole with coughing or other activities which raise chest pressure. In diving, this can allow blood with microbubbles in the venous blood from the body to return directly to the arteries (including arteries to the brain, spinal cord and heart) rather than pass through the lungs, where the bubbles would otherwise be filtered out by the lung capillary system. In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, infarction results in stroke, in the spinal cord it may result in paralysis, and in the heart it results in myocardial infarction (heart attack).

Signs and symptoms
Bubbles can form anywhere in the body, but symptomatic sensation is most frequently observed in the shoulders, elbows, knees, and ankles.

This table gives symptoms for the different DCS types. The "bends" (joint pain) accounts for about 60 to 70 percent of all altitude DCS cases, with the shoulder being the most common site. These types are classifed medically as DCS I. Neurological symptoms are present in 10 to 15 percent of all DCS cases with headache and visual disturbances the most common. DCS cases with neurological symptoms are generally classified as DCS II. The "chokes" are rare and occur in less than two-percent of all DCS cases. Skin manifestations are present in about 10 to 15 percent of all DCS cases.

Table 1. Signs and symptoms of decompression sickness. DCS Type Bubble Location Signs & Symptoms (Clinical Manifestations)
BENDS Mostly large joints of the body
(elbows, shoulders, hip,
wrists, knees, ankles) Localized deep pain, ranging from mild (a "niggle") to excruciating. Sometimes a dull ache, but rarely a sharp pain.
Active and passive motion of the joint aggravates the pain.
The pain may be reduced by bending the joint to find a more comfortable position.
If caused by altitude, pain can occur immediately or up to many hours later.

NEUROLOGIC Brain Confusion or memory loss
Headache
Spots in visual field (scotoma), tunnel vision, double vision (diplopia), or blurry vision
Unexplained extreme fatigue or behaviour changes
Seizures, dizziness, vertigo, nausea, vomiting and unconsciousness may occur, mainly due to labyrinthitis

Spinal Cord Abnormal sensations such as burning, stinging, and tingling around the lower chest and back
Symptoms may spread from the feet up and may be accompanied by ascending weakness or paralysis
Girdling abdominal or chest pain

Peripheral Nerves Urinary and rectal incontinence
Abnormal sensations, such as numbness, burning, stinging and tingling (paresthesia)
Muscle weakness or twitching

CHOKES Lungs Burning deep chest pain (under the sternum)
Pain is aggravated by breathing
Shortness of breath (dyspnea)
Dry constant cough

SKIN BENDS Skin Itching usually around the ears, face, neck arms, and upper torso
Sensation of tiny insects crawling over the skin
Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching
Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)

Treatment
Recompression is the only effective treatment for severe DCS, although rest and oxygen (increasing the percentage of oxygen in the air being breathed via a tight fitting oxygen mask) applied to lighter cases can be effective. Recompression is normally carried out in a recompression chamber. In diving, a high-risk alternative is in-water recompression.

Oxygen first aid treatment is useful for suspected DCS casualties or divers who have made fast ascents or missed decompression stops. Most fully closed-circuit rebreathers can deliver sustained high concentrations of oxygen-rich breathing gas and could be used as an alternative to pure open-circuit oxygen resuscitators.


Common pressure reductions that cause DCS
The main cause of DCS is a reduction in the pressure surrounding the body. Common ways in which the required reduction in pressure occur are:

leaving a high atmospheric pressure environment
rapid ascent through water during a dive
ascent to altitude while flying

Leaving a high pressure environment
The original name for DCS was caisson disease; this term was used in the 19th century, when large engineering excavations below the water table, such as with the piers of bridges and with tunnels, had to be done in caissons under pressure to keep water from flooding the excavations. Workers who spend time in high pressure atmospheric pressure conditions are at risk if they leave that environment and reduce the pressure surrounding them.

DCS was a major factor during construction of Eads Bridge, when 15 workers died from what was then a mysterious illness, and later during construction of the Brooklyn Bridge, where it incapacitated the project leader Washington Roebling.


Ascent during a dive
DCS is best known as an injury that affects scuba divers. The pressure of the surrounding water increases as the diver descends and reduces as the diver ascends. The risk of DCS increases by diving long or deep without slowly ascending and making the decompression stops needed to eliminate the inert gases normally, although the specific risk factors are not well understood. Some divers seem more susceptible than others under identical conditions.

There have been known cases of bends in snorkellers who have made many deep dives in succession. DCS may be the cause of the disease taravana which affects South Pacific island natives who for centuries have dived without equipment for food and pearls.

Two linked factors contribute to divers' DCS, although the complete relationship of causes is not fully understood:

deep or long dives: inert gases in breathing gases, such as nitrogen and helium, are absorbed into the tissues of the body in higher concentrations than normal (Henry's Law) when breathed at high pressure.
fast ascents: reducing the ambient pressure, as happens during the ascent, causes the absorbed gases to come back out of solution, and form "micro bubbles" in the blood. Those bubbles will safely leave the body through the lungs if the ascent is slow enough that the volume of bubbles does not rise too high.
The physiologist John Haldane studied this problem in the early 20th century, eventually devising the method of staged, gradual decompression, whereby the pressure on the diver is released slowly enough that the nitrogen comes gradually out of solution without leading to DCS. Bubbles form after every dive: slow ascent and decompression stops simply reduce the volume and number of the bubbles to a level at which there is no injury to the diver.

Severe cases of decompression sickness can lead to death. Large bubbles of gas impede the flow of oxygen-rich blood to the brain, central nervous system and other vital organs.

Even when the change in pressure causes no immediate symptoms, rapid pressure change can cause permanent bone injury called dysbaric osteonecrosis (DON) "bone cell death from bad pressure". DON can develop from a single exposure to rapid decompression. DON is diagnosed from lesions visible in X-ray images of the bones. Unfortunately, X-rays appear normal for at least 3 months after the permanent damage has occurred; it may take 4 years after the damage has occurred for its effects to become visible in the X-ray images. [1]


Avoidance
Decompression tables and dive computers have been developed that help the diver choose depth and duration of decompression stops for a particular dive profile at depth.

Avoiding decompression sickness is not an exact science. Accidents can occur after relatively shallow and short dives. To reduce the risks, divers should avoid long and deep dives and should ascend slowly. Also, dives requiring decompression stops and dives with less than a 16 hour interval since the previous dive increase the risk of DCS. There are many additional risk factors, such as age, obesity, fatigue, use of alcohol, dehydration and a patent foramen ovale. In addition, flying at high altitude less than 24 hours after a deep dive can be a precipitating factor for decompression illness.

Astronauts aboard the International Space Station preparing for Extra-vehicular activity "camp out" at low atmospheric pressure (approximately 10 psi = 700 mbar) spending 8 sleeping hours in the airlock chamber before their spacewalk. Their spacesuits can operate at 4.7 psi = 330 mbar for maximum flexibility.


Helium
Nitrogen is not the only breathing gas that causes DCS. Gas mixtures such as trimix and heliox include helium, which can also be implicated in decompression sickness.

Helium both enters and leaves the body faster than nitrogen, and for dives of three or more hours in duration, the body almost reaches saturation of helium. For such dives the decompression time is shorter than for nitrogen-based breathing gases such as air.

There is some debate as to the decompression effects of helium for shorter duration dives. Most divers do longer decompressions, whereas some groups like the WKPP have been pioneering the use of shorter decompression times by including deep stops.

Decompression time can be significantly shortened by breathing rich nitrox (or pure oxygen in very shallow water) during the decompression phase of the dive. The reason is that the nitrogen outgases at a rate proportional to the difference between the ppN2 (partial pressure of nitrogen) in the diver's body and the ppN2 in the gas that he or she is breathing; but the likelihood of bubbles is proportional to the difference between the ppN2 in the diver's body and the total surrounding air or water pressure.


Ascent to altitude
People flying in un-pressurized aircraft at high altitude, such as stowaways, or passengers in a cabin that has experienced rapid decompression, or pilots in an open cockpit, can suffer from decompression sickness. Even Lockheed U-2 pilots experienced altitude DCS in the mid-'50s during the Cold War flying over their targets. Divers who dive and then fly in aircraft are at risk even in pressurized aircraft because the cabin air pressure is less than the air pressure at sea level. The same applies to divers going into higher elevations by land after diving.

Altitude DCS became a commonly observed problem associated with high-altitude balloon and aircraft flights in the 1930s. In present-day aviation, technology allows civilian aircraft (commercial and private) to fly higher and faster than ever before. Though modern aircraft are safer and more reliable, occupants are still subject to the stresses of high-altitude flight and the unique problems that go with these lofty heights. A century-and-a-half after the first DCS case was described, our understanding of DCS has improved and a body of knowledge has accumulated; however, this problem is far from being solved. Altitude DCS is still a risk to the occupants of modern aircraft.

There is no specific altitude threshold that can be considered safe for everyone below which it can be assured that no one will develop altitude DCS. However, there is very little evidence of altitude DCS occurring among healthy individuals at pressure altitudes below 18,000 feet who have not been scuba diving. Individual exposures to pressure altitudes between 18,000 and 25,000 feet have shown a low occurrence of altitude DCS. Most cases of altitude DCS occur among individuals exposed to pressure altitudes of 25,000 feet or higher. A US Air Force study of altitude DCS cases reported that only 13 percent occurred below 25,000 feet The higher the altitude of exposure, the greater the risk of developing altitude DCS. It is important to clarify that although exposures to incremental altitudes above 18,000 feet show an incremental risk of altitude DCS they do not show a direct relationship with the severity of the various types of DCS (see Table 1).

Arterial gas embolism and DCS have very similar treatment because they are both the result of gas bubbles in the body. Their spectra of symptoms also overlap, although those from arterial gas embolism are more severe because they often cause infarction and tissue death as noted above. In a diving context, the two are joined under the general term of decompression illness. Another term, dysbarism, encompasses decompression sickness, arterial gas embolism, and barotrauma.

Ascent to altitude can happen without flying in places such as the Ethiopia and Eritrea highland (8000 feet = about 1.5 miles above sea level) and the Peru and Bolivia altiplano and Tibet (2 to 3 miles above sea level).

Medical treatment
Mild cases of the "bends" and skin bends (excluding mottled or marbled skin appearance) may disappear during descent from high altitude but still require medical evaluation. If the signs and symptoms persist during descent or reappear at ground level, it is necessary to provide hyperbaric oxygen treatment immediately (100-percent oxygen delivered in a high-pressure chamber). Neurological DCS, the "chokes," and skin bends with mottled or marbled skin lesions (see Table 1) should always be treated with hyperbaric oxygenation. These conditions are very serious and potentially fatal if untreated.

Effects of breathing pure oxygen

Breathing pure oxygen to remove nitrogen from the bloodstreamOne of the most significant breakthroughs in altitude DCS research was oxygen pre-breathing. Breathing pure oxygen before exposure to a low-barometric pressure decreases the risk of developing altitude DCS. Oxygen pre-breathing promotes the elimination or washout of nitrogen from body tissues. Pre-breathing pure oxygen for 30 minutes before starting ascent to altitude reduces the risk of altitude DCS for short exposures (10 to 30 minutes only) to altitudes between 18,000 and 43,000 feet. However, oxygen pre-breathing has to be continued without interruption with in-flight, pure oxygen to provide effective protection against altitude DCS. Furthermore, it is very important to understand that breathing pure oxygen only during flight (ascent, en route, descent) does not decrease the risk of altitude DCS, and should not be used instead of oxygen pre-breathing.

Although pure oxygen pre-breathing is an effective method to protect against altitude DCS, it is logistically complicated and expensive for the protection of civil aviation flyers, either commercial or private. Therefore, it is only used now by military flight crews and astronauts for their protection during high altitude and space operations.


Scuba diving before flying
The rule about decompression sickness risk on ascending to lower surrounding pressure, does not stop at sea level (even though decompression tables stop at sea level), but continues when a diver soon after diving goes into air pressure much less than at sea level. Altitude DCS can occur during exposure to altitudes as low as 5,000 feet or less. This can happen:

In an airliner at high altitude the cabin pressure is usually not at full sea level pressure, but like the air pressure at say 8000 feet altitude.
At high altitudes on land: e.g. if you scuba dive in Eritrea, and then go onto the Asmara plateau (where Eritrea's main airport is), which is about 8000 feet or 1.5 miles or 2400 meters above sea level.
Occasionally in cave diving, "Torricellian chambers" are found; they are full of water at less than atmospheric pressure. They arise when the water level drops and there is no way for air to get into the chamber.

Decompression Surgery

Alexthymia

Alexithymia (pronounced: /ˌeɪlɛksəˈθaɪmiə/) from the Greek words λεξις and θυμος (literally "without words for emotions") is a term coined by Peter Sifneos in 1973 to describe people who appeared to have deficiencies in understanding, processing, or describing their emotions.

Classification
Alexithymia describes "people who have difficulties recognizing, processing, and regulating emotions". It is a personality trait that places individuals at risk for other medical and psychiatric disorders while reducing the likelihood that these individuals will respond to conventional treatments for the other conditions. Alexithymia is not classified as a mental disorder in the DSM IV. It is a personality trait that varies in severity from person to person. A person's alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ)[or the Observer Alexithymia Scale (OAS).

Alexithymia is is defined by:

(i) difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal
(ii) difficulty describing feelings to other people
(iii) constricted imaginal processes, as evidenced by a paucity of fantasies
(iv) a stimulus-bound, externally oriented cognitive style.
In studies of the general population the degree of alexithymia was found to be influenced by age, but not by gender; the rates of alexithymia in healthy controls have been found at 8.3% (2 of 24 persons) 4.7% (2 of 43), 8.9% (16 of 179), and 7% (4 of 56). Thus, several studies have reported that the prevalence rate of alexithymia is less than 10% in healthy controls.

In another study, alexithymia was found to be approximately 13% of the population, with men (17%) almost twice as likely to be affected as women (10%). Specifically, men scored higher in difficulty describing feelings and for externally oriented thinking, but there was no gender difference whatsoever in difficulty in identifying feelings. The alexithymia construct is strongly inversely related to the concepts of psychological mindedness and emotional intelligence and M. Bagby and G. Taylor state that there is there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress". Other opinions differ and can show evidence that it may be state-dependent.

Objections have been raised to the methodology used, in particular that studies have been applied to clinical populations without correcting for the prevalence of depression in those populations.

Bagby and Taylor also suggest that there may be two kinds of alexithymia, 'primary alexithymia' which is an enduring psychological trait which does not alter over time, and 'secondary alexithymia' which is state dependent and disappears after the evoking stressful situation has changed. These two manifestations of alexithymia are otherwise called 'trait' or 'state' alexithymia.

Typical deficiencies may include problems identifying, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal. Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterizes alexithymia.

Some alexithymic individuals may appear to contradict the above mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings.

According to Henry Krystal, individuals suffering from alexithymia think in an operative way and may appear to be superadjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as the patients tends to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals lack imagination, intuition, empathy, and drive-fulfillment fantasy, especially in relation to objects. Instead, they seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy.

A common misconception about alexithymia is that victims of this construct are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as "happy" or "unhappy" when describing these feelings.[20] The core issue is that alexithymics have poorly differentiated emotions limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others that is typical of the alexithymic's experience.

Relational issues
According to Vanheule, Desmet and Meganck (2006) alexithymia creates interpersonal problems because these individuals avoid emotionally close relationships, or that if they do form relationships with others they tend to position themselves as either dependent or impersonal, "such that the relationship remains superficial." Inadequate differentiation between self and other by alexithymic individuals has been observed by Blaustein & Tuber (1998) and Taylor et al (1997).

In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal problems (IIP-64 which screens for:

(a) Domineering/Controlling, indicating difficulties relinquishing control over others;
(b) Vindictive/Self-Centered behaviour, which describes problems of hostile dominance and the tendency to fight with others;
(c) Cold/Distant behaviour, which refers to low degrees of affection for and connection with others;
(d) Socially Inhibited, which assesses the tendency to feel anxious and avoidant in the presence of others;
(e) Non-Assertiveness, which measures problems in taking initiative in relation to others and coping with social challenges;
(f) Overly Accommodating, which indicates an excess of friendly submissiveness;
(g) Self-Sacrificing, which indicates a tendency to affiliate excessively; and
(h) Intrusive/Needy, which describes problems with friendly dominance.
The study found that alexithymic individuals "had significantly higher scores on all IIP-64 subscales than did the nonclinical sample."

Chaotic interpersonal relations have also been observed by Sifneos. Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively effects relationship satisfaction between couples.

Alexthymia