MAYO CLINIC HEALTH LETTER

Transcription

Reliable Information for a Healthier Life
VOLUME 30
NUMBER 10 OCTOBER 2012
Inside this issue
HEALTH TIPS . . . . . . . . . . . . . . . . . 3
Sickness and grandchild visits.
NEWS AND OUR VIEWS . . . . . . 4
Heart benefit of ‘good’ cholesterol depends on how it occurs.
Closing in on a melanoma skin
cancer vaccine.
DIABETES
COMPLICATIONS . . . . . . . . . . . . . 4
Proactive care a must.
VAGINAL ATROPHY . . . . . . . . . . 6
Managing vaginal dryness and
irritation.
FRACTURED RIB . . . . . . . . . . . . . . . 7
Guarding against complications.
Gallstones
Symptoms usually
mean surgery
Years ago — after you had a test for
something else — your doctor told you
that you had gallstones in your gallbladder. The doctor also said not to
worry about them unless they started
to cause significant pain.
Recently, you’ve had a couple of
unusual attacks of pain in your upper
right abdomen that went away after an
hour or two.
It’s time to see your doctor. And if
you experience another attack in which
the pain is more constant and long
lasting — or includes other symptoms
such as nausea or spreading of pain to
your chest or back — a visit to the
emergency department is warranted.
Gallstones are common and occur
in about 10 to 15 percent of people in
the United States. About 75 percent of
people with gallstones experience no
symptoms and require no treatment,
because the risk of a surgical procedure
is greater than the risk of doing nothing.
However, when pain or other symptoms occur, there’s about a 70 percent
chance that they’ll occur again within
two years — and in some cases these
attacks can lead to life-threatening
complications.
That’s why, when symptoms occur,
surgery to remove the gallbladder is
typically performed. In fact, gallbladder
removal is one of the most common
surgical procedures performed in the
United States. ➧
SECOND OPINION . . . . . . . . . . . 8
Coming in November
MENISCUS TEARS
Knee pain isn’t a given.
COSMETIC SURGERY
Common options for older adults.
DENTURE CARE
A daily task.
OSTEOPOROSIS DRUGS
Current and future options.
When your gallbladder contracts to expel bile, some of the stones may be carried along
with the fluid and migrate to the outlet of the gallbladder leading to the bile duct. There,
they can block the outlet of the gallbladder, causing a gallbladder attack.
Digestive organ
Your gallbladder is a small, pearshaped sac tucked under your liver on
the right side of your upper abdomen.
It’s part of the biliary system, which
creates, stores and transports bile — a
digestive fluid that helps break down
fats and also helps pass waste and
cholesterol from the body.
Bile is produced in your liver and
drains through bile ducts to your gallbladder. The gallbladder serves as a
reservoir for bile. When you consume
foods containing fat or protein, the gallbladder contracts and empties the bile
it contains through bile ducts that lead
to the small intestine.
Preventing gallstones
Some risk factors for gallstone
development — such as being
female or having a family history
of stones — can’t be controlled.
However, you may be able to
reduce your risk of developing
gallstones with:
■ Regular exercise and physical
activity. In one study involving
women, this was associated with
about a 40 percent reduced risk
of gallstone development.
■ Maintaining a healthy weight,
because obesity is a key risk
factor for gallstone development.
■ Avoiding extreme diets that
involve low intake of calories and
rapid weight loss. Occasionally,
your doctor may prescribe a
medication, such as ursodiol, to
offset the increased risk associated with rapid weight loss, such
as may occur if you have undergone weight-loss surgery.
■ Long-term use of cholesterollowering drugs called statins.
These aren’t recommended s olely
for gallstone prevention, but gallstone prevention may be an additional benefit of taking them for
another reason.
2
www.HealthLetter.MayoClinic.com
When bile becomes chemically
imbalanced, it forms into hardened
particles. These can grow into stones
as small as a grain of sand or as large
as a golf ball. Some people may develop
just one stone, while others may
develop several stones or even hundreds or thousands of tiny stones that
are sometimes referred to as sludge.
Stone types
Many factors may contribute to
gallstone formation, some of which
aren’t well understood. One is too
much cholesterol in the bile. Normally,
your bile contains enough chemicals
to dissolve the cholesterol excreted by
your liver.
However, if bile contains more cholesterol than can be dissolved, the extra
cholesterol can form into stones. Also,
when the gallbladder isn’t contracting
and emptying as it should, bile stays in
the gallbladder and becomes too concentrated. This concentrated bile can
then become sludgy and form stones.
Either cause can lead to the formation
of cholesterol stones, which account
for about 80 percent of gallstones
diagnosed in the United States.
Factors that increase risk of cholesterol gallstones because of too much
cholesterol in the bile or improper gallbladder emptying — or both — i nclude:
■ Being female, because estrogen —
whether it’s natural estrogen or estrogen-containing medications — causes
more cholesterol to be excreted in bile
■ Being overweight or obese
■ Older age
■ Consuming a diet high in fat and
cholesterol and low in fiber
■Pregnancy
■ Rapid weight loss such as with
crash diets
■ A family history of gallstones
■ Being an American Indian or Mexican-American
■ Having diabetes
A second, less common type of gallstone (pigment stone) forms when bile
contains too much of a waste product
called bilirubin (bil-ih-ROO-bin). People
October 2012
with blood disorders and severe liver
diseases are most likely to get this type
of stone.
Gallstone attack
Gallstones usually settle at the
bottom of your gallbladder. Most of the
time they don’t cause problems. Many
people don’t even know they have them,
and they don’t require any treatment.
However, when your gallbladder
contracts to expel bile, some of the
stones may be carried along with the
fluid and migrate to the outlet of the
gallbladder. There, they can block the
outlet of the gallbladder.
The blockage causes the symptoms
of a gallbladder attack, such as sudden
moderate to severe pain in the upper
right abdomen, between the shoulder
blades or under the right shoulder.
Managing Editor
Aleta Capelle
Medical Editor
Robert Sheeler, M.D.
Associate Editors
Carol Gunderson
Joey Keillor
Associate Medical Editor
Amindra Arora, M.B.,
B.Chir.
Medical Illustration
Michael King
Editorial Research
Deirdre Herman
Customer Service Manager
Ann Allen
Proofreading
Miranda Attlesey
Donna Hanson
Julie Maas
Administrative Assistant
Beverly Steele
EDITORIAL BOARD
Shreyasee Amin, M.D., Rheumatology; Amindra
Arora, M.B., B.Chir., Gastroenterology and Hepatology;
Brent Bauer, M.D., Internal Medicine; Julie Bjoraker,
M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D.,
Pharmacy; Bart Clarke, M.D., Endocrinology and
Metabolism; William Cliby, M.D., Gynecologic
Surgery; Clayton Cowl, M.D., Pulmonary and Critical
Care; Mark Davis, M.D., Dermatology; Michael
Halasy, P.A.-C., Emergency Medicine; Timothy
Moynihan, M.D., Oncology; Suzanne Norby, M.D.,
Nephrology; Norman Rasmussen, Ed.D., Psychology;
Daniel Roberts, M.D., Hospital Internal Medicine;
Robert Sheeler, M.D., Family Medicine; Phillip
Sheridan, D.D.S., Periodontics; Peter Southorn, M.D.,
Anesthesiology; Ronald Swee, M.D., Radiology;
Farris Timimi, M.D., Cardiology; Matthew Tollefson,
M.D., Urology; Debra Zillmer, M.D., Orthopedics;
Aleta Capelle, Health Information. Ex officio: Carol
Gunderson, Joey Keillor.
Mayo Clinic Health Letter (ISSN 0741-6245) is
published monthly by Mayo Foundation for Medical
Education and Research, a subsidiary of Mayo
Foundation, 200 First St. SW, Rochester, MN 55905.
Subscription price is $29.55 a year, which includes a
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Stones that block the gallbladder
outlet usually drop back down into the
gallbladder, typically ending the gallbladder attack. However, a gallstone
may become lodged farther down the
bile duct and not dislodge. This may
block not only the gallbladder, but also
the bile ducts leading from the liver and
the pancreas.
When the blockage lasts for several
hours, the gallbladder or pancreas may
become inflamed and bile flow from
the liver may be blocked. Signs and
symptoms may worsen and include:
■ High fever and chills
■ Yellowing of your skin and the whites
of your eyes (jaundice) and itching
■ Dark-colored urine
■ Pale-colored stools
These signs and symptoms warrant
immediate medical attention.
Finding stones
In a nonemergency setting, ultrasound imaging is the most common way
to diagnose gallstones. However, it’s
usually not as effective at determining
if a stone has passed into a bile duct.
If a stone is suspected, additional
testing may include blood tests to detect
infection, jaundice or inflammation of
the pancreas. An X-ray dye may be injected directly into the bile duct from
an endoscope tube that’s passed down
the throat, through the stomach and to
the bile duct opening in the small
Gallbladder removal surgery is often performed through several small incisions in
your abdomen through which a tiny camera and surgical instruments are passed.
intestine. An X-ray image can reveal if a
stone is blocking the bile duct. If a stone
is found, it can usually be removed using
tools attached to the endoscope.
Treatment options
If you’ve had one or more gallbladder attacks, your doctor will probably
recommend surgery to remove your
gallbladder. Your gallbladder isn’t an
essential organ, and new stones usually
form if just the stones are removed or
dissolved away with medication.
Gallbladder removal surgery is
often performed laparoscopically. This
means that it’s performed through several small incisions in your abdomen
through which a tiny camera and surgical instruments are passed to remove
the organ. Laparoscopic surgery may
require a brief stay in the hospital.
You’ll likely be able to return to normal
activities within a few days.
Open surgery to remove the gallbladder requires larger incisions — including cutting through abdominal
muscles. This procedure generally requires several days in the hospital and
several weeks of recovery. Open surgery is only occasionally used, but it
may be the best choice for cases in
which the gallbladder is severely inflamed or infected, or if there’s scarring
from previous surgery.
Complications are possible with
both laparoscopic and open surgeries.
Recovery is usually quicker after laparoscopic surgery. Certain complications — though rare — are more common after laparoscopic surgery.
Life without a gallbladder
After gallbladder removal, your
liver still produces enough bile to digest
food from a normal diet. Instead of
being stored in your gallbladder, bile
flows out of the liver and empties
directly into the small intestine.
With bile flowing more frequently
into your small intestine, you may
experience a greater number of bowel
movements and stools may be softer.
Often, these changes are temporary. ❒
October 2012
Health tips
Sickness and
grandchild visits
Visits with your grandkids are
great, but it’s not so great when you
catch an illness from them. Minimize your risk of getting sick:
■ Postpone a visit — Avoid visiting when a child has a contagious
or severe illness, such as the flu or
pneumonia, or if the child is vomiting. If the child has a fever or has
just started coughing, the illness is
likely contagious.
■ Practice hand hygiene — Frequently wash your hands with
warm soap and water, or use an
alcohol-based hand sanitizer.
■ Avoid kisses and face-to-face
hugs — Save your love and affection — or rough-and-tumble play
— for a visit when the child is
feeling better.
■ Try not to touch your eyes,
nose and mouth — Avoid touching your face unless you’ve just
washed or sanitized your hands.
Avoid having your grandchildren
touch these areas, as well.
■ Remind your grandchildren
about good hygiene — This may
include reminding them to cough
or sneeze into a tissue or crook
of the elbow, or how to properly
wash hands.
■ Don’t share — Don’t drink
from the same glass or soda can
as your grandchildren, and don’t
share eating utensils.
■ Be healthy — Try to arrive
well rested and stay well rested.
■ Keep vaccines up to date —
Make sure that you and your
grandchildren are up to date with
vaccines, particularly vaccines for
pertussis, seasonal influenza and
pneumonia. ❒
3
News and our views
Heart benefit of ‘good’ cholesterol depends on how it occurs
There’s a reason why high-density lipoprotein (HDL) cholesterol is called
“good.” It’s long appeared that higher HDL levels corresponded to cardiovascular health and reduced risk of heart attack.
However, new research shows that raising HDL without making HDLincreasing lifestyle changes may have no cardiovascular benefit. A large
study, published in the journal The Lancet, looked at genetic variables of
participants in numerous studies, measuring incidence of heart attack.
Researchers were able to identify several thousand study participants
who had a gene variant that increases HDL cholesterol levels — without
affecting other risk factors for heart attack. But within this group with e levated
HDL, they found no reduction in heart attack risk.
Another large study examined the effect on heart attack risk of prescription-strength niacin — a B vitamin that can help raise HDL cholesterol.
Participants were at high risk of heart attack and had their low-density
lipoprotein (LDL), or “bad,” cholesterol levels controlled by a statin drug.
This study looked at whether raising HDL with niacin further reduced heart
attack risk. It didn’t, and the study was stopped early.
With reductions in LDL cholesterol, no matter how it’s achieved, there’s
a reduction in heart attack risk. HDL cholesterol doesn’t appear to work the
same way. Lifestyle factors that increase HDL cholesterol do indeed reduce
the risk of heart attack and cardiovascular disease. Raising HDL cholesterol
by other means has yet to be proved to reduce heart attack risk.
Mayo experts say that recent research further emphasizes that in addition
to controlling your LDL cholesterol level, changes in lifestyle — such as
increased exercise, eating a healthier diet and maintaining a healthy weight
— are among the most powerful steps that you can take to improve cardiovascular health and reduce your risk of heart attack. ❒
Closing in on a melanoma skin cancer vaccine
Mayo Clinic researchers are leading a novel approach to develop a skin cancer
vaccine that capitalizes on the body’s natural defender, the immune system.
The experimental vaccine uses an ancient cousin of the rabies virus — called
vesicular stomatitis virus (VSV). The virus has been genetically engineered to
deliver a broad spectrum of human DNA obtained from melanoma skin c ancer
cells directly to the lymph nodes, where immune cells congregate.
It’s a strategy called cancer immunotherapy, and early studies have produced encouraging results. The latest study involving this experimental vaccine appeared in the April 2012 issue of the journal Nature Biotechnology.
Tumor cells tend to mutate over time, making it difficult for the immune
system to identify them as enemies and fight them off. However, the immune
system is fine-tuned to identify and target viral invaders such as VSV. Combining
VSV with the whole array of a melanoma cancer cell’s DNA appears to make
melanoma much more visible and vulnerable to the immune system.
Mayo Clinic doctors say that recent results show that boosting the immune
system of people with melanoma appears beneficial. While this new vaccine
therapy is exciting, it will be many years before this is ready for human
clinical trials. ❒
4
October 2012
Diabetes
complications
Proactive care a must
If you’re one of the millions of Americans living with diabetes, you already
know that it takes regular attention on
your part to keep your blood sugar (glucose) levels under control.
Diabetes means that your blood
glucose levels are too high — and without proper management, prolonged
episodes of elevated glucose levels can
cause widespread organ damage and
serious complications. Those complications are directly related to the
changes that occur in the body’s larger
and smaller blood vessels after exposure to high glucose concentrations.
That’s why it’s imperative to approach
diabetes care proactively.
Glucose monitoring — including
periodic hemoglobin A1C blood tests
that reflect your average glucose level
during an approximately three-month
period — is a vital component in diabetes management. (See “Second opinion,” Page 8).
Because diabetes multiplies the
risks of complications, it’s equally important to control your blood pressure
and cholesterol levels together with
your blood glucose to lower your risk
of heart attack, stroke and related complications. Risk factors for these complications are commonly treated more
aggressively than would be the case if
you didn’t have diabetes.
Complicating factors
Complications related to diabetes
can be insidious, occurring even before
you know you have diabetes. Among
the complicating factors you may need
to address with your doctor’s guidance
and help are:
■ Heart and blood vessel disease —
Heart attack and stroke are the leading
causes of death for people who have
diabetes.
If you smoke, stopping smoking is
one of the most important steps you
can take for your vascular health and
long-term survival. Discuss with your
doctor the ways in which you can pursue smoking cessation.
High blood pressure also can
damage blood vessels. That’s why keeping your blood pressure under control
is so important. Lifestyle changes may
help, including loss of excess weight,
increased physical activity and a hearthealthy diet that reduces sodium.
If drug therapy is necessary, it’s
generally recommended that either an
angiotensin-converting enzyme (ACE)
inhibitor or an angiotensin II receptor
blocker (ARB) be included. Each also
offers potential protection for diabetesrelated kidney complications. The benefit of low-dose aspirin is less certain
and best discussed with your doctor.
Elevated blood fats also can damage blood vessels. The combination of
high levels of low-density lipoprotein
(LDL), or “bad,” cholesterol, low levels
of high-density lipoprotein (HDL), or
“good,” cholesterol and high triglycerides accelerates fatty plaque buildup in
arteries (atherosclerosis). These changes can contribute to heart attack and
stroke risk and poor circulation in the
legs and feet (peripheral artery disease).
Lifestyle changes previously mentioned along with lipid-lowering statin
drug therapy are generally recommended. For most people, the target goal for
LDL is below 100 milligrams per deciliter (mg/dL), although that target may
be lower for some.
■ Kidney disease (nephropathy) —
Diabetes is the most common cause of
kidney failure. While the progression
to kidney disease can be slow, careful
management of blood glucose levels
and high blood pressure can give your
kidneys a better chance of remaining
functional longer.
ACE inhibitors and ARBs used to
treat high blood pressure are known to
delay worsening of nephropathy.
■ Eye damage (diabetic retinopathy)
— The back part of your eye — called
the retina — is nourished by many tiny
blood vessels. These are among the first
blood vessels damaged by high blood
glucose. High blood pressure also contributes to this damage, which happens
slowly over years.
The potential risk with diabetic
retinopathy is loss of sight or even blindness if the retina becomes d
etached and
isn’t treated promptly. Reducing the
risk or slowing progression of diabetic
retinopathy is best done with careful
blood glucose control and blood pressure control.
■ Nerve damage (diabetic neuropathy) — This complication is associated
with unmanaged high blood glucose.
Damage generally occurs slowly and
over a number of years.
Usually, the sensory nerves are
affected, typically in the legs, beginning
at the tips of the toes. Sensory nerves
detect sensations such as pain, warmth,
coolness and texture. Damage may
produce sensations that are often mild
and may include tingling, numbness,
burning and stabbing pain. For some,
the sensations are painful and d
isabling.
Nonprescription pain relievers may
help, or for more severe pain your
doctor may prescribe medications that
reduce nerve pain. (See our October
2011 article, “Peripheral neuropathy.”)
■ Foot wounds — Over time, nerve
damage can cause loss of sensation in
your feet, putting you at greater risk of
unnoticed foot injuries, such as a simple blister or cut. In addition, wounds
tend to heal more slowly due to changes
in blood flow to the feet. As a result, a
small injury can develop into an open
sore (ulcer) that’s difficult to treat.
Carefully looking over your feet
each day may prevent bigger problems.
Your doctor may refer you to a diabetic foot care expert, such as a podiatrist, nurse or diabetes foot clinic.
Clinical evidence indicates people
with diabetes have an increased susceptibility to infections. The greater frequency of infections is tied to the effects
of high blood sugar on the immune
system’s ability to function properly.
October 2012
Age and hypoglycemia
Age itself can be a complicating
factor. While careful control of blood
glucose levels is important, adults older
than 65 may need to work closely with
their doctors to moderate blood glucose (glycemic) targets in order to avoid
episodes of blood glucose becoming
too low (hypoglycemia).
For some older adults, h
ypoglycemia
can be a tipping point. Hypoglycemia
may set off a dangerous irregular heart
rhythm in someone who already has
known heart concerns. Dizziness and
lightheadedness associated with hypoglycemia may lead to falls and possibly
bone fractures.
More importantly, hypoglycemia can
lead to stroke, impaired cognitive function and even death. For this reason —
especially in older adults and those who
live alone — the risk of high blood
sugar over time has to be balanced with
these life-threatening risks from low
blood sugar.
Sometimes, for these people, diabetes
can be less tightly controlled in order to
avoid the risks of these potentially devastating complications.
Diabetes treatment choices are
highly individualized. That’s why it’s
important to work closely with your
doctor to determine glycemic targets
and treatment goals and to develop a
plan to prevent complications.
In older adults, the focus is generally on drug safety, particularly when
it comes to protecting against hypoglycemia, heart failure, kidney failure,
bone fractures and possible interactions
when taking multiple medications.
Proactive management of diabetes
complications is in large part dependent on self-care. Self-care, in turn, is
related to your mood and your motivational level.
Remaining motivated and in a
positive mindset can be helped by

having an occasional and brief session
with a behavioral health counselor.
Most primary care clinics usually have
behavioral health counselors available
on their health care teams. ❒
5
Vaginal
atrophy
Managing vaginal dryness
and irritation
Like most women, you probably
expected menopause to cause some
changes in your body. You might not
have been prepared, however, for
vaginal itching, urinary incontinence
or discomfort during intercourse — all
symptoms of vaginal atrophy.
Vaginal atrophy (atrophic vaginitis)
is the thinning and inflammation of the
vaginal walls and lower urinary tract
due to a lack of estrogen. The condition
typically occurs in menopausal women.
By some estimates, about half of postmenopausal women experience vaginal atrophy. Though few women seek
help, there are a number of treatment
options for vaginal atrophy that can
offer relief.
Understanding estrogen
If you have vaginal atrophy, lower
levels of estrogen make your vaginal
tissues thinner, drier, less elastic and
more fragile. The condition can develop
anytime your estrogen production
declines, including the years leading
up to and after menopause, after childbirth, during breast-feeding, after the
surgical removal of both ovaries, after
pelvic radiation or chemotherapy for
cancer, or as a side effect of breast
cancer hormonal treatment.
The symptoms of vaginal atrophy
can vary from moderate to severe.
Vaginal symptoms might include
dryness, burning, discomfort during

intercourse and light bleeding after
intercourse. Burning with urination,

urgency with urination, urinary incontinence and more-frequent urinary tract
infections also might occur. The thinning of the vaginal walls and changes
in the acidity of the vagina caused by
vaginal atrophy also can increase your
risk of vaginal infections.
6
Symptoms of vaginal atrophy might
be more intense if you smoke, if you’ve
stopped having intercourse for a prolonged time and resume it again, if
you’ve had vaginal surgery, or if you’ve
never given birth vaginally.
Is it vaginal atrophy?
Diagnosis of vaginal atrophy generally includes:
■ Pelvic exam — Your doctor will
examine your pelvic organs and external genitalia, vagina, and cervix. Your
doctor may collect a sample of cervical
cells for microscopic examination. He
or she may also take a sample of your
vaginal secretions for analysis or place
a paper indicator strip in your vagina
to test its acidity.
■ Urinalysis — If you have urinary
symptoms, you’ll need to provide a
urine sample for analysis to rule out
any other possible conditions, such as
a urinary tract infection.
Treatment choices
If you’re experiencing mild vaginal
dryness or irritation, regularly applying
a nonprescription vaginal moisturizer
(Me Again, Replens, Silk-E, others) can
restore some moisture to your vaginal
area. A nonprescription water-based
lubricant (Astroglide, K-Y, others) also
can reduce friction and discomfort during intercourse. Try different products
to find a treatment that suits your needs.
If you use condoms or a diaphragm,
avoid oil-based products, which can
damage these types of contraceptives.
Sexual activity — either with or
without a partner — also can ease the
symptoms associated with vaginal atrophy. This is likely a result of enhanced
blood flow to your vagina, which helps
keep vaginal tissues healthy. If vaginal
intercourse is painful, give yourself
plenty of time to feel aroused.
For moderate or severe symptoms,
topical (vaginal) or systemic (oral,
transdermal or higher dose vaginal
application) estrogen can relieve vaginal dryness and itchiness and improve
vaginal elasticity. However, your docOctober 2012
tor might caution against use of
systemic estrogen if you have a history
of breast cancer or other hormonally
sensitive cancers.
If estrogen therapy is an option for
you, expect noticeable improvements
after a few weeks of use. Severe symptoms might take months to improve.
Side effects of estrogen therapy, while
uncommon, might include vaginal
bleeding or spotting or breast tenderness. Hormone therapy can also cause
nausea, bloating, headaches, dizziness
and mood changes. Ask your doctor
what to expect.
Estrogen options
Topical estrogen is more effective
than systemic estrogen at treating vaginal
atrophy and limiting your overall exposure to estrogen. Estrogen applied to the
vagina can still result in estrogen reaching
your bloodstream, but the amount is
significantly lower than with systemic
estrogen treatment. Vaginal estrogen

therapy comes in several forms, including:
■ Vaginal estrogen cream — This type
of cream (Estrace, Premarin) is inserted
directly into the vagina with an applicator — typically daily for the first two
weeks and then twice a week thereafter.
■ Vaginal estrogen ring — You or your
doctor will insert a soft, flexible ring
(Estring) into the upper part of your
vagina. The ring releases a consistent
low dose of estrogen. It will need to be
replaced every three months.
■ Vaginal estrogen tablet — You’ll use
a disposable applicator to place a
vaginal estrogen tablet (Vagifem) in your
vagina — typically daily for the first two
weeks and then twice a week thereafter.
Talk to your doctor
If you experience vaginal dryness
along with other symptoms of menopause — such as moderate or severe
hot flashes — your doctor might suggest estrogen pills, patches or gel, or a
vaginal estrogen ring. Talk to your doctor to decide if hormone treatment is
an option and, if so, which type is best
for your circumstances. ❒
Fractured rib
Guarding against
complications
It was that slip on the stairs that caused
you to bump your ribs on the railing.
That led to a painful injury on your rib
cage that your doctor confirmed is a rib
fracture.
Your doctor said that unlike other
types of fractures, there isn’t anything
that can be done to treat the rib. Still,
your doctor ordered numerous tests to
rule out other underlying injuries.
Your doctor was right. Usually,
nothing that can be done for a fractured
rib that isn’t moved out of normal
position and alignment (displaced).

Treatment is usually limited to providing
adequate pain control, avoiding strenuous activities and letting it heal. Use
of an incentive spirometer also may be
recommended to enhance lung function and help prevent pneumonia.
Complications of rib fractures can
be serious. One study of older adults
found that about 19 percent of those
who sustained a fracture of three to four
ribs ended up dying from complications.
Major trauma
Rib fractures are one of the most
common types of fracture in older
adults. In one study that looked at
causes of rib fracture in older adults,
about 25 percent of fractures were
caused by major trauma such as a car
accident. These account for the mostsevere injuries, where multiple ribs are
fractured, and when fractured bone
ends are displaced.
Displaced bones can cause many
serious, life-threatening complications,
including punctures of the lungs, lung
bruising and swelling, bleeding into or
around the lungs, and damage to critical blood vessels or organs such as the
liver, kidney or spleen. Emergency care
is appropriate in most cases of major
trauma and for anyone with three or
more fractured or displaced ribs.
More-common causes
The study on rib fracture causes also
found that about one-third of the rib fracture causes were due to moderate trauma
such as falling from a standing height.
For about 40 percent of the fractures
in the study, there was no identifiable
trauma that caused the fracture, which
means that nontraumatic events such
as the repeated stress of a coughing
spell or swinging a golf club may have
caused it. This may be more likely to
occur in someone with weakened
bones due to osteoporosis. A tiny
percentage of fractures had a direct
pathological cause, such as a cancer
that had spread to rib bones.
Rib fractures that are the result of
mild to moderate trauma or repeated
stress on the bone are usually less severe initially, but can be very painful.
Pain often occurs when you take a deep
breath. It’s often possible to isolate a
spot on the bone that hurts to the touch
or that hurts when you bend or twist.
Serious complications requiring
prompt medical intervention — such
as lung bruising and swelling, bleeding
into or around the lungs, or a collapsed
lung — can occur after rib fracture due
to minor to moderate trauma. Such
complications may require insertion of
a chest tube or other surgery, blood
transfusion, and artificial ventilation.
Emergency care may be indicated
if you have:
■Lightheadedness
■ Shortness of breath
■ Significant chest pain, particularly
if it’s worsening
Even if a suspected fractured rib
doesn’t require emergency care, it’s still
important to see your family doctor for
diagnosis and possible treatment.
occurring in roughly 30 to 35 percent
of adults age 65 and older.
Pain control may include nonprescription drugs such as acetaminophen
(Tylenol, others), ibuprofen (Advil,
Motrin IB, others) and naproxen (Aleve).
If these aren’t enough, your doctor
may prescribe stronger medications.
For severe fractures, regional anesthesia may be considered.
Most nondisplaced rib fractures
heal within six weeks. Although pain
will gradually subside over this time,
you’re likely to experience some bouts
of pain because it’s hard to totally avoid
jostling the healing rib. You can often
return to your daily activities in less
than six weeks. However, for stresstype rib fractures, it may be best to
avoid for a longer time the activity that
led to the stress fracture. ❒
Pain control is critical
Controlling pain of a rib fracture is
critical so that you can breathe deeply
and cough. When pain prevents you
from doing this, the risk of developing
pneumonia rises. In fact, pneumonia is
the most prevalent and serious complication of rib fractures in older adults,
October 2012
7
Second opinion
Q
I was recently diagnosed with
type 2 diabetes and am getting
used to doing daily blood sugar tests
and logging my results. Why does my
doctor want to do a blood sugar test
called A1C every few months, too?
A
Monitoring blood sugar (glucose)
levels in your bloodstream is a
critical part of keeping your diabetes
under control — but on its own, daily
glucose testing isn’t enough. It can only
capture your glucose level at one
particular instant. The A1C blood test
reflects your average glucose level for
the past three months. After a diabetes
diagnosis, A1C provides a gauge of
how well your diabetes treatment plan
is working over a span of time. The
higher your A1C level, the poorer your
glucose control.
The A1C test measures what
percentage of hemoglobin — which is
a protein in red blood cells responsible
for carrying oxygen — is coated with
sugar. When diabetes is uncontrolled,
there’s too much glucose in your blood.
That extra glucose links up with hemoglobin and continues to c irculate for
the life of a red blood cell, which is
typically about 120 days.
An A1C level of 6.5 percent or
higher on two separate tests indicates
the presence of diabetes. For most
people diagnosed with diabetes, an
A1C level of 7 percent or lower is a
common treatment target, but the target
may be somewhat higher for some.
Careful management of blood
glucose levels is necessary to minimize
diabetes complications, such as damage to kidneys, eyes, nerves and the
cardiovascular system. The combination
of home glucose monitoring and A1C
testing allows you to work with your
doctor on targeted goals and, when
needed, to make adjustments to your
treatment plan to control your diabetes
— whether that’s changes in lifestyle
or medications. ❒
Q
I was diagnosed with heart
failure earlier in the year. I’ve
taken steps to manage the problem.
The disease is stable and I feel good.
Still, I’m wondering if I should skip our
annual ski vacation to Colorado due
to the high elevation?
A
Your concern is justified, and it’s
best to make a final decision after
talking with your doctor.
Traveling to the thinner air of high
elevations — and exercising — puts
extra stress on the heart and cardiovascular system that wouldn’t be experienced at lower elevations. Cold w
eather
can add even more stress. This can
cause problems for anyone — and can
be especially concerning for people
with heart failure or other problems,
such as a history of heart attack, angina,
bypass surgery or high blood pressure.
Up to about 6,500 feet (2,000
meters), people with stable heart

conditions are unlikely to experience
altitude-related problems if they’re
performing activities of similar intensity and duration as performed at
lower altitudes.
Between 6,500 feet and about
9,800 feet (3,000 meters), health
concerns begin to mount. Activity at
these elevations can be generally
tolerated in those with stable heart
conditions. However, it’s wise to take
precautions, including:
■ Ascending slowly — such as by
spending a day or two at around 6,000
to 7,000 feet — to allow the body to
acclimatize.
■ Restricting activity on the first day
or two after arrival at your destination
to allow for further acclimatization.
■ Generally exercising at an easier
effort than you would at lower elevations.
Symptoms that come on with exercise,
such as those of chest pain (angina) or
heart failure, may come on earlier at
higher elevations than they would at
lower elevations.
■ Staying hydrated and avoiding
alcohol.
Travel or activity above 9,800 feet
isn’t necessarily forbidden for those
with stable heart conditions, but should
be done only with approval from a
doctor after a thorough evaluation. ❒
Have a question or comment?
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October 2012
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