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Ask Your Doctor 166 (10.04.2014)

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Please read this before you ask your question.....!

We are pleased that this column has become popular among our visitors. This column is purely of educative and informative type. We do not intend to suggest any definite treatment or give name of any specific drug or doctor either in India or abroad.

We are receiving questions from many of our visitors from different parts of the world. Though we have the desire to give the reply at the earliest, we are unable to do so. At present we are updating the column once in two weeks, but at times there is inadvertent delay. This results in lot of back log. We answer the questions in first come first serve basis. Even then to answer a particular question, it may take more than a month. We request our visitors to bear with us.
We regret, we are not able to help when reply is sought urgently. It is absolutely not possible to help in emergency situations. There is no facility to give personal reply through e-mail.

Please fill up all the relevant details in the columns when you send the question. Please give your correct name, e-mail address etc. While answering we are editing the name and try to conceal the identity of the person who sends the question whenever it is required. We will not attend the question when the details are not sent. This is just to see that the person is serious of his question.
You might have noticed that, the answers can not be perfect if all the details of the problem are not given. Please send all the details of the problem in the relevant question. Many such details where the identity might be revealed will not be published.
If you want further clarification or want to react to the answer please use the same column. Indicate the specific question or answer where further details/clarification is sought. Your reactions/suggestions are highly appreciated.

Even when a person consults the doctor in person, there can be error in diagnosis and treatment! Please remember the answers here are based on the perception of the problem sent in the questions. There can be an error in perception by us and the answer may not be suitable. It is always advisable to consult the appropriate doctor before taking any treatment.
Dr. Edward Nazareth

Must Read Books by Dr Edward Nazareth (Konkani)
Child Health & Care , and Health Tips
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1. J.L. Kuwait

* My son who is seven and half years is studying in 2nd standard has the habit of soiling his pants at least once in a week sometimes twice in a week, only when he goes to school. He had started play school when he was 3, never had any problems even wetting his pants or bed at night, never ever at home or even when we were out he can hold for long time but from mid of his LKG he has started with this habit. Earlier it was like very alternative day of school but now has reduced. We spoke to him lovingly, beat him, shouted, punished but nothing works out, even spoke to the teacher, she is not aware of this.

We are totally upset, so embarrassed to discuss with any one, feel bad to punish him also as every time he pleads he will not do again. Some times he has used the school toilet and said that he is not comfortable and he is scared that other kids laugh at him as there are no locks to the doors etc. But we make sure he goes to toilet at home morning as well as after he comes back from school, still the problem continues. Doctor kindly advice is this related to his psychological issues or his ignorance. He is a bit hyper boy and sometimes has constipation problems. Is there anyone in Mangalore with whom we can consult? It has been almost three years now hoping this will stopped.

** Soiling occurs when a child does not reliably use the toilet for a bowel motion. They may dirty their pants, or go to the toilet in inappropriate places. The problem is medically known as encopresis. It is the medical term for a toilet-trained child (aged four or older) soiling their clothes.
Parents should remember that the children are not doing this voluntarily. They usually cannot help it, and some children may not even realize they have had accidently soiled the clothes. The soiling usually happens during the day, when the child is awake and active, often in the late afternoon. Children who have this problem may feel ashamed, guilty, frustrated or angry, and may act secretively to try and hide the problem.  As soiling can be one example of several similar problems like bed-wetting, let me deal this issue in detail. Parents should learn to handle their children with unacceptable habits intelligently and patiently.

• Most children who soil their pants may be having a real problem like constipation. They may ignore the urge to go to the toilet and 'hold on' to avoid the pain or the ‘trouble’ of passing stools. This leads to fecal impaction – when a large, solid stool becomes stuck in their rectum (back passage) and begins to stretch and weaken the surrounding muscle walls. Watery stools then leak out from around this blockage.

• Children who do not get enough fiber and fluids in their diet are most likely get constipated. Constipation may also be related to a lack of toilet training or toilet training at too early an age. Constantly intervening when  the child is using the toilet may make them feel anxious about it and reluctant to go, which only makes the problem worse.

• Not learning a regular toilet routine is a common cause of soiling. The child may be reluctant to use the toilet. This may sometimes be part of a general pattern of behavior, where a child refuses to do what you want them to.

• Sometimes a change in diet, an infection, taking medication or life events such as a house move, starting nursery or another change within the family can trigger constipation.

• Sometimes a child links pain with going to toilet. They are fearful and try to hold in their stools, making it even harder and difficult to pass. This happens when a child in the past has had hard stool in the bowel, causing a small split in the anus called a ‘fissure’ that is extremely painful.
First step to deal with the problems is to seek medical opinion. Initially you should take the child to pediatrician for an examination, to investigate the possibility of a physical cause, such as an injury, constipation, etc.

• The most important thing you can do is not to make the child feel bad about soiling. Avoid showing your distaste or repulsion as this can lead to further embarrassment and anxiety. Do not punish the child or get angry with them for soiling.

• Try to be patient and calm. It may take a while for the soiling to stop completely. Tell the child that  these types of unaccepted things happen and that they should not feel embarrassed about it. However, at the same time try to remain neutral – too much positive attention or reassurance can give the message that you are happy for them to continue to soil themselves.

• Try to give the child the message that you are keen for them to stop soiling themselves, but that you are not disappointed if it takes a long time.

• Talk to the child, and try to find out if there is anything that they are worried or anxious about, or something that is otherwise troubling them, e.g. bullying, studies etc

• Ensure that the child has a healthy diet with plenty of fiber, e.g. fruit and vegetables, whole grain cereals, etc. and that they drink plenty of water to avoid dehydration. This makes constipation and painful bowel movements less likely.

• Try to encourage the child to use the bathroom after meals. The bowels tend to naturally move after food intake, so this can be a useful way of preventing accidents.

• Make sure that the child can get to the toilet easily at any time. This means making sure that at school they can leave the classroom with the minimum of fuss.

• Involve the child in their own hygiene, appropriate to their age, but make this as positive an experience as possible. The child should never have to clean up after him/herself as a punishment. Make sure that they are able to clean themselves properly and have access to wet wipes, clean underwear and plastic bags for soiled clothes.

• It may be not ideal to reward for not soiling, as the problem is that the child is not in control of their bowel movements, so in this case it can be frustrating for them if they can not repeat the desired behavior.

• If the child is specifically anxious about using the toilet, do not force them or put pressure on them to do so. Remember that they are anxious and worried to begin with, and any pressure is only going to make the situation worse. Instead, talk to the school authorities and see that the toilet doors can be securely closed may be with magnetic stopper or some other device which children can handle.

2. A.R. Muscat

*I am aged 35 years; married for 9 years now and have 2 kids. For the past 6 months I am having strange problem. Though we have sex once a week I am not getting proper erection, sometimes it remains only for  few minutes. I really do not know what the reason is and whom to consult. I have sugar /cholesterol/ blood pressure, but all in border levels. Is it affecting?

** The  man's sexual function declines with age. As his testosterone level falls, it takes more time to arouse him. Once aroused, he takes longer to get an erection and to achieve orgasm and, following orgasm, to become aroused again it might take days. Age brings marked decline in semen volume and sperm quality. Erectile dysfunction(ED), or impotence, is clearly linked to advancing years; studies show that between the ages of 40 and 70, the percentage of potent men falls from 60% to roughly 30%. This is a gradual process, a man at the age of 30 may not be as potent as at the age of 20! Along with advancing age medical problems like diabetes, obesity can add up to the problem and some men may experience declining sexual function much earlier. In the same way, some healthy men may remain active even at sixties.

Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this inability at some point in their lives, usually by age 35 to 40, and are not psychologically affected by it. Some men experience chronic, complete erectile dysfunction (impotence), and others achieve partial or brief erections. The erectile dysfunction can have a negative impact on self-esteem, quality of life and interpersonal relationships. It has many causes, most of which are treatable.

The causes of erectile dysfunction can generally be classified as either organic or psychological. Although the majority of men with erectile dysfunction are thought to have an organic factor, psychological aspects of anxiety, depression,  lack of self-confidence, and partner relationship are important contributing factors.  Consequently, many men have a combination of organic and psychological factors.

The organic causes and risk factors of erectile dysfunction include vascular disease, diabetes mellitus, hypertension (high blood pressure), certain medications, neurological disorders such as multiple sclerosis, chronic alcoholism, prolonged heavy smoking, pelvic trauma and spinal cord injury, pelvic surgery such as radical prostatectomy, cystectomy, hormonal abnormalities, and other medical and surgical conditions.

Although erectile dysfunction is often assumed to be a natural consequence of aging because its incidence increases with age, it is not inevitable. However, many conditions associated with aging—vascular disease, diabetes, and their treatments—may cause erectile dysfunction.

Erectile dysfunction can cause emotional strain between a couple. Many times, men will avoid sexual situations due to their emotional pain associated with erectile dysfunction, causing their partner to feel rejected or inadequate. Some couples consider seeking treatment for erectile dysfunction together, while other men prefer to seek treatment without their partner’s knowledge. A lack of communication is the primary barrier for seeking treatment, and can prolong the suffering.

As there is effective treatment for the problem, you may seek the help from an urologist first.  He will do a thorough assessment to find organic causes and suggest proper treatment. If there are no organic causes and if required the help from a psychiatrist may be sought. The support and co-operation from your partner will go a long way in managing the problem. The problem can be treated, so do not worry.

3. E.M. Qatar

*I am 42 years of age. About two years  ago, I had myomectomy  and cystectomy. Now for the past 6 months I have brown discharge from vagina i.e. starts immediately after the periods and continues throughout, till the next period and I also have heavy bleeding and pain for which I am taking Mefanamic acid 500mg tablet.  About two months ago I had endometrial biopsy which  reported that histological features were of proliferative phase of endometrial. Also seen were the endocervical tissue with features of endocervicitis with healthy cervix. Ultrasonography report was that multiple follicles in both ovary. For the brown discharge doctor  had given me Meprate 10mg tablets for 12 days each month for 3 months starting from 14th day of period. While taking the tablet brown discharge stops and start again after the period stops and it is becomes more. Please advise on this issue what to do & how to get rid off this brown discharge.

**  The tablet Meprate contains medroxyprogesterone acetate a hormone which is similar to the hormone progesterone that is naturally produced by the body. It is used for the treatment of menstrual problems and such as irregular bleeding. As you do not have significant problems, the discharge may be related to the hormonal imbalance which is not unusual during premenopausal period. Discuss with your doctor whether you need to continue the medication or you can ignore the discharge if it is minimal.

4. P.A., Mangalore

*I am 28 years,  I got married last October. I am having the problems with my periods, they were irregular before my marriage and I had consulted a doctor who had prescribed the medicines for about six months; I was also advised to reduce the weight. I had normal periods when I was on medicines. My weight is now 60 kgs. My periods are irregular again.

**Irregular periods are an indication that your cycles are  imbalanced. There are a variety of reasons for this and also many ways to address the imbalance. The average length of the menstrual cycle is 28 days; however in reality the normal menstrual cycle may vary in length from 26-35 days. Menstruation (bleeding) usually lasts 3-5 days. Menstrual cycles have two phases. The first, or proliferative phase, may vary from 13-20 days and ends when ovulation occurs. This phase varies from one woman to another and may also differ from month to month. The second, or secretory phase, begins after ovulation and ends when the period starts. This phase generally lasts 14 days for all women.

The irregularities in the menstrual cycle can be broadly grouped in two:

Irregularities due to unknown cause:

For some unknown reasons in many of the women the proliferative phases are irregular from the beginning. As a result the menstrual cycle also becomes irregular. In some they are regularly irregular, that is in every month their cycle remains at 40 days or 45 days and in others they are irregularly irregular, in some of the months it is 40 days, in others it is 50 days, it may even go beyond 60 days. These irregularities are very difficult to correct. A few of them may respond to hormonal treatment, where as in majority of the women the cycles remain irregular throughout. These women can conceive normally and can have normal pregnancy and childbirth.  There are incidences where the cycles resume regularity after child birth.
Irregularities due to traceable causes:

Menstruation is controlled by a complex series of hormonal interactions between the thyroid, adrenal and pituitary glands, hypothalamus and the ovaries. Menstrual period changes are usually a symptom of some underlying physical or hormonal imbalance. Changes in the amount or timing of hormones released by the thyroid, adrenal and pituitary glands, or hypothalamus may cause the ovary to delay or skip ovulation. Without ovulation a period will not occur. However the same changes in hormones may trigger bleeding at abnormal times (in the middle of a cycle or several weeks late) or in abnormal amounts (very light or very heavy). 

One of the most common causes of anovulation (failure to ovulate) is body weight. Low body weight may cause a prolonged absence of periods. Excessive body weight tends to cause abnormal bleeding. Sudden changes in exercise levels or in body weight may cause temporary changes in bleeding patterns.

Emotional stress and physical illness are also common causes of menstrual irregularities although the menstrual changes may not occur at the time of the perceived stress. Prescribed medications and herbal preparations may also affect menstrual patterns by changing the interaction and transmission of the body’s natural hormones. Occasionally the thyroid, pituitary or adrenal gland may malfunction and produce too little or too much hormone.

If the periods are irregular from the beginning, they normally do not require treatment. They may become regular when on medication and might return to the previous pattern when not on medication. It may not be wise to continue the medication for long. However you may try to reduce the excess body weight by dieting and exercises like walking.

 5. S.Y.K., Mangalore

*I am 24 years of age. If I meet my would be on daily basis and if touch her,  I am able to control ejaculation. But if we meet in a gap of 8-10 days and when I just touch her I ejaculate. Why this is happening? Do I have any problem?

** This is not abnormal or related to any deficiency. It is related to hyper-excitability and is common in the beginning.  Once you marry your would be and have regular marital act, the issue of hyper-excitability is likely to resolve. Nothing need to be done now. Maintain a pure relationship till you marry her and then you can have real pleasure in your married life.

6. D.C., Mangalore

*I am 28 years of age. I got married in December 2012 and I have been trying for a baby. My periods are normal. In May 2013 I had spotting for nearly everyday twenty days after the periods and when I consulted the doctor she informed that I had PCOD and gave the tablets. But I did not take them and had normal periods after 15 days. My periods are regular but I am not able to conceive. Doctor has given some more tablets(names given) and I am taking them. What shall I do next?

** You have been put on medication to treat the problem of PCOD; some other tablets are to facilitate maturation of ovum and ovulation. You may consult the gynecologist who has been treating you and continue the medication. It may take six months to one year or more to get the desired result. Some more details about PCOD are given in the answer to the 12th question in this column.  

7. A.P. Chickmagalore

*I am 23 years, married for 2 months. Till today there is no sexual relation between me and my husband as I have hell lot of pain whenever we try to have. I am very tensed about this; as my husband is very understanding he is not forcing me. Can you please let me know why it happens? Is there in pills to reduce the pain? I am interested in it and there is no lubrication problem as we have enough foreplay but I get severe pain on penetration and we have to stop at that.

** Painful intercourse can occur for a variety of reasons — ranging from structural problems to psychological concerns. The medical term for painful intercourse is dyspareunia— which is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse
Pain during intercourse or dyspareunia, can cause problems in a couple's sexual relationship. In addition to the physically painful sex, there is also the possibility of negative emotional effects, so the problem should be addressed as soon as it becomes evident.

Physical causes of painful intercourse tend to differ, depending on whether the pain occurs at entry or with deep thrusting. Emotional factors can be associated with many types of painful intercourse.

Pain during penetration may be associated with a range of factors, including insufficient lubrication, inflammation or infection in the genital region.
Insufficient lubrication during early part of marriage is often the result of inadequate foreplay. (Insufficient lubrication is also commonly caused by a drop in estrogen levels after menopause, after childbirth or during breast-feeding. In addition, certain medications are known to inhibit desire or arousal, which can decrease lubrication and make sex painful).

An infection in the genital area or urinary tract can cause painful intercourse even during early days of marriage. Pain during intercourse can be the only symptom of infection.

Involuntary spasms of the muscles of the vaginal wall known as vaginismus, can make attempts at penetration very painful in certain women.
Deep pain usually occurs with deep penetration and the causes include  endometriosis, pelvic inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, irritable bowel syndrome, hemorrhoids and ovarian cysts etc.

Emotions are deeply intertwined with sexual activity and may play a role in any type of sexual pain. Anxiety, depression, concerns about  the physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain. Any stress also can cause pain as the pelvic floor muscles tend to tighten in response to stress.

You can seek the help of a gynecologist for assessing the cause and for treatment. The treatment depends on the cause. If pain is due to inadequate lubrication, even though you feel you have,  you may be advised to use an artificial lubricant. The infection or inflammation may require proper medication.

8. R.M. Dubai

*I am 23 years of age. I got married 2 years ago and came to Dubai. I have put on weight after marriage. Earlier my weight was 42 kgs and now I weigh 70 kgs. Now I feel very difficult to walk and sit though from  the past one week I go for walking every evening. I walk around 2 Kms every day and do some exercises, but whatever I do, I found  no difference in my weight. I don’t have kids and planning to get;  but because of my fat I feel  I have the problem. The doctor has advised me to burn my fat  at least 20kgs. What can I do for this? I want to burn my fat as soon as possible..can you please tell me some diet planning and exercises that can burn my fat.

** It appears to me that you were not doing any work or exercise after marriage and it must be the main reason to gain weight. Some times hormonal imbalances also can lead to weight gain in a short span. You may not able to reduce the bodyweight drastically within few days or weeks, it might take months to become slim.

The body weight is comparable to bank balance in the savings account. To increase the balances you have to deposit more and to reduce you have to withdraw. In our body the same principle works. However here deposition is easy and withdrawal is difficult.

The food contains the substances that finally form the energy in the body. The energy is measured by a unit known as ‘calorie’. Some food items like meat, fat produce more calories and others such as green leafy vegetables produce less calories. The calories are required for normal body functions like breathing, digestion of food, walking etc. The calories are also required for our daily work. If you do sedentary work (such as the office work, routine household work) then the amount of calories you require are much less. If you do physical exertion or hard work then the calories requirement is more. One of the main reasons of over weight of the people is their wrong meals schedules. It is very important to have a correct meal at a correct time. An adequate time period should be left in between each meal. It has to be remembered that skipping of meals is not a solution to the problem of weight gaining.

Many of us eat the food that produce large amount of calories, but we do very little work to use them. The extra calories thus produced in the body are finally stored as fat and it increases our body weight and disfigure us.

To reduce the body weight you have to reduce the quantity of the calories you intake.  The amount of food intake has to be reduced and the food should be such that it produces less of calories. The food items like cheese, ghee, oil, meat and meat products are to be reduced. The diet should contain more of vegetables. The overall quantity of food intake has to be reduced gradually. Sudden reduction in the quantity of food is not good, moreover it is not feasible.

Regular exercises such as walking, swimming, bicycle riding help in burning the extra calories that is stored as fat. These are to be started and followed regularly. It may take long time to lose the weight.

Gradual and steady reduction in weight is ideal. It is not possible to reduce weight in the same speed in which it is gained. Reduction should be slow and steady.

There are certain medicines available which might help to curb the appetite and thereby help in weight reduction. However these medicines carry several adverse effects and have to be used cautiously.

Remember these:

• Initially you may consult your doctor to know whether you have any hormonal problem which might be the cause for gaining excess weight. Some women of your age can have hormonal imbalance which might not allow weight reduction unless it is addressed.

• Determine with the help of your doctor how much weight has to be reduced. Your doctor will be able to inform you the ideal weight depending on your height by using BMI chart.

• Stay motivated to lose weight.

• Slow weight loss is the safest and most effective. (One to one and half pound per week).

• Set several short terms but realistic goals.

• Reward yourself each time you make progress (Not food items).( Like I will buy a new dress if I reduce this  much pounds or Kgs)

• Even small weight losses have shown to be beneficial.

• Make gradual changes in eating habits. (The human body reacts negatively when calories are reduced drastically by slowing basal metabolic rate.
This makes weight loss harder.)

• You will lose weight when you burn more calories than you consume. Hence eating less and being more active help in losing weight.

• Sound eating habits keep you out of putting on weight.

9. C.L. Oman

*I am 42 years of age and my wife is 40; we married 14 years ago  and are having daughter of 13 years and a 6 year old son. My wife is not interested in having sex, not interested even in kissing. I am very upset on this. She is a housewife  and Ii am working. What may be done?

** It is very difficult to predict the sexual desire of woman, it naturally fluctuate over the years. Highs and lows commonly coincide with the beginning or end of a relationship or with major life changes, such as pregnancy, menopause or illness. Some antidepressants and anti-seizure medications also can cause low sex drive in women.

A woman's desire for sex is based on a complex interaction of many components affecting intimacy, including physical well-being, emotional well-being, experiences, beliefs, lifestyle and current relationship. If a woman has persistent or recurrent lack of interest in sex that causes  her personal distress, she may be having hypoactive sexual desire disorder.

A wide range of  causes, physical changes and medications can cause a low sex drive. Assessing the causes may be needed to solve the problems. The causes can be one or more of the following:

• If  a woman experiences pain during sex or unable to attain orgasm, it can hamper her desire for sex.
• Estrogen levels drop during the transition to menopause. This can be a common cause in many healthy women when they are nearing menopause. Decreased hormones can cause decreased interest in sex and dryer vaginal tissues, resulting in painful or uncomfortable sex. At the same time, women may also experience a decrease in the hormone testosterone, which boosts sex drive in men and women alike. Although many women continue to have satisfying sex during menopause and beyond, some women experience a lagging libido during this hormonal change.
• Numerous nonsexual diseases can also affect desire for sex, including arthritis, diabetes, high blood pressure, coronary artery disease, malignancies and neurological diseases.
• Many prescription medications — including some antidepressants and anti-seizure medications — are notorious libido killers.
• A glass of wine may make her feel amorous, but too much alcohol can spoil the sex drive.
• Any surgery related to the breasts or the genital tract can affect her body image, sexual function and desire for sex.
• The exhaustion of household or office work can contribute to low sex drive.
• There are many psychological causes of low sex drive, such as anxiety or depression, stress, such as financial stress or work stress, poor body image low self-esteem etc.
• For many women, emotional closeness is an essential prelude to sexual intimacy. So problems in the relationship can be a major factor in low sex drive. Decreased interest in sex is often a result of ongoing issues, such as lack of connection with  the partner, unresolved conflicts or fights, poor communication of sexual needs and preferences

Most women benefit from a treatment approach aimed at the many causes behind this condition. Recommendations may include sex education, counseling and sometimes medication.

Your wife  may consult a gynecologist and talk about the problem. The specialist may be able to find the cause and advice appropriately. Along with this healthy lifestyle changes can make a big difference in her desire for sex:

• Regular aerobic exercise and strength training can increase  the stamina, improve the body image, elevate the mood and boost her libido.
• Lack of communication can be a major hindrance in solving marital issues. Couples who learn to communicate in an open, honest way usually maintain a stronger emotional connection, which can lead to better sex. Communicating about sex also is important. Talking about  the likes and dislikes can set the stage for greater sexual intimacy.
• Scheduling sex into the calendar may seem contrived and boring. But making intimacy a priority can help put the sex drive back on track.
• Try a different sexual position, a different time of day or a different location for sex. If possible you both can go for an vacation to a place where you two alone can spend time together.

10. P.S. UAE

*I am 29 years old female and my husband is 35 years old(he is slightly hypertensive and on diet control).We are married for 2 years now. My problem is since 2 years we never had sexual intercourse, not even once. We initiate foreplay and he gets proper erection but then he resists himself from intercourse, does not even ejaculate out. Why is he unable to have intercourse even though he has erection?? I want to have baby now... this is making me so depressed and helpless. I pressurize him to seek medical help but he keeps delaying because somewhere it is hurting his ego. I cannot share my problem with parents or siblings fearing it may lead to divorce. I love my husband and want to be with him forever, but lack of normal sex life is making me depressed.

** It is surprising that you have been tolerating the strange behavior of your husband so long. It appears that he has some  psychological inhibition to have sex. He requires counseling from a trained counselor. You have to talk to him freely and convince him that he needs help. In case he refuses, you are left with no option but to seek the help of one of your family members whom you feel may handle the issue properly maintaining secrecy. You may share this also with your husband before you involve someone else. As you are already 29, waiting too long may affect the chances of conception.

11. S.C. Dubai

*My sister’s age is 24. She gets sum bumps on her whole body and it itches her a lot. It gets worse in the night. We thought she had  gold allergy. But it was still itching even after she stopped wearing gold.

**Your sister seems to be having a problem known as urticaria. Urticaria refers to a group of disorders in which red patches and weals (the bumps referred by you) occur in the skin. The release of chemicals from certain cells in the skin causes small blood vessels to leak and results in tissue swelling. The weals can be a few millimeters or several centimeters in diameter, colored white or red, often surrounded by a red flare, and frequently itchy. Each weal may last a few minutes or several hours, and may change shape.

Generalized urticaria (hives) is often classified according to how long it has been present. As acute urticaria is of recent onset (hours, days or a few weeks) and chronic urticaria has persisted for several months or years.

Acute urticaria is sometimes due to allergy. Allergy depends on previous exposure to the material, and the development of an immune reaction to it. The cause of an allergy may be medicine, food such as tiny amounts of fish, eggs, nuts or chocolate, bee or wasp stings, skin contact with a potent allergen.

Most cases of urticaria are not due to allergy. Histamine and other vasoactive chemicals can be released into the skin for many reasons. Non-allergic causes of acute urticaria include viral or bacterial infection, certain food items.

Treatment to some extent depends on which type or types of urticaria one has.

Oral antihisaminics control wealing and itching for the majority of patients with urticaria. They do not affect the underlying cause of the rash. Antihistamines may need to be taken intermittently or continuously until the underlying tendency to urticaria disappears.  Sometimes a combination of antihistamines works better than a single type alone. Urticaria that fails to clear with antihistamines may be helped by  oral steroids immunosuppressive medications etc.

Your sister may consult a skin specialist for proper assessment and advice

12.M.D’S, Mangalore

*I am 24 years  of age; I got married in December 2012. Now we are planning for a baby, but I am suffering from PCOD problem, I consulted the doctor- she advised me to take folic acid and Metformin 500 mg tablet . Almost 6 months over still no result . After the marriage only I came to know that I have PCOD. Is it any problem to become pregnant?

** Poly Cystic Ovaries syndrome(PCOS) or polycystic ovarian disease(PCOD) or Stein- Leventhal syndrome is a condition in which there is an association between the presence of polycystic ovaries and signs of hirsutism, amenorrhea or oligomenorrhea and obesity. This  is a common hormonal disorder among women of reproductive age. In this syndrome, other than an ovarian defect there can be biochemical, clinical, and endocrinal abnormalities. Infrequent or prolonged menstrual periods, excess hair growth, acne and obesity can all occur in women with polycystic ovary syndrome. In adolescents, infrequent or absent menstruation may signal the condition. In women past adolescence, difficulty becoming pregnant or unexplained weight gain may be the first sign. The exact cause of polycystic ovary syndrome is unknown. Early diagnosis and treatment may reduce the risk of long-term complications, such as type 2 diabetes and heart disease.

Although the condition is now referred to as polycystic ovary syndrome (PCOS) it may occur in women without ovarian cysts. Women with PCOS have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. High serum concentrations of androgenic hormones also may be encountered in these patients. PCOS is not a rare problem and approximately 6-10% of women in the developed countries have PCOS.

The extent of the problems associated with PCOS varies from woman to woman. However, there is effective treatment for the condition and it depends on the problems the individual has. Many of these women are able to conceive if the abnormalities are set right. The treatment can be medical with varieties of drugs- certain anti-diabetic agents like metformin, oral contraceptives etc. Rarely surgery is done. Some of the women with PCOS are able to conceive if the hormonal abnormalities are set right. You may consult your gynecologist for this.

Certain lifestyle modifications also might help to reduce the effects of PCOS:

• Reduce the weight: Obesity makes the problem worse. Weight loss can reduce both insulin and androgen levels, and may restore ovulation. No single specific dietary approach is best, but losing weight by reducing total calorie intake can benefit the overall health of women with polycystic ovary syndrome. For details refer the answer for the 8th question of this column.
• Restrict diet: Low-fat, high-carbohydrate diets may  help in weight reduction, so consider a low-carbohydrate diet—if your doctor recommends it. Instead of restricting carbohydrates severely complex carbohydrates which are high in fiber may be chosen. High-fiber carbohydrates include whole-grain breads and cereals, brown rice, beans etc. Limit less healthy, simple carbohydrates such as excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.
• Exercise: Exercises helps lower blood sugar levels. If you have PCOS, increasing the daily activity and participating in a regular exercise program may treat or even prevent insulin resistance and help you keep your weight under control.

13. T.R. Qutar

* My daughter is 18 years of age and her periods started when she was 13 and ever since she has irregular periods. Sometimes she only has two in a whole year or sometimes she skips a few months. Is this normal or should she be examined?

** As explained in the answer to the third question of this column, the irregularity in the cycles can be normal. However,  assessment by a gynecologist can be assuring.

14. C.D. England

* I am 24 years. I suffer from pain in my abdomen area right after I eat and then I vomit out everything. I know this is an issue and I did consult my doctor, he said it is nothing serious and is the weather but I am not satisfied with his response. What do you think?

** Weather  changes does not cause pain abdomen and vomiting. You are required to be assessed by a specialist. An ultrasound scan of the abdomen may be needed.

15. K.H. Singapore

*I am 16 years. I have a very bad habit of masturbating on regular basis (not everyday) I read articles online in which some people say it is good others say it is bad. I want to know whether it is okay or not? Is it morally wrong?

** There are many false beliefs or myths about masturbation. First of all, masturbation is a perfectly normal method of relieving sexual tension. It is estimated that over 80% of the male population masturbates. Masturbation is one of those issues that guys normally can't talk about. Most people masturbate. It doesn't matter who people are, what they do, or what they say, they masturbate or had masturbated. In fact, many people masturbate throughout their lives regardless of whether they have a sexual partner or not.

Masturbation is a common and harmless habit during youth. Almost every man would have masturbated during youth. In few of the men the habit persists even in marriage without affecting their marital life. It has no effect on general or sexual health. It is very difficult and almost impossible to stop the habit during youth. Some of the men stop it once they have natural outlet in marriage.

Though it is harmless, if one worry about it then there can be psychological stress which might lead to sexual difficulties. The person with such worries has to be convinced that masturbation is a common habit and every man had this habit at one or other part of his life. If he is convinced that there are no problems because of masturbation, he will be able to lead a normal sex life.

While it once was regarded as a perversion and a sign of a mental problem, masturbation now is regarded by majority of experts that it as a normal, healthy sexual activity that is pleasant, fulfilling, acceptable, and safe. It is a good way to experience sexual pleasure and can be done throughout life.
Masturbation is only considered a problem when it inhibits sexual activity with a partner, is done in public, or causes significant distress to the person. It may cause distress if it is done compulsively and/or interferes with daily life and activities.

In general, the medical community considers masturbation to be a natural and harmless expression of sexuality for both men and women. It does not cause any physical injury or harm to the body, and can be performed in moderation throughout a person's lifetime as a part of normal sexual behavior. Some cultures and religions oppose masturbation or even label it as sinful. This can lead to guilt or shame about the behavior.

Some experts suggest that masturbation can actually improve  sexual health and relationships. By exploring own body through masturbation, one can determine what is erotically pleasing and can share this with the partner. Some partners use mutual masturbation to discover techniques for a more satisfying sexual relationship and to add to their mutual intimacy.

16. Y.J. Maharashtra

* I am 21 years of age. I have the habit of masturbation regularly, may be once in three days. I have the problem of loose motion which could not be cured even after consulting many doctors. What shall I do?

** I have translated your question from Marathi into English and if you find it difficult to follow, you may seek the help of a translator. Your problem of loose motion is not related to masturbation. You may be having some infection or infestation of the digestive tract. Consult a specialist for proper assessment.

17. S.S. Udupi

* I am 33 years of age. I am facing some skin diseases in my penis tip where I feel itching. The color has changed red and it is covered with white patches. I have taken treatment several times, but the problem recurs. I was treated with anti-fungal ointments and tablets.

** As you have not got relief from anti-fungal medication, your problem may be unlikely due to fungal infection. You may consult a skin specialist-may be not the same one who treated you earlier- and discuss why your problem has remained inspite of treatment. You may require re-assessment and some different treatment.

18. A.D’S., Mangalore

* My  daughter who is  six and half years is in 2nd standard and she telling that her mind is disturbing. She is feeling full day and night somebody telling in her mind Jesus is bad like that is telling me and crying too much. Some times  she plays, watches TV after sometime she is asking me to put off the TV and she would sit quietly and cry.  She is not sleeping properly. We are very upset that such a active girl before has suddenly changed in the behavior for the past one week.  What shall I do?

** The symptom expressed by your child is known as hallucination. Hallucinations both in adults and children happen when someone sees, hears, smells, tastes or feels things that do not exist in reality, but is produced in their mind. Most common hallucinations are hearing voices.  Often, hallucinations in children are seen as a concern for both parents and clinicians; however, not always are they a symptom of a mental illness. In fact, hallucinations in children are quite common and part of a normal development. Some other causes of hallucinations, or false sensory perceptions unassociated with real external stimuli and may be due to stress, developmental difficulties, nonpsychotic psychopathology, psychotic illness, and family dysfunction. You may take your child to her pediatrician and after assessing he might direct you to consult other specialists if needed.

19.P. Vijayawada

*I am 23 years of age. I used to masturbate daily. I have problem with the foreskin of my penis. The foreskin is not opening fully. Is there any treatment for this.

** You seem to be having the problem of phimosis. It is not related to masturbation.

The problems with tight foreskin can be any one or more of the following

• There might be trouble in urinating.
• Infections may occur under the foreskin.
• At erection, a contracted foreskin may cause trouble by hurting when an attempt is made to pull the foreskin back. It may not go back over the glans before the penis is limp again. If the foreskin becomes inflamed in this position it may lead to paraphimosis, the inflamed foreskin may constrict further and can be painful. This itself may require surgery to rectify.
• Pain during sexual intercourse.
• Very rarely, a malignant growth can occur in a long-standing phimosis.
A tight foreskin –phimosis – is unlikely to resolve by any medication. If any problems arise they usually happen after puberty when sexual activity begins. The tightness of foreskin in an adult usually requires  surgical correction or circumcision. You may consult an urologist or a general surgeon for proper assessment and treatment.

20. S.M. Delhi

* I have been in relation for around 1 year. I did not have sex with him, but other physical relation we had. After our broke up, I masturbate. Will it affect my future relationship?

**There are no side effects of masturbation - male or female. May be it is far better than being promiscuous, catching an STD, or being mentally depressed. There is no treatment and nothing to "overcome" because it is not a disease or condition

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