Author Archives: amanda

Abnormal Pap Smears

Pap smears are screening tests for cervical cancer in which a swab introduced into the vagina is used to collect cell samples. Pap smears have been instrumental in decreasing the number of cases of cervical cancer in North America by detecting a precancerous condition called dysplasia.

Dysplasia is an alteration in the skin of the cervix, vagina, vulva or anus that has the potential to progress to cancer if left untreated. It usually doesn’t cause any symptoms but sometimes can be associated with abnormal bleeding or spotting.

Pap smears are an excellent way to detect dysplasia of the cervix, which is the most common site for dysplasia in women. The test is the most effective form of cancer prevention available to women. It has recently been adapted as a screening test for the anus, to detect anal dysplasias and cancer. It is recommended that females, age 25 to 65, who have had sex get regular Pap smear tests. Guidelines on test frequency vary, from annually to every five years.

In North America, about 2-3 million abnormal Pap smear results are found each year. Sometimes, pap smears can be abnormal when there are no pre-cancerous conditions present. Some common types of abnormal pap smears are:

  • Insufficient — There was not enough material to ensure that no abnormal cells were present.
  • Obscuring — There was an infection or bleeding that limited the pathologist’s ability to read the pap smear.
  • Atypical — The cells don’t look quite normal, but it is difficult to tell what exactly is going on.

Once dysplasia has been detected on a pap smear, the genital area should be examined under magnification — a procedure known as colposcopy — to identify exactly where the dysplasia is located, followed by removal of the dysplasia if indicated.

There are a number of ways to remove the abnormal cells created by dysplasia. They include:

  • Loop excision — This technique uses a fine wire loop with electrical energy flowing through it to remove the abnormal area of the cervix. The removed tissue is sent to the laboratory for examination.
  • Cone biopsy — This is an outpatient surgical procedure in which a cone-shaped section of the cervix is removed using a scalpel. The tissue is then sent to the laboratory for examination.
  • Laser therapy — Laser therapy uses a tiny beam of light to vaporize abnormal cells. The laser is directed through a colposcope so that the area and depth of treatment can be controlled precisely.
  • Cryotherapy — In cryotherapy, a probe is used to cool the cervix to sub-zero temperatures. The cells damaged by freezing are shed over the next month in a heavy watery discharge.

For other abnormal pap smears, the next step usually is to repeat the test. Sometimes, the practitioner will prescribe antibiotics or hormones, either oral or vaginal, before repeating the pap smear.

Abnormal Menstrual Periods

Missing or absent menstrual periods, when not due to pregnancy, usually have a hormonal cause.

One of the most common of these is menopause, in which a woman stops having periods because her ovaries are no longer producing estrogen. Other reasons for absent menstrual periods include:

  • Lack of ovulation
  • Excess prolactin secretion by the brain
  • Thyroid disorders
  • Eating disorders
  • Excessive exercise

Rarely, absent menstrual periods can be caused by scarring of the uterine cavity as a result of a medical curettage procedure.

You may be experiencing an abnormal menstrual cycle if:

  • your menstrual cycle is longer than 31 to 35 days apart
  • day one of your period to day one of your next period is shorter than two weeks
  • you need to change tampons or sanitary pads after only one or two hours
  • your period lasts longer than 7 days
  • you suddenly begin experiencing severe menstrual cramps

See your health care provider if you experience any of the above symptoms.

Treatment options are selected once the cause of the infrequent or absent menstrual periods has been identified. Treatment may involve lifestyle changes, such as moderation of diet or exercise habits, and hormonal medications such as oral contraceptive pills, thyroid medication or estrogen replacement therapy.

Peripheral Artery Disease

Peripheral artery disease (PAD) is a progressive narrowing of the blood vessels not within the coronary, aortic arch vasculature, or brain. It is most often caused by atherosclerosis, the collection of plaque or a fatty substance along the inner lining of the artery wall. Over time, this substance hardens and thickens, which may interfere with blood circulation to the arms, legs, stomach and kidneys. Blood circulation to the brain and heart may be reduced, increasing your risk for stroke and heart disease.

While PAD can affect anyone, one of out three diabetics over age 50 has the disease. Approximately 5 percent of the population over the age of 65 has detectable arterial blockage in the legs. About 20% of patients with mild PAD may be asymptomatic.

If untreated, it may result in severe disability and in serious cases, leg amputation. Up to 70 percent of all limb amputations not caused by trauma are performed on diabetics with severe PAD.

Blockage of the circulation in the legs is a common sign of atherosclerosis, or hardening of the arteries. Poor circulation of the legs also can be the result of less common causes including aneurysms, the compression of arteries and dissections or internal tears extending along the length of the artery.

While many patients with peripheral artery disease (PAD) have mild symptoms or no symptoms at all, about one in 10 experiences painful cramping or fatigue in the legs, hip, thigh or calf muscles after walking or climbing stairs, which is relieved by a short period of rest. This condition is called intermittent claudication.

The symptoms of arterial blockage vary by individual, including:

  • Change in the color of the legs
  • Changes in the toenails
  • Coldness in the lower leg or foot, especially compared to the other leg
  • Hair loss on the feet and legs
  • Leg numbness or weakness
  • Sores on the toes, feet or legs that won’t heal
  • Pain when walking, called claudication
  • Pain when at rest
  • Foot ulcers
  • Gangrene

Treatment is based on the degree of blockage and the symptoms present. Many patients can be managed with non-invasive therapies such as lifestyle changes, medication, or both. If your condition does not respond to these approaches, surgery may be necessary. In the most advanced cases, limb amputation may be required.

Treatment may include the following:

  • Lifestyle Changes
    • Smoking cessation
    • Diabetes control
    • Blood pressure management
    • Physical activity
    • Diet low in saturated fats
    • Cholesterol medication
  • Specific medications
    • Medications to prevent blood clots, called antiplatelet therapy, such as aspirin or clopidigrel
    • Medications to lower your cholesterol, called statins, such as simvastatin, atorvastatin or pravastatin
    • Medications that may help you walk, such as cilostazol or pentoxifylline
    • Medications to treat your high blood pressure, called ACE inhibitors
  • Balloon angioplasty where a catheter-guided balloon is inflated inside the affected artery to relieve the blockage
  • Surgery — often bypass surgery to direct blood flow around the blocked area of the artery, or endarterectomy, the surgical removal of plaque from the blocked artery.

Orthostatic Hypotension

Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position. It is also known as postural hypotension, orthostasis, and colloquially as “head rush” or a dizzy spell.

Orthostatic hypotension is primarily caused by gravity-induced blood pooling in the lower extremities. It may also be caused by hypovolemia (a decreased amount of blood in the body), resulting from the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest.

The disorder may be associated with:

  • Addison’s disease
  • Atherosclerosis – build-up of fatty deposits in the arteries
  • Diabetes
  • Certain neurological disorders including Shy-Drager syndrome and other dysautonomias

The incidence of orthostatic hypotension increases with age.

Symptoms, which generally occur after sudden standing, include:

  • Dizziness
  • Lightheadedness
  • Blurred vision
  • Syncope – temporary loss of consciousness

The prognosis for individuals with orthostatic hypotension depends on the underlying cause of the condition.

When orthostatic hypotension is caused by hypovolemia due to medications, the disorder may be reversed by adjusting the dosage or by discontinuing the medication. When the condition is caused by prolonged bed rest, improvement may occur by sitting up with increasing frequency each day. In some cases, physical counterpressure such as elastic hose or whole-body inflatable suits may be required. Dehydration is treated with salt and fluids.

Hyperhidrosis

Hyperhidrosis is the condition characterized by abnormal, profuse sweating, in excess of that required for regulation of body temperature. For some, the abundant sweating is localized to one area, such as the hands, while others may experience increased sweating in a combination of areas.

It can affect one or a combination of the following:

  • Hands, called palmar hyperhidrosis
  • Armpits, called axillary hyperhidrosis
  • Feet, called plantar hyperhidrosis

Hyperhidrosis is rare, affecting about 1 percent of the population. It affects men and women equally, and most commonly occurs among people aged 25–64 years. Some may have been affected since early childhood. There may be a genetic predisposition to hyperhidrosis, as approximately 30–50% of sufferers have another family member afflicted.

Often there is no identifiable cause, but excessive activity of the sympathetic nervous system is believed to be responsible in the majority of those affected. The sympathetic nervous system controls the sweating throughout the body. These nerves primarily affect blood flow to the skin and the function of the sweat glands.

Symptoms of hyperhidrosis often become noticeable during childhood and adolescence. In many cases sweating can be quite severe, affecting everyday life and causing social embarrassment. It is thought that the excessive sweating may be brought on by stress, emotions or exercise. However, it also can occur spontaneously.

The excessive sweating often interferes with daily activities. For example, patients with palmar hyperhidrosis have wet, moist hands that sometimes interfere with grasping objects. Those with axillary hyperhidrosis sweat profusely from their underarms causing them to stain their clothes shortly after they dress. Plantar hyperhidrosis, excessive sweating of the feet, makes ones socks and shoes wet, which leads to increased foot odor.

Many patients with hyperhidrosis try topical medications or herbal remedies to ease their condition, but these efforts have only temporary or no benefit. The only treatment with proven long-term results involves surgical interruption of the sympathetic chain. Interrupting the sympathetic nerves in the chest results in dilation of the veins and arteries in the arm and hand as well as the complete blockage of sweating.

A minimally invasive procedure called endoscopic thoracic sympathectomy (ETS) can be used to treat hyperhidrosis. Using very small incisions, the sympathetic chain is cut or clamped to eliminate the excessive sympathetic nerve activity. Using this approach, the procedure may be done on an outpatient basis with quicker recovery and less scarring than open surgery. The procedure is highly effective in eliminating excessive sweating of the hands in over 98 percent of patients. In addition, the risk of complication is very low. ETS also can be applied in selected patients with axillary hyperhidrosis, or excessiving sweating of the armpits.

Embolization

Embolization is a nonsurgical procedure for clogging small blood vessels and blocking the flow of blood.

Embolization is used to manage complex lesions (abnormal body tissues), such as arteriovenous malformations and combined vascular malformations. It is often used as part of an overall treatment strategy that combines a variety of approaches. Patients may also need embolization prior to surgery to prevent bleeding. When lesions are extensive and surgery is not possible, embolization may improve the overall quality of life by controlling the lesion and lessening the symptoms.

Arteriovenous and combined vascular malformations may require a series of two to three treatments to block all of the abnormal vessels. Treatments usually are spaced several months apart. Long-term follow-up and evaluation is required to determine if re-treatment is necessary.

Your child’s procedure will be scheduled by an Interventional RN or technologist. Before the day of the procedure, your child may be seen in the Interventional Radiology clinic where you will meet the radiologist, nurse practitioner and RN who will care for your child. The radiologist will discuss the procedure with you and answer any questions you may have. The nurse will give you instructions for the day of the procedure.

You will be able to stay with your child until just before the procedure is performed and will be escorted to the surgical waiting area for the duration of the procedure.

Your child will receive general anesthesia and will not experience pain during the procedure.

A doctor called an interventional radiologist places a tiny plastic tube called a catheter through the femoral artery or vein, which is located in the upper leg. The doctor then positions the tip of the catheter into an abnormal artery or vein and injects small foam-like particles or titanium coils. This closes the blood vessel and prevents the flow of blood into the malformation.

X-rays are taken during the procedure so the doctor can clearly see which blood vessels need embolization. When the procedure is completed, the catheter is removed and pressure is applied to the catheter site to prevent bleeding. Embolization usually takes three to four hours.

As your child begins to wake up from the anesthesia, he/she will be taken to the Post Anesthesia Care Unit (PACU) where he/she will be closely watched. You may stay with your child in the PACU. Your child will be admitted to the hospital after the procedure for 6-23 hours. Your child must lie very still and cannot bend his/her leg for 4-6 hours after the procedure. The radiologist will speak to you about the results after the procedure is complete.

After discharge from the hospital your child may experience mild discomfort or pain at the catheter site. He/She may also have a fever of 100° F or less for the first few days. This is normal. You may give acetaminophen (Tylenol) for discomfort or fever, following the instructions on the label. If needed, the doctor or nurse practitioner will give you a prescription for pain medication. To prevent bleeding at the catheter site, it is important that you do not give aspirin or medications that contain aspirin – unless prescribed by a member of the interventional radiology team. Aspirin may make your child more susceptible to bleeding.

Your child will not have any restrictions on bathing or routine activities; however, heavy lifting, stair climbing and contact sports should be avoided for several days.

Embolization is a safe and effective procedure that has been shown to be invaluable in treating arteriovenous and combined vascular malformations. Most patients do not have problems or serious side effects; however, bleeding or bruising can occur at the catheter site. Clotting of an artery or damage to normal tissue can also occur.

Dural Arteriovenous Fistulae

Dural Arteriovenous Fistulae (DAVF) are rare, abnormal direct connections (fistula) betweenarteries and veins in a protective membrane on the outer layer of the brain and spine, called the dura.

These abnormal blood vessels divert blood from the normal paths. If the volume of diverted blood flow is large, tissue downstream may not receive an adequate blood and oxygen supply. An unusually heavy blood flow also can lead to aneurysms or ruptures in the veins.

This condition can be caused by:

  • Head trauma
  • Infection
  • Surgery
  • Blood clots in the brain, called thrombosis
  • Congenital birth defect

Although symptoms of dural arteriovenous fistulae (DAVF) may vary, some of the more common include:

  • An unusual ringing or humming in the ears
  • Headaches
  • Visual problems
  • Stroke-like symptoms

Treatment for dural arteriovenous fistulae (DAVF) depends on the blood vessels involved. Endovascular techniques, which are minimally invasive procedures that are performed through the blood vessels, have been developed to safely treat DAVFs.

One approach used for treatment is embolization, a non-surgical, minimally-invasive procedure that reduces blood flow to the DAVF by obstructing surrounding blood vessels. During this procedure, the DAVF is filled with specially designed coils, glues or spheres that plug the vessels.

Some fistulas can’t be completely blocked with embolization and may require surgery to disconnect or close them. In some cases, doctors may try to close the fistula with what’s called stereotactic radiosurgery or the Gamma Knife.

Cavernous Malformations

Cavernous malformations, also called cavernous angiomas and cavernomas, are abnormal clusters of dilated blood vessels. These masses are made up of little pockets, called caverns. They are filled with blood and lined with a special layer of cells, called the endothelium. Ranging in size from microscopic to inches in diameter, cavernous malformations can be located anywhere in the body including the liver, rectum, kidney, eyes, nerves, spinal cord and brain. Those that develop in the brain or spinal cord, called cerebral cavernous malformations (CCM), are the most serious.

About one in 200 people have a cavernous malformation, affecting men and women almost equally and occurring in people of all races, sexes and ages. In some cases, these malformations may run in families and are inherited. The abnormality either occurs spontaneously, typically with one lesion or frequently, producing many lesions.

Cavernous malformations usually are not diagnosed until they start causing symptoms. Clinical symptoms typically appear between 20 to 30 years of age. When possible symptoms appear, your doctor may recommend a magnetic resonance imaging (MRI) scan, which remains the best way to diagnose cavernous malformations.

Approximately 15% of people with cavernous malformations may not experience any symptoms at all, while others may suffer from a variety of effects. Symptoms typically depend on the location of the malformation and may include:

  • Seizures ranging in severity, duration and intensity
  • Neurological deficits, such as weakness in arms and legs as well as problems with vision, balance, memory and attention
  • Headaches ranging in severity, duration and intensity
  • Bleeding, called a hemorrhage, in the brain that may damage surrounding brain tissue

Currently, the treatments available for cavernous malformations include observation and surgery.

  • Observation — If your cavernous malformation does not seem to be causing any problems, your doctor may recommend that the malformation simply be observed with yearly magnetic resonance imaging (MRI) scans to detect any changes.However, it is impossible to predict what will happen with any cavernous malformation. Some will cause repeated hemorrhages with worsening symptoms, while others remain inactive and do not cause symptoms for many years.
  • Surgery — Surgery is often recommended for the treatment of cavernous malformations. Because these malformations are so distinct from the surrounding brain tissue, they can at times be completely removed and cure associated seizures. It is very important to remove the entire malformation because it can grow back if a small piece is left behind. The risk of the operation depends on the size and location of the cavernous malformation and your general health.

Carotid Artery Disease

Carotid artery disease refers to a narrowing within the carotid arteries (the arteries that supply blood and oxygen to the brain). It is usually caused by the buildup of plaque within the artery (atherosclerosis).

Blockages caused by atherosclerosis in the carotid arteries cause about 25 percent of preventable strokes. Stroke is the third leading cause of death in North America.

Risk factors for atherosclerosis include:

In its early stages, carotid artery disease may not have any symptoms until you experience what’s commonly called a “mini-stroke” or transient ischemic attack (TIA). If your doctor suspects you have carotid artery disease, it can be easily diagnosed using ultrasound or other imaging technology.

Strokes occur when pieces of the diseased artery break off and travel into the brain, eventually blocking blood flow, causing part of the brain to die. This can either cause a full-blown stroke, resulting in permanent neurological problems in a minority of people, a or a transient ischemic attack (TIA), which produces the same symptoms as a stroke but resolves in less than a day, often in a matter of minutes.

Symptoms of both stroke and a transient ischemic attack (TIA) include:

  • Weakness, numbness, or paralysis of a limb or one side of the body
  • Inability to speak or articulate clearly
  • Blindness or other visual changes in one or both eyes
  • Sudden, severe headache
  • Dizziness or difficulty walking

Along with atherosclerosis, there are other less common conditions that also can affect the carotid arteries, including:

  • Aneurysms, or swelling of the artery
  • Carotid artery dissections, where the wall of the artery splits
  • Carotid body tumors, which are tumor that arises from and involves the carotid arteries
  • Fibromuscular dysplasia, an inflammatory condition of the artery
  • Inominate artery disease, or blockages in an artery below the carotid artery
  • Recurrent blockages after prior carotid artery surgery

Mild to moderate blockages in the carotid artery are treated with medications called antiplatelet agents, such as aspirin, that block the formation of blood clots. In addition, treatment involves identifying and reducing risk factors, such as cigarette smoking and high blood pressure.

Ultrasound studies are repeated over time to monitor the blockage.

If your carotid artery disease progresses, you may need surgery. Carotid endarterectomy surgery is currently the best treatment for reducing the risk of stroke in patients with severe blockages in the carotid arteries.

Carotid artery endarterectomy involves:

  • Opening the artery
  • Removing the plaque that is causing the narrowing
  • Closing the artery, usually with a synthetic patch

During surgery, a temporary bypass is often used to allow blood to flow around the area of surgery as it travels to the brain.

Not all patients are candidates for surgery, particularly those patients who are in overall poor health or have other health issues.

Other non-surgical options to treat blockages in the carotid arteries include balloon angioplasty and stents. Both of these procedures use a catheter-guided balloon, inflated in the blocked area, to open up the carotid artery. A metal stent may be inserted to help keep the artery expanded.

Currently, angioplasty and stents are recommended only for patients who aren’t candidates for conventional surgery because the risk of stroke during the procedures and the long-term results are still being studied.