Medical Weblog

Danazol is the drug which is most commonly used for the treatment of endometriosis. First developed in the early 1960s, it has been used for the treatment of endometriosis in Australia since the late 1970s; it is also used for the treatment of menorrhagia (heavy bleeding).

Danazol is a weakened form of the male hormone testosterone. Testosterone is one of a group of male hormones known as androgens which are produced by the male testes. They are responsible for the functioning of the male reproductive system and the development of the male characteristics such as facial hair and a deep voice. Women also produce very small amounts of androgens in their ovaries.

Danazol is distributed by Winthrop in the form of 100 and 200 milligram white gelatin capsules. In Australia, Danazol is also known by its trade name of Danocrine. In the United States, the United Kingdom and Canada it is marketed under the trade names of Danocrine, Danol and Cyclomen respectively.

In Australia, Danazol can only be supplied under the Pharmaceutical Benefits Scheme for the treatment of endometriosis if your endometriosis has been definitely diagnosed during a laparoscopy or a laparotomy and if your doctor fills in a special prescription form known as an ‘Authority’. If this is done a script of Danazol will only cost you the maximum cost of a prescription under the Pharmaceutical Benefits Scheme ($15 in March 1991) as opposed to its full cost (approximately $ 150 per script in March 1991).

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While it’s up to you to make sure that you take sensible precautions at home to protect your health, it’s a different matter when you’re at work where the demands of the job or the facilities provided for doing it can force you into a situation where damage to your back can result.

Sciatica and back pain are. of course, part of a much wider range of, at times, work-related ailments of all kinds that fall under the broad label of ‘musculoskeletal disorders’, a term that encompasses those conditions that affect the bones and muscles of the body and the tissues that hold them together.

Musculoskeletal problems often arise from tasks performed while employed, and each year more than half a million cases are reported as being caused by work. Says the Health and Safety Executive (HSE): “The potential to cause these conditions exists in most workplaces – although certain types of work are more often associated with musculoskeletal disorders than others, such as poultry processing, clothing manufacture, keyboard operation, nursing and assembly line work.”

According to the HSE, the causes fall into three main categories:

Manual handling and lifting – poorly designed tasks and incorrect lifting techniques and posture all increase the risk to workers. More than 55,000 injuries due to handling, lifting or carrying accidents are reported yearly.

Repetitive work – where work is done too quickly, such as in piecework, or where the work rate is controlled by a machine. This can be a particular problem when combined with the need for force; where the operator is positioned badly; or where the job is not varied enough.

Unsuitable posture – often caused by poor seating arrangements or by reaching and stretching awkwardly.

While a specific injury to the affected part can be detected in many instances of work-related disorders, in others, pain and discomfort may be the only evidence of problems, as in the case of chronic back pain or sciatica.

The HSE firmly believes that most of these problems can be avoided, often through relatively simple corrective action, such as perhaps modifying how a job is performed, or through re-siting parts of machinery or adapting seating positions.

The responsibility for preventing health problems caused by working conditions is one that is shared to a large extent by both the employee and the employer, and these can be summed up as follows:

The employer has a legal duty to safeguard the employee’s health and safety, and should identify tasks which could cause problems and take steps to improve the situation.

The employee must, however, exercise care and follow good work practices, particularly where lifting and carrying are involved. It is also up to the employee to ensure that any workstation is correctly adjusted when adequate adjustment is possible. Spelling this out more fully, current relevant legislation includes:

- Section 2 of the Health and Safety at Work etc Act 1974 (HSW Act) which places a duty on employers to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all their employees.

Section 6 of this Act also places a duty on manufacturers, designers, suppliers and importers of articles for use at work to ensure, so far as is reasonably practicable, that the article is so designed and constructed as to be safe and without risks to health.

Under section 7 of the Act, employees have to take reasonable care for their own health and safety and that of others who may be affected by what they do (or fail to do); they also have to cooperate with their employer, so far as is necessary, to enable

the employer to comply with legal duties.

It must be noted that the HSW Act deals with general duties and does not provide specific requirements on the prevention of particular ailments. However, various Regulations are more to the point as far as reducing the risk of back pain or injury are concerned, as shown below.

The Management of Health and Safety at Work Regulations 1992 (the Management Regulations) include requirements for employers to:

Assess risks to health or safety.

Arrange for the effective planning, organisation, control, monitoring and review of preventive and protective measures.

Appoint competent people to assist the employer in complying with health and safety law.

Cooperate and coordinate health and safety actions where the activities of different employers interact.

Provide appropriate health surveillance, information and training.

The Provision and Use of Work Equipment Regulations 1992 place duties on employers concerning the safe and proper use of work equipment. The risk assessment carried out under the Management Regulations, as mentioned above, is intended to help employers select work equipment and assess its suitability.

The Health and Safety (Display Screen Equipment) Regulations 1992 are directed mainly to protect employees who habitually use display screen equipment as a significant part of their normal work. Employers have duties to:

Assess and reduce risks.

Make sure new workstations meet minimum requirements covering equipment, furniture, the working environment, task design and software. There was a transition period until 31 December 1996 for existing workstations

Provide breaks or changes of activity, information and training.

While the health risks most commonly associated with operating computers and other VDUs are upper limb disorders (including repetitive strain injury) and sight problems, back troubles can easily arise from inadequate seating and a lack of breaks in the day’s work.

The Manual Handling Operations Regulations 1992 require the avoidance or reduction of risk where the manual handling of loads involves a risk of injury.

The Workplace (Health, Safety and Welfare) Regulations 1992 include requirements for lighting, workspace, workstation arrangements, seating and facilities for rest.

The Supply of Machinery (Safety) Regulations 1992 apply to the supply of new machinery which will need to meet relevant essential health and safety requirements.

Taken together, the HSW Act and the various Regulations put a strong onus upon any employer to ensure that everything reasonable be done to prevent employees from contracting work-related ailments. Despite that, it remains a fact that many sufferers from back problems certainly attribute their difficulties to conditions at work. Should you think that your health problems are due to unsatisfactory work practices, this is what the HSE says you should do:

In the first instance, consult your doctor, giving as much information as is possible to enable him to decide whether or not your condition is likely to be due to your work. In some cases individuals suffering from specified conditions can get state compensation under the Industrial Injuries Prescribed Diseases Regulations. Ask your doctor about this or get leaflet N12 from your nearest Social Security office.

If you suffer from symptoms which may be attributable to work, particularly if they recur, then it is important to tell your doctor and employer. If you have a works nurse or doctor, then you should also tell them about your problem. You may also want your union representative to know that -you think your job is affecting you. If you are off sick for more than seven days your doctor will inform your employer of the cause via a sick note.

You can also contact a doctor or nurse from your local Employment Medical Advisory Service. You’ll find them at your local office of the Health and Safety Executive.

If you need more information, contact the HSE’s Information Centre on 0541 545500.

Additionally, should you develop a musculoskeletal disorder that makes it difficult for you to continue with your current job or you are out of work, you can get advice from your local Job Centre on assessment and rehabilitation schemes, registration as a disabled person, job retention, work aids for people with disabilities and help with job applications.

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Support groups now exist for many serious and debilitating illnesses, and depression is no exception in this regard. Such organizations provide up-to-date information and meetings to help members and their families cope with depression. A listing of available support groups that deal with depression and related disorders is provided in the Resources chapter at the end of this book.

Recovery or 12-step groups are modelled on the principles set down by Alcoholics Anonymous, which was the first such group to be developed. There are currently recovery groups for drug addicts, sex and love addicts, compulsive gamblers, overeaters and the adult children of alcoholics. There are also separate groups for the spouses, partners or family members of those who participate in these various groups. Recovery groups combine a programme consisting of working through a series of specific steps with fellowship, support and simple wisdom. In meetings people learn that they are not alone in their unhappiness. They are encouraged to talk freely and are listened to in a non-judgemental way without being challenged or confronted. There is a spirit of respect for what people have to say and the problems they are grappling with.

I have encouraged many of my patients with depressions and addictions to go to an appropriate recovery group, often with good results. At times I have managed to locate another group member who is willing to pick the newcomer up and take him or her to a meeting of the group. I have encountered considerable reluctance in my patients to go along with this suggestion and they have frequently cited concerns about confidentiality and their professional reputations. Nevertheless, all those who have followed my suggestion have found such groups to be quite valuable. It is very important in choosing a group to pick one where you feel you can identify with the other group members. Token contributions are requested of members. I often appeal to the ordinary human instinct (possibly genetically programmed) for finding a bargain, by pointing out to my patients that at 50 pence a meeting, recovery groups are the best deal in town.

Even if one is not an addict, these groups might still be helpful and, given the large number of groups available, it is usually not difficult to find one where you feel at home. One of my patients, a woman in her mid-sixties, has suffered from severe intermittent depressions for decades despite my best efforts at medicating her with multiple anti-depressants including St John’s Wort. She would qualify as an adult child of an alcoholic as her mother was drunk through much of her childhood and died of cirrhosis of the liver when the patient was a young girl. She was reluctant, however, to go to a recovery group, so I shared with her some of the slogans that members of recovery groups often repeat to themselves and to others by way of encouragement.

To my surprise, this extremely sophisticated woman, a veteran of many years of all sorts of psychotherapy, repeated the slogans to herself several times and wrote them down carefully every day. The slogans I shared were:

One day at a time.

Just get your body there; the rest will follow.

Fake it till you make it.

These are all useful slogans for the depressed person, who amplifies his or her troubles and projects them into the distant future. Take one day at a time, the slogan urges. If you consider all possible future problems at once they will seem overwhelming and you can drown in a sea of sorrows. In the case of an addict, this can drive a person to drink, drugs or acting out in some addictive way.

In a depressive person, it can drive one to despair. In contemplating some professional or social commitment, a depressed person frequently asks, ‘How can I possibly handle it?’ Just get there, urges the slogan. Often your automatic pilot will take over and see you through. In a song written to encourage those in despair, the singer Billy Joel counsels the listener not to forget his second wind but rather to wait for the momentum to kick in. My patient used this way of thinking to help her get to a wedding which she had no wish to attend. Once there, however, she surprised herself by having quite a good time and afterwards felt very pleased that she had been able to come through for her friends and family. The slogan ‘fake it till you make it’ suggests that if you pretend you are managing, you might be surprised to discover that you really are managing after all. Things may turn out this way for all sorts of reasons. First, the anticipation of the task or event may be worse than the thing itself. In certain types of depression it is impossible to anticipate pleasure, but once placed in a pleasurable situation you may actually be capable of enjoying it. Another reason why you might make it after you fake it is related to daily or circadian rhythms of mood, whereby it is common for a person’s depression to be at its worst in the morning and to improve as the day wears on.

Some people balk at recovery groups because many of the steps are geared round the concept of a Higher Power and, as such, may offend a person’s religious sentiments or lack thereof. Nevertheless, the whole matter is generally handled with a light touch and in a non-coercive way that many people find acceptable.

In summary, support groups offer invaluable information and encouragement around specific illnesses including depression, while recovery groups provide fellowship, wisdom and tangible assistance for people with all manner of sorrows and problems.

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(PETIT MAL SEIZURES)

Although a translation of petit mal is the ‘little illness’, petit mal does not mean the same as ‘minor epilepsy’ as there are all sorts of small attacks which are not attacks of petit mal. True petit mal seizures, or typical absences are, by definition, associated with a characteristic EEG discharge. Short-lived partial seizures arising from a focus of abnormal nerve cells in one temporal lobe of the brain may be somewhat similar on clinical grounds, but the distinction is worth making because of the difference in cause, treatment, and outcome between the two.

Absence epilepsy is virtually invariably a disorder of childhood. A typical attack is very brief, lasting only a few seconds. The onset and termination are abrupt. The child will suddenly cease what she is doing, stare, look a little pale, perhaps flutter her eyelids, and drop her head slightly forwards. Posture of the limbs and trunk is usually maintained so she does not fall. After the seizure, the child resumes what she has been doing. Because the interruption of the normal stream of consciousness is so brief, attacks may be unobserved by parents, and not remarked upon by the affected children. One of us has seen a typical attack in a supermarket. A girl aged about nine was helping her mother unload a wire basket at the checkout. She suddenly paused, with a pot of honey held in the air between basket and counter, fluttered her eyelids, and then continued transferring the purchase without further pause.

Whereas one would be unfortunate to have more then one grand mal seizure in a day, absence seizures may be very frequent—10 to 50 seizures a day being occasionally encountered. Fortunately most children have far fewer attacks.

Absence seizures are often associated with myoclonic jerks, which are particularly frequent soon after waking. These are brief shock-like contractions of the muscles, which are so

short-lived it is not really possible to tell whether consciousness is disturbed or not. We have heard this described by one family as ‘the flying saucer syndrome’ in reference to the broken crockery that may occur as a result of jerks at breakfast-time!

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Signs and symptoms

Hives appear as itchy, red, raised welts that can range in size from 5 millimeters to several centimeters across. The most noticeable characteristic of hives is that they change appearance rapidly – they come and go and change in size from one hour to the next. No other type of rash has these same characteristics, so you can be pretty sure that any welts that itch and change appearance rapidly are hives.

Sometimes an insect bite looks like a hive at the point of a bite; however, it does not come and go as rapidly. Hives that are triggered by an allergic reaction to an insect bite appear at sites distant from the bite itself. Hives can also accompany allergic arthritis, which is signaled by stiff, swollen, red joints.

The form of hives known as erythema multiforme appears as welts that look like red targets of different sizes painted on the skin.

You can sometimes pinpoint the cause of your child’s hives by considering his or her activities in the minutes or hours before the hives appeared.

Home care

Unless the child has been given medication with instructions to take it when the hives recur, home treatment of hives should be confined to measures to relieve the itching. Cold water compresses, calamine lotion, and corn flour baths may help make the child more comfortable. Frequent or repeated cases of hives require medical attention. Also, if the child has been given medication but the medication fails to relieve the symptoms, you should call the doctor.

Precautions

• If hives appear on the tongue, make the child cough, or cause difficulty in breathing or swallowing, see your doctor immediately.

• If hives are accompanied by fever see your doctor to rule out a strep infection.

• If antihistamines don’t help relieve a case of hives, telephone your doctor for advice.

Medical treatment

When your child has hives the doctor may administer epinephrine to reduce the intensity of the outbreak and then prescribe antihistamines to be taken by mouth. If the hives recur and it’s not possible to pinpoint the cause, the doctor may order skin tests or refer the child to an allergy specialist. The doctor may also order a throat culture to check for strep infection. If the child shows symptoms of arthritis, tests are necessary to confirm or rule out that possibility. If the hives are caused by an allergy to the venom released in an insect bite, the doctor may suggest a long-term course of injections to decrease the child’s sensitivity to the venom; these shots may be given over a period of years. In the case of an allergy of this type, the child may also be given medication and instructed to take it if he or she gets bitten.

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What are they?

There are many problems connected with wearing dentures, many of which are related to the fact that they are not nearly as stable as natural teeth. Advertisements suggest that denture fixatives are the answer and they certainly do work, but even the best false teeth are clumsy and cannot match up to natural teeth. Surveys have found that between 15 and 45 per cent of denture wearers are unhappy with them, and that 20 million people wear dentures in the US alone. This amounts to a very large number of individuals worldwide. One study found that about 30 per cent of denture wearers thought they needed refitting, or that they needed new dentures.

What causes them?

Some problems with dentures are inevitable because they are not fixed structures like natural teeth. They are only as good as the bony ridge or foundation on which they sit. In a fair percentage of denture wearers the bony ridge shrinks away. As this happens the dentures fit less and less well. This bone loss can be prevented.

Prevention

• Take more calcium. One study of people with denture problems found that those with good underlying bone were consuming about 900 mg calcium a day and that those who had jawbone problems were getting only about 500 mg calcium. Another trial looked at dummy tablets versus vitamin D (which helps with calcium absorption and better bone formation) for jawbone loss. After a year those taking the supplemental calcium had lost 34 per cent less bone from their upper jaws and 39 per cent less from their lower jaws than had the un-supplemented group. This study also found that the ratio of calcium to phosphorus the person consumed was important too. As levels of phosphorus rose jawbone resorption speeded up. The ideal ratio of calcium to phosphorus is 1:1. In red meat, though, there is twenty times too much phosphorus and in refined cereal products six times too much. They found that meat, bread and potato eaters experienced more of this bone loss than did other people. Also, soft drinks contain lots of phosphorus. Even teenage girls have been found to have started losing bone abnormally as a result of their soft-drink intake. This study recommended taking Dolomite, a phosphorus-free calcium and magnesium supplement. It can be bought at health-food shops and chemists. All of this is interesting even to those of us who still have our teeth, because the breakdown of tooth support is seen in gum disease. A study of people with bleeding, inflamed gums found that taking l g of supplemental calcium for six months produced considerable improvement. X-rays of the jawbones showed that bone loss reversed in 70 per cent of the cases.

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Trials and influential factors

In order to determine the safety and value of substances that are to be used to create a change in human or anima conditions, various trials are necessary. Even cosmetic preparations can come into this category because they can influence the physiology of the body by being absorbed through the skin and hair. Trials usually begin with animals and progress to studies using human patients, once safety and reasonable chances of efficacy have been established.

There is little to criticize in the actual trials themselves, provided that they are carried out with the true aim of the trial in mind. This means that these trials should not just be thought of as routine procedures: they must take account of any special application that the substance under trial may have. They must also take into account both the specific nature of the substance and the specific purpose for which it is being used. This all sounds so obvious, but unfortunately trials are not always carried out this way. This can, of course, mean that a potentially valuable substance can be missed or given a false evaluation because of incompetence in trial application.

The interpretation of results

Perhaps the main faults in trial work come in the interpretation of results. In most scientific trials or survey work, once the structure of the trial system has been suitably established, the trial procedures are fairly simple and can be conducted by non-specialist staff. Where expertise and specialist training come in is the interpretation of the results produced by the trial. Unfortunately, even in some of the highly-rated establishments, errors in judgment and mismanagement creep in.

It might be argued that this is, after all, the kind of human error that occurs in all spheres of life. Agreed; but in these cases such errors can result in something of great value in the treatment of disease being incorrectly assessed and perhaps lost, to the detriment of thousands of afflicted people. There are also problems of corruption and bias, particularly when governmental and commercial interests are involved. Having pointed out, perhaps rather dramatically, the way in which trial results are so dependent on the character and ability of those who organize and interpret them, it might be as well to suggest a possible remedy for this disorder in the testing system.

Basically, there is no guaranteed remedy because there will always be corruption. If we ignore this aspect and concentrate on the more practical one of ability, then there are possibilities. Normally, the rating of a person or an establishment is based on ability, though not always. It is suggested that future assessment of potential, new, therapeutic substances will need to be done by assessors who have ability as well as knowledge. This means that they are able to apply their knowledge beyond the narrow confines of books of regulations. This will be a necessity in the future as we progress into the greater utilization of the earth’s resources for survival. This sort of comment is not so dramatic as it may sound. Just think for a moment of the world-wide change in energy and fuel policy over the last few years! The same may happen in medicine and nutrition, though perhaps to a lesser degree.

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Complications of general anesthesia

As has already been mentioned, there is always a small risk associated with the use of a general anesthetic. However, you are far more likely to be run over while crossing the road than you are to suffer any serious complication caused by a general anesthetic.

Very rarely, the supply of oxygen to the brain can be interrupted during anesthesia, and brain damage, possibly with paralysis, or death can occur. Although this risk has to be borne in mind, it should be kept in perspective.

Other minor complications are a sore throat, coughs and chest infections. Muscle pain which may develop as a result of the muscle relaxants used usually lasts for no more than 48 hours.

If a complication arises

If you are at all concerned about anything that occurs after your operation, contact your doctor, the consultant or the hospital ward for advice. Although serious complications are not common, it is better to err on the safe side, and most doctors will be happy to discuss your worries with you.

Recurrence

One of the worst complications to follow surgery for cancer is to have a recurrence of the disease. The risk of cancer recurring in the scar of the operation or in the lymphatic in the armpit should be less than 5 per cent. The surgeon will take all possible steps to be sure that local control of the cancer is achieved. Recurrence outside the area of the breast and its immediate lymphatic drainage is less easy to predict and to treat.

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The hormonal treatments currently available in Australia for the treatment of endometriosis are Danazol, Duphaston, Provera, Depo-Provera, Primolut N and the oral contraceptive pill.

GnRH agonists and Gestrinone are two newly developed forms of hormonal treatment used in some overseas countries which are currently only available in Australia on a trial basis.

Danazol is the drug which is most commonly used for the treatment of endometriosis. First developed in the early 1960s, it has been used for the treatment of endometriosis in Australia since the late 1970s; it is also used for the treatment of menorrhagia (heavy bleeding).

Danazol is a weakened form of the male hormone testosterone. Testosterone is one of a group of male hormones known as androgens which are produced by the male testes. They are responsible for the functioning of the male reproductive system and the development of the male characteristics such as facial hair and a deep voice. Women also produce very small amounts of androgens in their ovaries.

Danazol is distributed by Winthrop in the form of 100 and 200 milligram white gelatin capsules. In Australia, Danazol is also known by its trade name of Danocrine. In die United States, the United Kingdom and Canada it is marketed under the trade names of Danocrine, Danol and Cyclomen respectively.

In Australia, Danazol can only be supplied under the Pharmaceutical Benefits Scheme for the treatment of endometriosis if your endometriosis has been definitely diagnosed during a laparoscopy or a laparotomy and if your doctor fills in a special prescription form known as an ‘Authority’. If this is done a script of Danazol will only cost you the maximum cost of a prescription under the Pharmaceutical Benefits Scheme as opposed to its full cost.

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Treatment of bulimia has a different focus. For one thing, anorexics need to do more of something – eating – while bulimics need to do less of something – bingeing and purging.

Rodney Dangerfield, the comedian, tells about the time he went to his doctor with a sore shoulder. Raising his arm, he said, “It hurts when I go like that.” The doctor replied, “Don’t go like that.”

Unfortunately, breaking the binge-purge cycle is rarely that easy. Instead of just telling the patient, “Don’t go like that,” one must reduce the forces behind the urge to binge and purge. These forces include the physical effects that are caused by an irregular pattern of eating or trying to maintain a weight that is too low.

Another goal of treatment is to change the patient’s characteristic cognitive distortions and disturbed emotional responses. For example, learning how to be more assertive can be a key element in recovery. A binge is frequently triggered by anger that the patient feels powerless to express. One woman told me her boss demanded that she work on a Saturday when she had made other plans. She suppressed her fury, telling herself that “I’m lucky to have this job, no one else would hire such a worthless person.” She worked that Saturday, then went home and pigged out for two hours. After assertiveness training, such patients find it easier to “just say no” without feeling guilt or self-hatred.

Finally, improving family relationships can be very helpful, especially for patients living at home. But because bulimic families can vary widely in their dynamics, therapy must address the particular family pattern involved.

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