Snoring & Sleep Apnea

Snoring and sleep apnea are related conditions. They are both very common in adults. Snoring by itself can be bothersome to the bed partner but usually has no direct impact on the snorer's health. However, people who snore loudly every night are at risk for having a condition called Obstructive Sleep Apnea (OSA). In this condition, the snorer has repeated obstruction of the breathing passage during sleep that can lead to some very serious health consequences.

Although so-called "Primary Snoring" (snoring without apnea) does not lead to serious medical conditions, it can create a severe strain on a relationship. The consequences of this are difficult to quantify but are important nonetheless. For example, a divorce or break-up rates as high on the stress scale as the death of a close family member or suffering a serious acute illness.

Snoring is an indication that there is narrowing of the air passage during sleep. Even in people who do not snore or have OSA, the upper airway collapses during sleep. Patients with chronic lung disease or neuromuscular disease such as spinal cord injury may experience more problems with a given degree of narrowing than people who are otherwise healthy.

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New surgical technique for treating enlarged prostate

HoLAP or Holmium laser ablation of the prostate is a new, minimally invasive surgical technique for treating the enlarged prostate. The procedure uses a high energy Holmium laser delivered by the Versa Pulse Power Suite Laser unit manufactured by Lumenis Corporation.

A side-firing laser fiber is inserted through a cystoscope introduced in the urethra. The pulsatile laser energy creates a vapor bubble at the tip of the laser fiber that in turn heats the adjoining prostatic tissue causing it to vaporize without any significant tissue damage and excellent hemostasis. This process leads to the removal of the obstruction caused by the enlarged prostate. The Holmium laser penetrates less than 0.5 mm in the tissues, resulting in immediate tissue vaporization before heat can be conducted deeper into the tissues.

The HoLAP procedure is safe and effective and compares favorably with others more invasive procedures to treat an enlarged prostate. It is performed as an inpatient or outpatient procedure and usually takes less than one hour to complete. Recovery is fast and uncomplicated. Adverse post-operative complications such as dysuria urinary retention, delayed sloughing of tissue and bleeding occur rarely, contrary to more invasive treatments such as open Prostatectomy and Trans-Urethral- Prostatectomy (T.U.R.P).

Mr.A. Economides M.D., F.R.C.S
Member of European Association of Urology

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The Menopause

Firstly, let’s start with the good news …. Yours is a great age to be a woman.
Today, thanks in part to improved healthcare and better medicines, your life expectancy is much longer than previous generations.
This graph shows the increase in female life expectancy at birth between 1850 – 2000. Notice that the average age of menopause remains relatively constant.
Menopause is defined by the absence of periods for more than one year, no regular or even artificial menses, and loss of estrogen that starts declining at the peri-menopausal level. The menopause marks the end of menstruation, but as with the menache in relation to puberty, it reflects only one manifestation of a series of changes.
The age of the physiological menopause varies with race and socio-economic conditions, but in Western Europe and the USA, the average age of onset is between 49 and 50 years. Spontaneous cessation of the periods before the age of 40 years is defined as premature menopause.
The menopause may be physiological or artificial, when it is associated with the removal of the Ovaries or the Uterus.
HOW DO WE FEEL THE APPROACH OF THE MENOPAUSE?
In the short term, the first signal of menopause is hot flushes. The woman will begin to experience night sweats, insomnia and frequent mood swings. The duration of this phase is quite short, and varies independently from one woman to another.
The onset of menopause can also mean many mental and physical changes for women. What may also annoy the woman is the irritability. Postmenopausal women become very irritable with fatigue sensitivity. She might experience facial hair growth, sometimes acne appears or even thinning of the hair on the scalp.
Some women may find these symptoms merely annoying and decide to just “tough it out. Others however may suffer severely from these feelings and experience detrimental consequences, both mental and physical
The commonest symptom of the menopause is the development of hot flushes. These episodes, which consist of flushes and perspiration, occur in about 80% of the female population and may persist for up to 5 years after the menopause.
Changes in the organs that are under the influence of hormones:
The most obvious response is the cessation of menstruation. Periods generally exhibit a gradual reduction in both amount and duration with occasional delays in menstruation.
The vaginal walls lose their rigosity (spongy and elastic quality) and become smooth and atrophic. In severe cases, this may also be associated with chronic infection and atrophic Vaginitis.
The cervix diminishes in size and there is a reduction in cervical mucus production.
The uterus also shrinks in size and the endometrium, which is the internal membrane of the uterus, becomes atrophic.
The breasts exhibit parallel changes in structure and the cyclical breast changes disappear which may bring considerable relief to some women.
The Bladder becomes atrophic as well, which causes frequent bouts of cystitis.
Epidermal appendage: The skin tends to become thinner and wrinkled after the menopause as a result of estrogen deprivation. There is loss of scalp hair and of pubic and auxiliary hair. There is an androgen-based - or male hormone based - increase in the growth of coarse facial hair so that a slight moustache may develop, and loss of scalp hair sometimes results in partial or complete baldness, but this is uncommon.
Physiological and emotional symptoms: Many women experience severe emotional disorders at the time of the menopause, with depression and anxiety states.
There are many other symptoms ascribed to the menopause, including anorexia, excessive fatigue, nausea, and vomiting and bowel disorders.
Cardiovascular complications:
There is evidence of an increase in Coronary Heart Disease following the menopause which is not simply an age-related phenomenon.
Serum Cholesterol levels rise at the time of the menopause. There is an increase in all Tryglicerides which can lead to cardiovascular problems.
There is no specific association between the menopause and Hypertension.

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OSTEOPOROSIS

Bone changes: Osteoporosis is an important health hazard in the menopausal woman. It is defined as a systemic skeletal disease characterized by low bone mass and the deterioration of bone with resultant bone fragility.
1. It is well known fact that the human skeleton reaches it’s maximum height between the ages of 18 to 25 years. There are other factors which influence this overall height like –
- genetic factors
- environmental factors
What is not so well known is that the skeleton continues to grow both in density and mass.
2. Bone mass continues to build until approximately the age of 30 years and remains constant for approximately 5 years, after which bone mass gradually diminishes until the onset of the menopause when bone mass is rapidly lost.
3. Bone loss occurs at the rate of about 2.5% per year for the first year after the menopause so that fractures become a major source of morbidity in the menopausal female.
4. After menopause your body produces much less estrogen which greatly accelerates the decrease in bone mass. During the first five years after menopause a woman can loose as much as 25% of her total bone mass and 33% of her spinal bone mass. The biggest impact of Osteoporosis is fracture leading to back pain, loss of mobility with loss of independence.
Osteoporosis is sometimes known as the “silent disease” because bone loss often occurs largely without symptoms. The first sign of Osteoporosis may be a bone fracture or collapsed vertebra from something as simple as a bump, strain or fall...
When it comes to clinical attention, collapsed vertebrae may first be recognized by a number of factors including: Severe back pain, Loss of height, Spinal deformities, and Stooped posture.
Bone is made up of two layers. The outer cortical bone which is the toughness and the inner Trabecular spongy bone
Women loose approximately half of their cancellous - or Trabencular - bone and 1/3 of cortical bone during their lifetimes. Cancellous bone is concentrated at the ends of long bones and in the vertebral column, the sites of the most common osteoporosis related fractures. Vertebral and wrist fractures are the most common manifestations of postmenopausal osteoporosis, whereas hip fractures are the most common manifestation of senile osteoporosis. Secondary osteoporosis results from certain medical conditions including renal disease, hypogonadism, hyperthyroidism and multiple myeloma, and from drugs that have deleterious effects on bone, including corticosteroids and anticonvulsants.
You may be at increased risk for osteoporosis if you have one or more of these risk factors –
Osteoporosis risk factors:
- A thin, small boned frame
- Early estrogen deficiency
- Advanced age
- Diet low in Calcium and Vit. D.

- Inactive Lifestyle
- Cigarette smoking
- Excessive use of alcohol
- Caucasian and Asian women
- Prolonged use of certain medications
The good news … If you don’t have Osteoporosis, you can prevent it
If you do have Osteoporosis, you can treat it.
Nutrition:
Are milk and cheese enough?
After menopause, these measures may not be enough to protect yourself from Osteoporosis. Dietary levels of calcium and factors that influence calcium balance are believed to pay important roles in regulating bone mass.
Exercise:
The same applies to exercise. Lack of physical activity is a suspected risk factor for Osteoporosis. It is important to ask your doctor what you can do. He or she may recommend a prescription medicine to help you prevent or treat Osteoporosis.
What are the alternatives that your doctor may prescribe? - Hormone replacement therapy (HRT)
- Serum / Evista
- Bisphosphonates
- Calcitonin

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PREVENTION OF OSTEOPOROSIS Bisphosphonates

Bisphosphonates are a therapeutic class that addresses only the bone problem of the postmenopausal women.
They provide the treatment and prevention for Osteoporosis, but they also induce a lot of gastric problems.
In addition, the patient has to stand upright for half an hour, and not eat or drink anything for 30 minutes before and after taking the drug.
Calcitonin: Calcitonin is the hormone produced by the Thyroid Gland. It is a natural pain killer and prevents Osteoporosis. There is no existing data on the treatment of Osteoporosis, only on preventative treatment.
The dilemma of Oestrogen:
The decrease in Oestrogen associated with menopause is an important factor in the development of osteoporosis. HRT is good for short term treatment of the menopause. It helps to combat the symptoms of the menopause – hot flushes, night sweats, depression and mood swings.
Contra-indications:
- 1. Women with Breast Cancer
- 2. Deep vein Thrombosis – D.V.T
- 3. Liver problems
Complications of HRT:
- 1. Causes tender breasts
- 2. Spotting / bleeding from the Uterus
- 3. Fluid retention and increase in weight.
Serum: (Selective Estrogen Receptor Modulator)
These are a new therapeutic class for the management of Osteoporosis. Evista provides postmenopausal women with treatment and prevention for Osteoporosis. In addition, Evista has a beneficial effect on the heart, it has a breast cancer protective effect and is safe on the Uterus.
To summarize, Evista is a solution for long term risk, however it does not provide a solution for the short term symptoms.
Impact on bone:
On the skeletal system, Evista builds healthy bones by increasing bone mass and stops the thinning of the bones. It also reduces fracture risk by 68% after one year of treatment.
Afraid of the side effects?
On the Uterus Evista is very safe.
On the Breast, Evista has a protective effect against breast cancer.
Whom should not take Evista?
Patients with a history of deep venous thrombosis
Complications of Evista :
Patients might experience hot flushes & Leg cramps
Ease of use: - One tablet per day, regardless of meals
- Can be taken at any time of the day
- There are no interruptions to the daily routine

In conclusion:

Osteoporotic fractures have considerable negative impact on health-related quality of life among the elderly. Because the number of hip fracture patients is rising and increased dependency in older patients is becoming more common, costs of long – term care is expected to rise.
The prevention of osteoporosis and osteoporictic fractures is an important priority and constitutes the only cost effective approach to this disease. Therapy that decreases bone loss could greatly reduce osteoporictic fracture risk, counteracting the exponential increase in risk with age. Measures to reduce falls in the elderly could also reduce the incidence of fractures.