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Medical Reducing
menopausal difficulties
'To
take estrogen or not to take estrogen.' The subject has stimulated
so much debate that women approaching menopause are unsure of what
action to take in view of the contradictory information available.
While some studies show that this potent hormone can ward off many
age-related ailments, it also suggests the increase in chances of
getting breast cancer. When women
reach the age of 45 - 50, their ovaries gradually produce lower
levels of estrogen before stopping altogether. It is the last stage
of a biological process, a transition between a woman's childbearing
years and her non-childbearing years called menopause. Women who
have had surgery to remove both their ovaries experience surgical
menopause, when hormone production and menstruation stop immediately.
Estrogen and
other female sex hormones such as progesterone and testosterone
are involved in the development and maintenance of secondary sex
characteristics such as breasts and affect many aspects of women's
physical and emotional health. According to
Prof. Harsha Seneviratne, "Estrogen is a hormone that makes
women what they are. Manufactured primarily by the ovaries, it is
a natural hormone that develops female characteristics such as voice,
skin texture, genital tracts and the female psyche itself. Women
tend to lose all those when they stop producing estrogen." At this point,
most women experience menopausal symptoms such as hot flashes, night
sweats, insomnia, irritation, anxiety, forgetfulness, depression
and lack of concentration. There are other signs too. All of a sudden
women seem to develop high cholesterol, high blood pressure or osteoporosis.
A couple of decades ago, women suffered these symptoms in silence
and accepted them as part of life or the ageing process. "It
did not matter those days when life expectancy was around 55 years
for a woman. Life expectancy for an average Sri Lankan woman now
is 74 years," Prof. Seneviratne says. "With
one third of her life ahead of her, a woman is capable of doing
many things. By taking HRT, she can be assured of a better quality
of life," says Dr. Ranjith Almeida (gynaecologist) who practises
at Asha Central Hospital and Castle Street Hospital. "Modern
day women need not resign themselves to this when there is a remedy
available." Menopausal
symptoms cause much agony. Even with the A.C. on, women break out
in a cold sweat, experience hot flushes and suffer from various
vaginal infections. Many also suffer from back pain. From a simple
fall or the smallest impact, women are known to break bones. Emotional health
is also affected. Acute mood swings, lack of energy, fatigue and
depression are common. Metabolism changes and slows down. They can
just look at food and put on weight and are also more prone to heart
attacks. "People
on insulin cannot do without it. Similarly, the lack of estrogen
can cause much distress and therefore needs to be replaced,"
explains Dr. Seneviratne. Today, gynaecologists in Sri Lanka recommend
Hormone Replacement Therapy (HRT) for women suffering from severe
symptoms of menopause. "They can benefit from the replacement
of these female hormones." "The obvious
repercussions of not taking estrogen on a short-term basis are hot
flushes, profuse sweating and an effect on brain functions (depression,
anxiety, etc.) which can be very distressing, although they may
not apply to all. On a long term basis, bones lose their calcium
and no amount of calcium intake can replace the loss. This may lead
to hip fracture, bent spine (hunch), spine fracture, etc. Further,
all pelvic organs and support ligaments are dependent on estrogen
for integrity and activity. These include the female genital tract
and urinary system. Women with cholesterol are also known to benefit
from estrogen," Dr. Seneviratne continues. What are the
benefits? Estrogen has been proved to be very effective in treating
menopausal symptoms. It can certainly reduce those immediate symptoms
like hot flushes, sleeplessness and vaginal dryness. It may improve
mood and psychological wellbeing in women, their behaviour and sleep
patterns. There are other reports stating that estrogen prevents
memory loss, delays the onset of Alzheimer's disease, prevents colon
and bowel cancer and improves urinary incontinence. HRT involves
treatment with estrogen alone or in combination with progestin.
This compensates for the decrease in natural hormones that occurs
at menopause. Women who have had their uterus removed are given
estrogen alone, whereas women with a uterus take a combination of
estrogen plus progestin. What of the
side-effects? There are thousands of web sites that highlight the
adverse effects - breast cancer, cardiovascular disease, uterine
cancer, etc. These results indicate that the risks of long-term
estrogen with progestin outweigh the benefits. HRT sounds
like a risky proposition. How safe is it? Most gynaecologists think
it is a necessary solution to evade the agonising effects of menopause.
Explaining
that some, possibly because of a healthy lifestyle 'age gracefully'
while others have a traumatic time, Dr. Nalini Prasad, gynaecologist
of Apollo Hospital says, "HRT should be tailormade for women
after balancing the risks and benefits. The risk factor varies from
woman to woman depending on their genetics, the environment they
were brought up in, their lifestyle and family history of health
problems and therefore cannot be generalised." Patients are
counselled and advised of the pros and cons of taking HRT and are
encouraged to take the treatment with a specialist's approval and
under medical supervision. "Cancer
can occur in women who are on HRT. But the incident is only slightly
higher than three in a thousand. We cannot predict it. You can still
get cancer even if you do not take HRT. You may die of high blood
pressure or stroke, you may fall and fracture a bone caused by low
estrogen levels. We know for sure that women who take estrogen,
do not get infarcts," says another gynaecologist. Most drugs
have adverse effects, the gynaecologists say. Even the common aspirin
is known to cause stomach ulcers. The risk of taking HRT however,
can be overcome by regular routine breast examinations or pap smears,
ultra sounds and endometrial biopsy (DNC) once every two years,
thereby detecting any cancer in its earliest stage and commencing
treatment that in most cases can cure a person. On
the floor, on a trolley All distinctions
of social hierarchy blurred into a very facile nonentity as I had
to sleep all three days without a bed, two days on the ward floor
desperately trying to cushion the knocks of my ageing bones on concrete
with a mat provided to all and sundry by a seemingly considerate
yet voluble male attendant. The day spent on a trolley was the biggest
trauma, for, following the CA - just out of the theatre - you were
supposed to stay put without even turning your leg lest the slit
made on your crotch to insert a tube into an artery might open up
by the slightest movement or jerk making you bleed profusely. Lying on your
back on the metal surface of a trolley for nearly 10 hours was agony
for me. Specially since all eight other people, some thirty or thirty-five
year olds among them taken for the same test that day being lucky
enough to get a bed. However, I tremendously enjoyed the camaraderie
among the patients with social ranks merging into nothingness, despite
all difficulties. Having declared
that I would require by-pass surgery, I was sent a day after the
CA to see a surgeon at the OPD. Four of us jostled into an ambulance
by a youthful yet arrogant attendant, we arrived there to wait with
a milling crowd under a low asbestos roof heated like an oven -
ideal conditions for a weak heart patient like me - only to find
that the surgeon had not turned up and only his assistants were
there which meant that you would be put to a ward there until the
day the big man comes. After consulting
the doctor, we sat on the now empty benches as the crowd diminished
with the evening and were waiting for our conveyance when somebody
arrived to call it a day ordering us out and locking up the place.
Now, minus even a bench to slump down on and dead beat too, we,
the four victims of licensed lethargy hung on, resting our haunches
on the brick paving of a building for nearly one hour waiting to
be taken back to our ward. The nurses
at the CU however were doing a thorough job of work to treat and
keep the patients in comfort as far as possible and this much is
commendable apart from the young set of doctors attached to the
wards who proved to be kind-hearted gentlemen so far as their duty
was concerned. On the operating
table, a young doctor performed the CA on me puncturing an artery
on my crotch. They applied a liquid profusely over that area and
then started inserting the tube. Immediately I could feel the pain.
No one asked me if I could feel or not, as the private dentist would
ask you about the injection before he pulls out your tooth. I jerked
my leg in pain only to be met with a stern warning of more pain
if repeated. When later I asked a partner in adversity he told me
surprisingly that he had not felt anything at all, and it was a
different surgeon who had done his CA. Is there an individual factor
involved in whether you are severely dealt with or not, on the operating
table? In a cubicle
outside the theatre it is a veritable pantomime enacted by some
attendants (or are they nurses?) to plug the flow of blood from
my injury. They dabbed it with a thick wad of wool and kept pressing
upon it with both hands. Using their full body weight, they removed
the wad and if it still flowed repeated the same procedure several
times taking about 20 minutes. My problem was that I had a slight
swelling on probably a gland on my crotch which at least the doctor
should have noticed before puncturing the place. So the pain was
excruciating when the young fellow was pressing on the very place
with his full body weight and I had no choice but to undergo the
ordeal in silence. But these drawbacks
apart, the wards of the unit prove to be a place akin to heaven
except for a few inevitable shortcomings. I saw even in small hours
of the night female nurses come running to patients who begin to
shout in pain and provide them with whatever was necessary. Even
the doctors made several rounds in the dead of night to attend to
a patient who had taken a bad turn. The meals were
tolerable with two or three curries while the standards of sanitation
was kept at a fairly high level - the ward floor was regularly mopped
and it was the fault of patients themselves that often created problems
- for instance, clogging the sinks with food particles in spite
of having a bin. I believe that the CU is run according to some principles to do with the actual conditions governing a heart patient who deserves to be dealt with tenderly as he is more prone to anxiety and tension than an ordinary one. The staff therefore appears to have been well-trained accordingly, not to cause unnecessary mental stress for them. There are however two issues requiring discreet handling; firstly, getting the patients to sign the document undertaking to bear the risk involved in CA is only kept open to those who can read English well, lest only plebeians will try to make a scene if risks are made clear to them. The second point that should improve is the obvious favours rendered on grounds of attachment which is anyway inevitable and therefore those at the receiving end should not try to make a show of it. If these aspects are improved, the Cardiology Unit would be rated much better than any of its much - vaunted private counterparts. Peace
and quiet for the hopeless There are two
wards, each having 16 beds - the one for males is downstairs and
the female ward is upstairs. There are also two rooms to accommodate
patients who come with a carer to stay with them. The kitchen is
clean and shining. The toilets are well kept. The bed 1inen looked
fresh and clean and the patients appeared well cared for. The nursing
Sister who showed us round, Sister Pannala, seemed dedicated to
her work. With long service in government hospitals behind her,
and a stint at the Royal Marsden Hospital in England, she had taken
early retirement and then opted to serve here. While the nurses
I saw were on the elderly side, the attendants, both male and female,
were youthful. There is also a team of volunteers who visit the
patients on a regular basis, but we did not meet any on that particular
day. I spoke to
a patient who was sitting on his bed with his legs dangling down.
He was Mr. Appuhamy who appeared to have cancer of the mouth, for
he could only speak from one corner of it. He said he had been in
the hospice for 1 l/2 years, after a long stay at the Cancer Hospital,
and he was fortunate to be able to end his days in a place like
this. He had no family, friends nor relatives to visit him, yet
was cheerful and uncomplaining. Moving on,
I came to the bed of a man with a big, greying moustache and a ready
smile and only one leg. There were crutches leaning on the wall
beside his bed. He was Mr. Subramaniam from Wattala and he had children
who often visited him. He told us that he had been promised an artificial
limb by some society at the Gangaramaya and he was awaiting that.
I winced when he volunteered to take off the bandage round his stump,
but he cheerfully undid it and told us how, after the original amputation,
a further portion had to be cut off. It has now healed completely
and he looks forward to getting the new limb and learning to walk
with it. He even talked of going home, but I learned privately from
the Sister that it was more likely he would remain at Shantha Sevana
because, although he didn't seem to be aware of it, he was a terminally
ill patient, like all the others in the hospice. In the female
ward upstairs, we were drawn to the bedside of a patient who had
bunches of gaily-coloured artificial flowers on her bed. She, Karunawathie,
spends most of her time making these flowers and sells them to visitors.
It was something she had learned while in domestic service. Karunawathie
had suffered from a brain tumour and was blind when she was admitted
to the Cancer Hospital. After surgery to remove the tumour, she
got partial sight - just enough to enable her to engage herself
in this therapeutic occupation which she enjoys and which also brings
her a modest income. She told us that one of the volunteers buys
the required materials for her. Everyone of us was glad to buy a
bunch of Karunawathie's pretty flowers priced at Rs. 10 per flower. Seelawathie,
paralysed on one side, sits up in bed making drawings, using pastels
and this is obviously occupational therapy for her. Sometimes, the
nurses pin up her work on the wall beside her and this makes her
happy. Several of the patients were out in the hall, listening to
a bana sermon being given by a monk, preceding a dhana that a benefactor
was giving the patients that day. That must be how we missed meeting
Malkanthi. This lady has lost her husband and only child and now,
stricken with cancer, she bravely carries on and finds some meaning
to her days in teaching English to the young nurse-aides. We met only
one patient who was in tears. This lady had been brought to Shantha
Sevana from Trincomalee only the day before and must have felt strange
and lonely in the unfamiliar surroundings because she spoke only
Tamil and therefore couldn't communicate by word with nurses or
fellow-patients. She cheered up considerably when one of our group
who knew Tamil, spent a little time chatting with her and listening
to her. The three young
nurse-aides have one off day a week and 21 days privilege leave
for a year. I asked them whether they didn't find it depressing
to care for terminally ill patients, some of whom were in constant
pain. They smiled and said "No" and one of them, Chandima
Ratnayake, spoke for all three when she said in Sinhala, "This
is merit-earning work." In a passage,
I saw a large board on which the meals donated for each day are
written down, along with the names of the donors. I noticed that
breakfast for on that particular day had been 'donated by Miss Chandima
Ratnayake in loving memory of her father.' I was touched that this
young girl had been moved to give Rs. 350 out of her hard-earned
money (we later enquired from the office about the amount required
for different meals). We were also told that two items often in
short supply are milk powder and sugar and that gifts of these are
always welcome. Only the terminally
ill are admitted to Shantha Sevana, so a letter from a consultant
recommending admission is essential. It's absolutely free of charge.
If well-to-do patients come in, they may make a voluntary donation
if they wish, but they are not asked to make any payment for services
rendered. No treatment is given at the hospice, for that part is
over for those who come here. A doctor visits the patients regularly
and pain-killers are given to those who need them and they are kept
as comfortable as possible. We were surprised
that there were a few vacant beds. Vacancies do occur, of course,
as and when terminally ill patients die, but I would have expected
there to be a long waiting list and that vacant beds would be immediately
snapped up. I asked Ms. Perin Captain about this and she too was
dismayed that this didn't always happen and wondered herself why
it was so. This hospice was Perin's dream which the Captain family
helped her to fulfil. I attended its formal opening by Prime Minister
Sirimavo Bandaranaike in 1996 and she said it was a place that would
meet a felt need. Shantha Sevana
gives hope to people who might feel hopeless after the long and
painful process of being treated for cancer. I don't mean the hope
of recovery, but hope of some quality of life during the months
or years that are left to them. I noticed pictures on the walls,
television in the ward, fish tanks, a well-tended garden with stone
benches. To destitute and lonely people, particularly, a haven such
as this where they meet with kindness and tender care and can die
in clean and pleasant surroundings, with decency and dignity, must
make a world of difference. Symposium
on Asthma The presentations
will be as follows: Current scenario in asthma - Dr. Kirthi Gunasekera,
Inflammatory mechanisms and airway remodelling - Dr. Manela Joseph,
Natural history and clinical spectrum - Dr. A. T. Munasinghe, Allergens,
immunology and immunotherapy - Dr. Anura Weerasinghe, Recent developments
in occupational asthma - Ms. K. N. Lankathilaka, Clinical studies
in asthma - Dr. Rajitha Wickremasinghe, Diagnostic difficulties
in asthma - Dr. J.H.L Cooray, Acute, severe asthma - Dr. Shyam Fernando,
Ventilatory strategies in asthma - Dr. Vajira Tennekoon, Conventional
pharmacotherapy - Dr. Bandu Gunasena and Inhaled cortcosteroids
- Dr. B. J. C. Perera. |
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Copyright © 2001 Wijeya Newspapers
Ltd. All rights reserved. |
