(menorrhagia) Heavy periods

Heavy periods (menorrhagia) affect many women. However it is difficult to be sure what people mean by heavy periods. Heaviness of periods is very subjective. As with many other bodily functions, that which is considered perfectly normal by some might be thought extremely abnormal by others.

Symptoms

An average amount of blood loss during a period (menses, menstruation) is 30 to 40ml (six to eight teaspoons). Measurement of the exact amount of blood lost is very difficult. (Researchers have to weigh new and used sanitary towels, but this is not the sort of thing most of us would want or need to undertake!)
When you are losing excessive amounts of blood, you may keep passing large clots (like liver) and you may need to change sanitary towels or tampons very frequently.
Women vary in how long it is from the start of one period to the next. In some it is less than a month and others it is longer. Some have an irregular pattern. The actual length of the period varies, too, and may be from three to seven days. In menorrhagia, some women have very prolonged blood loss, with only days before the next episode.
Heavy periods may be accompanied by cramp-like period pain, but some women find even their heavy periods painless. (The medical term for painful periods is dysmenorrhoea.)
Persistent heavy periods can lead to thinning of the blood (anaemia), which can cause tiredness, shortness of breath, faintness, and even angina. Symptoms of this sort would usually prompt people to see the doctor anyway.

Causes

Many times there is no particular cause to be found. Sometimes a structural irritation in the womb is to blame, such as a quite common condition where there are localized areas of overgrowth of the muscle wall of the womb (fibroids or fibromyomas), and when there is a coil (or Intra Uterine Device) in the womb.
Heavy periods are more common after sterilization, and happen more in women who are overweight, and also with certain hormonal upsets.

Diagnosis

You should see your doctor if your periods are disrupting your life. Another point to discuss with your doctor is if you get even light bleeding or "spotting" between periods or after intercourse.
Your doctor is likely to examine you internally to check on the womb and the ovaries. At that time you may well have a (PAP) smear taken. Occasionally a sample of the lining of the womb is taken at the time of an internal (vaginal) examination.
The doctor may arrange a blood test to check for anaemia, and possibly for other tests such as thyroid and the reproductive hormones.
If necessary, your doctor may arrange for you to see a specialist (gynaecologist).

Treatment

If you are anaemic, you may need to take extra iron, which your doctor may prescribe, but which may work out cheaper if you buy it over the counter from a pharmacy.
There are medications which can cut down the blood loss. Some of these do not use hormones, and merely work on the way in which the blood clots. Many people see that as an advantage. Some pain relieving anti-inflammatory drugs which people take for period pain do actually cut down blood loss as well.
Other treatments stop the bleeding, but do so by affecting your hormone levels (eg adding progesterone).
The oral contraceptive pill tends to lead to lighter bleeds, which come regularly, and some people find this is the answer for them. There are also hormone treatments which can stop you having periods all together, this may be in tablet form or by injection.
If all else fails, and the symptoms drive you to it, an operation to remove your womb (hysterectomy) is an option, and more recently an operation using lasers or microwave technology has been used to remove the lining of the womb (endometrium), which is the part that bleeds, while leaving the rest of the womb behind.

Depression

Depression is a very common condition, which affects about 5% of people significantly at any one time. It affects mood and brain function, disrupting sleep, home life, work, and relationships.
Treatment may be approached in different ways, and sometimes more than one type of approach can be used at the same time.

Symptoms

Depression brings feelings of misery, tearfulness and sadness. There are many other symptoms which may be present, to varying degrees. These include:

• Tiredness all the time
• Loss of drive
• A sense of uselessness and helplessness
• Loss of appetite and weight
• Weight gain (through "comfort eating")
• Sleep disturbance
• Loss of interest in sex
• Memory problems
• Irritability, and aggression
• Suicidal ideas
• Loss of self worth

If you think you might be or know you are suffering from depression, you should see your doctor.

Causes

In depression there is a relative lack of some of the chemicals used in the working of the brain. These chemicals are known as neuro-transmitters.
Often depression follows stresses, such as deaths, marital/relationship breakdown, job loss, money worries, retirement, etc. Changes in the body's hormones, as after pregnancy, may also be a trigger. There is a connection with the weather in some people - Seasonal Affective Disorder (SAD) where the lower amount of sunlight in the Winter is said to contribute to the depression.
Many times there is no obvious external cause, and it is just one of those things that nature does.

Diagnosis

If you or your family are worried about the possibility that you are depressed, it is wise to see your doctor. Your doctor will ask you to describe your feelings and symptoms, and probably ask some questions to highlight other possible symptoms. These questions may take the form of a questionnaire which allows the doctor to give a score to how you are feeling. This is not only useful at that consultation, but enables monitoring over time and also makes it easier for other professionals to understand how you were at that time.
Depending on your symptoms, your doctor may arrange blood tests to make sure you do not have anaemia, hormone or other chemical disturbance. There are no blood tests as such for depression.

Treatment

There are many ways in which to deal with depression. The "Just pull yourself together" approach does not often work, and, in fact, when the sufferer cannot do this, they feel even worse. Professional counselling can be helpful, as can psychotherapy and psychoanalysis, but these latter two are very time consuming and quite costly.
One of the treatments most readily available to your doctor is antidepressant medication. These may be looked upon as a chemical crutch, which will help you to carry on your daily life. Depression can otherwise make day to day decisions very difficult, that might otherwise be easy. You will probably be able to stay at work, although this must be a decision between you and your doctor, bearing in mind the nature of your occupation.
You will have to decide whether antidepressant medication is right for you, based on your own circumstances, and the advice of your doctor, but they can dramatically improve the situation. They are not to be confused with some of the tranquillisers which were widely used in the past (eg diazepam/Valium), and work in a completely different way.
They are not addictive, as they work by allowing your body to make better use of its own depleted brain chemicals (neurotransmitters). No drug is without side effects, but the side effects of the modern antidepressants are much less than the original ones.
Antidepressants take a while (between two weeks and two months) to have their full effect. To begin with you may notice side effects, which usually lessen after a few days, so if you can, it is worth persevering with the treatment. You should eventually get the benefits of regular, daily use of your medication. Your doctor can advise you on the possible adverse effects of the drug you are to take.
There are a number of different types of antidepressant drug, and your doctor will try to select the one most suitable for your circumstances. Possibly the most likely type you will receive will be a tricyclic antidepressant (eg amitriptyline, imipramine, dosulepin and lofepramine) or a selective serotonin re-uptake inhibitor (SSRI eg fluoxetine/Prozac, citalopram, sertraline), but be guided by your doctor, not what suited your friend or neighbour!
In the normal way of things most people do better staying on their antidepressant treatment for between three and six months. By that time, if you stop the medication, you will usually be back to normal.
It is usually better to step down the dose slowly before stopping, eg once down to the lowest strength tablet or capsule, to taking it on alternate days, then every third day. You should discuss this with your doctor, and if, after stopping the drug, you either get new symptoms or revert to being depressed, you should see your doctor again.

Self help

• Relaxation techniques, meditation, yoga, and self-hypnosis all offer similar benefits, and if you can find a teacher or a class where you can learn one of these it might benefit your physical, as well as your mental health. There are also some good books and tapes on the subject.
  
• Regular exercise is good for the mind and the body.
  
• Eat a healthy diet, with plenty of fresh fruit and vegetables. This is good for mind and body.
  
• Consider slowing down your pace of living. A short holiday might help.
  
• Avoid the things we tend to turn to under stress, as these will probably only make things worse. ie alcohol, too much coffee or tea, tobacco, or illicit drugs.
  
• Try to keep your mind active, eg on a hobby, a book, or watching the TV, rather than dwelling on your feelings, which will only make you feel worse.
  
• If you are feeling desperate, ring the Samaritans, or at least share it with someone. A friend, relative, clergyman, counsellor or medical professional may not be able to solve everything at once, but sharing a problem helps, and the other person will probably be able to help you to find appropriate further support.
  

Prevention

It is impossible to live without stress of any kind, but it may be that there is something about your lifestyle which, on reflection, could be changed to reduce the stress for you. Do not, however make major life decisions while you are depressed. You could make a bad choice, and regret it later.
Part of the problem with depression is not admitting to yourself, or others that you are suffering. What we British call "keeping a stiff upper lip" or "putting a brave face on it" is not always a good thing.
Certainly, once you have had a period of depression, you or your family or friends should be able to recognise the signs a bit earlier if it happens again. If that occurs, seek help from your doctor sooner, especially if you have found a treatment that works for you.

Deep vein thrombosis (DVT)

Deep vein thrombosis (DVT) is the term given to a blood clot forming and blocking one of the deep veins, usually in your leg, but sometimes in the pelvis. DVT does not refer to a blood clot of the veins that you can see on the skin surface (superficial thrombophlebitis) which is usually much less serious.

Symptoms

You may notice one or more of the following:

• Swelling of one of your legs
• Pain and tenderness of one of your legs (coming from inside, not the surface)
• The leg may seem a bit hotter than usual
• The veins on the surface of your leg may be more swollen than usual
• Your leg may be redder than usual, or a bit purple in colour
• Your temperature might be slightly higher than usual

If you think you may have a DVT you should contact your doctor as a matter of urgency to seek further advice.

Complications

Many times DVT will settle without major problems, but it can have serious complications and you should contact your doctor or the out of hours service as a matter of urgency.
The two main possible complications are:

Pulmonary embolism / pulmonary embolus

This is when part of the blood clot in the vein breaks off and moves up, through the heart, to become embedded in the blood vessels of lungs. This is a rare complication, but of those people who have a DVT affecting their thigh, up to one in ten may be affected. Pulmonary embolism is serious, and can be fatal, and it is for this reason that we take DVT so seriously.

Post-thrombotic syndrome

This is a fairly common complication, and may affect between half and three quarters of people who have had a DVT. It varies in severity, and is more likely if the DVT affects the thigh. Post-thrombotic syndrome causes the veins to work less efficiently, resulting in varicose veins, aching and swelling, rashes and sometimes ulcers of the lower kegs.

Causes

The veins are the slow moving blood vessels that return the blood to the heart from all parts of the body. The veins we are talking about here are the ones deep inside your legs and into the pelvis. Normally they have smooth walls and blood continues flowing through them. When you have a deep vein thrombosis a blood clot blocks off one of the deep veins in your leg.
DVT is more common if you:

• are over 40
• are obese (significantly overweight)
• have previously had a DVT or Pulmonary Embolism (PE)
• have one or more close family members who have had DVT or PE
• have cancer or are on treatment for cancer (especially hormone treatment)
• are on treatment for heart failure or similar problems
• have had a recent operation, especially on your hips, knees or legs
• have an inherited blood clotting disorder (rare)
• have had a stroke or are paralysed
• have been stuck in one position for some time on a long journey
• are pregnant or have recently had a baby
• are taking the oral contraceptive pill or hormone replacement therapy

Diagnosis

Your doctor will examine you, looking for evidence supporting the diagnosis as listed under symptoms.
If your doctor suspects a DVT it is likely they will ask for further tests. In UK these are usually done in the hospital and your doctor will arrange this urgently.
These may include:

• a blood test (D-dimer blood assay)
• an ultrasound examination (Compression ultrasound)
• an X-ray with an injection into the vein (venography)

Treatment

In UK this will usually be started in hospital, and involves drugs which slow the blood's natural process of clotting (anticoagulants).
Usually this starts with heparin treatment. This used to be Unfractionated Heparin (UFH), given in to a vein (by intravenous infusion), but there is now another form, Low Molecular Weight Heparin (LMWH), that is given by a simple injection under the skin (subcutaneous injection), which may be used.
It is likely you will be started on tablets which take a while to get into your system, but will take over from the heparin after a few days. (eg Warfarin, otherwise known as a rat poison!) Once blood tests confirm that the oral anticoagulant has reached a level that is having adequate effect on prolonging blood clotting (usually 4-6 days), the heparin treatment will be stopped.
Under certain circumstances (eg pregnancy) the doctors may continue heparin therapy (usually by subcutaneous injection) rather than transferring to Warfarin. In the case of pregnancy, Warfarin may be started after the baby has been born.
Your Warfarin dosage will need close monitoring with regular blood tests. Initially these will be every few days, but once the best dose for you is discovered and the blood test stabilises, you will only need a test every few weeks.
Treatment is usually for a few months, but may be long-term if you have any risk factors that make it more likely that you will get a further DVT.
It may be suggested that you wear a support stocking (graduated elastic compression stocking), especially if your DVT was in your thigh. This helps to reduce the back pressure of blood on the leg veins and cuts down the risk of developing post-thrombotic syndrome.
You will be encouraged to take a regular walk and to keep your legs up when resting.

Prevention

Looking at the list of causes, there are some which we cannot influence, but there some factors we can improve in order to reduce the likelihood of DVT or a recurrent DVT:

• Try to keep your weight in the recommended range.
• Where possible, avoid long periods of immobility.
• Stay active, take regular walks.
• If you have had a DVT while on the Oral Contraceptive Pill or HRT, it is likely that you will be advised to avoid this in future.
• If your DVT has come on during pregnancy or in the post-natal period this does not mean that you can have no more babies, but you should discuss the issues around this with your doctor. This may also suggests that you may be more at risk from the Oral Contraceptive Pill or HRT.
• If an underlying blood clotting problem (eg thrombophilia) is to blame, or there other factors which are likely to lead to an increased ongoing risk of DVT, you are likely to be kept on long-term anticoagulants.
• If you are due to have a major operation, especially on your hip or knee, the surgeon will ensure that appropriate precautions are taken, and may recommend aspirin or heparin. You may be provided with support stockings and sometimes a special inflatable sleeve, attached to a pump is put round your leg during the procedure.

Precautions when travelling

If travelling a long way in a confined space, as in a plane or car:

• Get up and have a walk every now and again.
• Keep drinking plenty of fluid (not alcohol, or drinks containing caffeine, as these end up dehydrating you, which makes the blood thicker and stickier).
• Exercise your calf muscles every now and again, even when you are not getting up.
• Below knee (Class 2) support stockings may help to prevent travel-related DVT.
• There is no evidence that aspirin is effective in preventing travel-related DVT.
• If you are more at risk of developing DVT, and have to take a long flight, discuss it with your family doctor.

Eczema

Eczema is an inflammation of the skin which may cause dryness, flakiness, heat, and probably most importantly, itching. Dermatitis is a term which is sometimes connected, in people's minds, with exposure to chemicals. It really only means inflammation of the skin, and could be used interchangeably with eczema, as it often is by doctors.
Eczema can be caused by a number of different factors, and may result in just a small patch of skin being affected, but can affect skin anywhere on the body.

Symptoms

Whatever causes your eczema, it leads to itching and redness, and may make the skin dry and flaky. Sometimes, itchy blisters form. When these burst, or when scratching damages the skin, the surface may be left moist and crusty.
Often, in the commonest form of eczema (atopic eczema), the problem is worst in the folds of the skin where your limbs bend.
The itch is intense, and makes you want to scratch. You should avoid this if you possibly can, as scratching only makes the symptoms worse. People say that if you have to do anything, gentle rubbing, with the flat of your hands, is better than scratching.
Whatever the cause of your eczema, the skin becomes more sensitive, and you may well notice that you are more easily upset by cosmetics, soaps, detergents, etc.

Causes

Many things cause eczema. The commonest is a general allergic over sensitivity (atopy). This sort of eczema is known as atopic eczema, and it is linked with asthma and hayfever. That is, these conditions often run together in a family.
The other possible causes include:

• Infantile eczema which often affects young babies. This may lead to a patch below their chins, which gets wettest from dribbling, and may be associated with cradle cap.
  
• Contact with substances which irritate the skin chemically. This is caused by direct contact between the skin and the substance, which might be such things as detergents, soaps, diesel or engine oils, strong chemicals, cleaners etc.
  
• Contact with substances which the body has become allergic to. Commonly this involves nickel, rubbers etc. If a woman was sensitive to nickel in the past it would cause a reaction where the bra hooks and suspenders came near her skin, as these typically contained nickel. Plastics have helped to overcome this risk, but jewellery and watches are still a common cause. Suddenly people need to spend a bit more on their presents to you!
  
• Varicose veins can lead to a form of eczema affecting the lower legs. This is known as varicose or gravitational eczema. As well as treatment of the skin, it is important to improve the blood circulation in the legs, and for most people this includes wearing support stockings and staying active on your feet. Your doctor will discuss the options.
  

Diagnosis

Your doctor will usually come to the diagnosis from examining you. If in doubt, or if he or she feels that you need further tests, then you may be referred to a skin specialist (dermatologist).
Further tests may include blood tests, patch tests (where little patches of different substances are stuck to your skin for a few days, to see if you react to any of them) and other allergy tests.

Treatment

There is essentially no cure for eczema. It involves a sensitivity of the skin that you are likely to have to some degree from now on. There are, however, a number of approaches which help to minimise your symptoms.

1. The mainstay of treatment is moisturising the skin. For this we use creams, ointments and shower and bath oils which help to replenish the skin's natural protective oils.
   You should discuss these with your doctor, nurse or pharmacist. Washing tends to dry out the skin and make eczema worse. It helps to use an emollient cream as a substitute for soap, and you can apply it liberally at other times during the day. The special bath oils and shower gels also leave a coating of oils on the skin. Some of the creams and oils contain an antiseptic, as it has been found that eczema often flares up as a result of a germ infecting the skin.
   
2. Your doctor may prescribe a cream or ointment containing a steroid (topical steroid). These are very effective at reducing inflammation and itch. Your doctor will want you to use this sparingly, and only while the eczema is bad. There are different strengths of steroid applications, and the tendency is to use the lowest strength that the skin requires at the time, in order to minimise the risk of possible side effects of using steroids.
   
3. In moderate to severe atopic eczema, where topical steroid treatment has not worked, your doctor may prescribe a new type of treatment to be applied to the skin (topical treatment). The preparations are made from a type of drug known as immunomodulators (calcineurin inhibitors, eg tacrolimus and pimecrolimus) that are used, when taken internally, for such things as preventing rejection of transplanted organs. They are strong drugs, but given as an ointment they do not affect your general immunity, and the main possible side effect is a burning sensation. They are certainly effective on atopic eczema and, used under the supervision of your doctor, may make a difference where the previous treatments were not doing enough. In England and Wales there are guidelines on their usage from the National Institute of Clinical Excellence.
   
4. Antihistamines taken by mouth may be helpful in reducing the itch. Your doctor will advise.
   
5. If the skin becomes obviously infected, which is more likely as its normal protective surface has been damaged, your doctor will prescribe antibiotics.
   
6. There are a number of older fashioned remedies which are still effective and may be suggested by your doctor or specialist. For example tars, menthol.
   
7. Evening primrose oil supplements are used for eczema, and are a safe treatment, but have not consistently proved to be effective in research trials. It would appear that the evidence may not support them being any more effective than capsules or medicine containing no active ingredient (placebo).
   
8. If the skin is not responding well, your doctor will probably ask a skin specialist (dermatologist) to see you. There are a number of options that the specialist may use. These may include:
   
   • Bandages and wet wraps.
   • Drugs to suppress the immune system of the body as a whole. These are only used in severe cases, and include Cyclosporin, a drug otherwise mainly used to stop rejection in patients receiving transplants.
   • Phototherapy. Ultra-violet light treatment (UVB and PUVA) can be used in the treatment of atopic eczema. Ultra-violet therapy potentially increases the risks of skin cancer, so it is only used in severe cases.
9. Naturally, if your eczema is a result of a specific allergy or sensitivity, then it is wise to avoid the thing which causes it if you can.
   

Prevention

• Use the cream or ointment which your doctor recommends on a regular basis, and as a soap substitute, to keep the skin supple and to prevent drying.
  
• Avoid scratching when you itch. If you can not stop yourself, then gently rubbing, with the flat of your hand, is less likely to do damage.
  
• Avoid exposure to chemicals and strong detergents. It is usually better to avoid using biological agents altogether. Use protective gloves when you use such things in the house or at work.
  
• If you have been found to be allergic to a specific substance, avoid contact with it, if this is feasible.
  
• Use your treatments according to the instructions from your doctor and the pharmacist.
  

(Infectious mononucleosis) Glandular fever

Glandular fever (Infectious mononucleosis) is a virus infection causing sore throat, fever, enlarged and tender glands, and sometimes inflammation of the liver (hepatitis). It frequently causes a prolonged period of tiredness and debility.

Symptoms

Glandular fever often starts with a few days of mild symptoms, including headache, and tiredness. The major symptoms then develop, and may last seven to twenty one days. They vary in how badly they affect you, but usually include a fever, sore throat, and tiredness, along with aches and pains all over the body.
This phase of the illness may last a few days to a few weeks. It is accompanied by tender enlargement of the glands (the lymph glands or lymph nodes) which are around the body to help defend against infection.
A small number of people (about one in ten) develop a faint red rash on the trunk and limbs. Sometimes the liver may become inflamed (hepatitis), even to the extent of making you go yellow (jaundiced).
After the worst of the initial symptoms have passed, most people continue to feel tired all the time, and easily exhausted. This is frequently accompanied by depression.
After a period of weeks or months, most people return to normal.

Complications

The spleen, an organ tucked in under the ribs on the left side at the back, is sometimes enlarged in glandular fever. A rare complication is for the spleen to get very swollen and to rupture.
If this happens an urgent operation to remove the spleen is required, as it can lead to heavy internal bleeding. This would probably be associated with abdominal pain and a sudden deterioration in the patient. This is a rare occurrence, but if you suspect such a change in yourself or someone in your family, it is wise to contact the duty doctor.

Causes

The cause of glandular fever (infectious mononucleosis) is a virus known as Epstein-Barr virus (EBV). This is most frequently seen in teenagers and young adults. It is thought to spread in a similar way to many other viruses, from saliva, and is sometimes jokingly referred to as the "kissing disease", as it is often passed from boyfriend to girlfriend or vice versa.

Incubation period

Glandular fever takes about four to seven weeks to come out after contact with someone who has it, although it is sometimes faster.

Infectivity

It appears that someone who catches glandular fever may be infectious for weeks to months afterwards, but just over half of the population have developed immunity while young, with a milder form of the condition. These people are not at risk of catching it again. The rest are more likely to pick up glandular fever as teenagers or young adults.

Diagnosis

Your doctor may suspect the diagnosis from the fact that you have recently been in contact with someone with glandular fever. It may be suspected from your symptoms and the findings on examining you.
Your doctor may ask for a blood test to look for any abnormalities in the white blood cells, and a specific test for glandular fever. If your doctor suspects hepatitis a test will be done to check on the liver.

Treatment

There is no specific treatment for glandular fever. Antibiotics are not helpful, as this is a virus infection. In fact there is one antibiotic, ampicillin, which is more likely to cause a rash if given to people with glandular fever.
You can treat the symptoms of fever and pain with pain killers (analgesics) such as paracetamol or non-steroidal anti inflammatory drugs such as ibuprofen or aspirin (16+ only). You will probably need more rest and sleep than usual for a prolonged period.
Drink plenty of fluids, even if you are off your food.
If you have any evidence of hepatitis you should avoid alcohol until the liver is completely recovered, which might be many months. Your doctor will, of course, advise you.
It is wise not to rush back to full activity too soon, and to build up slowly.
Glandular fever often affects children and young adults at the time of critical examinations, and may well affect revision and even performance in the examinations. If this applies to you, you would be well advised to either consider delaying the examination, or asking your doctor for a letter to present to the examining board before you sit the exam.

Gout

Gout is a condition that most commonly causes a painful, red, swollen, hot joint or joints. It is caused by such high levels of a natural chemical (uric acid) in the blood (hyperuricaemia) that crystals begin to form.

Symptoms

Attacks may last a few days to a few weeks and usually there are long periods between attacks.
Mostly, one joint becomes painful, red, hot, and swollen (inflamed) over a very short time. Most often the first joint to be affected is the big toe, just like the popular image of the person with gout, but in up to a third of people the attack starts elsewhere. Sometimes more than one joint, or soft tissues (muscles, tendons, tissues below the skin) may be affected by inflammation.
Sometimes hard, yellowish lumps are visible close beneath the skin (tophi). Crystals may cause troubles elsewhere, sometimes leading to stones in the kidneys.

Causes

Uric acid is a natural substance, produced by the body as a by-product of the breakdown of old body cells, and from foods we eat. Most of it leaves the body via the kidneys, in the urine. Some is passed out in the bile.

Idiopathic gout

Most times the cause is inbuilt and not a direct result of drinking or eating the wrong things. Where no other cause is identified it is known as idiopathic gout. About 20% of people with idiopathic gout have relatives who have hyperuricaemia or gout. The inherited problem may be one of over-production or reduced elimination of uric acid via the kidneys.

Secondary gout

Certain other conditions, especially affecting the blood, and treatment with some cancer drugs, can cause higher levels of uric acid. Certain food products are high in uric acid (eg offal, meat extracts and fish roe), and alcohol causes increased levels, by producing another substance (lactic acid) which competes with uric acid for excretion.
Kidney failure can lead to high uric acid levels (hyperuricaemia) as can the use of "water tablets" (diuretics).

Diagnosis

Your doctor will be able to tell a lot from the speaking to and examining you. You may well also have a blood sample taken to test the uric acid level. Sometimes a sample of fluid from a swollen joint, or a crystal from one of the lumps near to the skin surface may be looked at under a microscope.
When gout has caused a lot of damage to a joint it may show up on an X-ray, but this does not usually help with making the diagnosis in the first place.

Treatment

In an acute attack, the drugs most likely to be prescribed are the non-steroidal anti-inflammatory drugs (NSAIDs) eg indometacin. These are not usually used if the patient has a history of peptic ulcer or indigestion, or when the patient is on blood-thinning drugs (anti-coagulants), and in certain other cases. If the NSAIDs cannot be used, then your doctor may prescribe colchicine.
If you have a persistently elevated uric acid level and are having frequent attacks of gout, your doctor is likely to suggest the use of a regular preventative (prophylactic) treatment. The most likely suggestion is allopurinol, which is taken daily. This prevents the build-up of uric acid.
An alternative is the use of a drug which causes more uric acid to pass out through the kidneys (a uricosuric agent) eg probenecid.
Your doctor may well continue with the acute treatment when the prophylactic treatment is started, as this may, in itself, cause a flare-up.

Prevention

• Avoid excesses of alcohol or food.
• Lose weight if overweight.
• Avoid offal, fish roe and meat extracts.

Ear wax

Wax in the ears is a common and easily treatable cause of deafness, discomfort, and sometimes noises in your ears (tinnitus).
Ear wax is produced by all of us. It only causes problems when it builds up, which may be due to over-production or difficulties in the natural clearance of the wax.

Symptoms

You may notice a build-up of wax by:

• having increasing difficulty hearing
• pain in your ear or ears
• hearing a noise or ringing in your ears (tinnitus)
• an awareness of something blocking your ears
• temporary deafness after swimming or having a bath or shower

Causes

The skin cells lining our outer ear canals include tiny glands, similar to sweat glands, which produce wax. The point seems to be that this acts as a protective layer, which traps dust and other particles which get into the ear. The wax slowly works its way to the outside, taking the trapped dirt and dust with it.
Most people's ears clear the wax, which probably comes off on our pillows and towels etc., at a rate which means that it does not build up. Some people may, at some stages in their lives produce wax at a faster rate. Other people have either one or both ear canals that is narrow, or that is at an angle which slows the natural passage of the wax. In these people the wax builds up.
The wax may eventually block off the ear canal all together. If this happens, hearing is reduced, and there is an increased likelihood that stagnation may lead to an infection building up behind the obstruction.

Diagnosis

The doctor or nurse will look in your ears. We all produce wax, so what they are looking for is evidence of the wax actually blocking off the ear canal.
Deafness can be caused by other problems in the ear, and if there is not enough wax to explain your problem, the doctor will be able to discuss other possible causes for your symptoms, eg fluid collecting on the other side of the ear drum when the tube which drains from the middle ear to the throat (the eustachian tube) has become blocked, as after a cold.

Treatment

If you think you have ear wax blocking your ears, either buy some wax softening drops, from the pharmacy, or use a couple of drops of warmed (body temperature) olive oil into your ear two or three times a day, for a few days.
After three or four days arrange to see someone regarding having your ears washed out. The nurse at your doctor's office will usually be able to do this for you.
If you have ear pain, a temperature, or are otherwise concerned, you should speak to or see your doctor sooner.
If you know that you have a hole in your ear drum (a perforation), you should not put drops in your ear without having first discussed it with your doctor or a competent medical advisor.

Prevention

• Do not try to clean out your ears by using a cotton bud. (Ear Nose and Throat specialists sometimes say "You shouldn't stick anything in your ear that's any smaller than your elbow!") This may merely act like a ram rod, and could damage the ear drum.
• It may help to wear ear plugs if you work in a particularly dusty environment.
• If you keep getting ears blocked with wax, it may be worth using a couple of drops of olive oil into each ear once or twice a week.

Osteoarthritis

Osteoarthritis is a very common condition, affecting the joints, often described as "wear and tear" arthritis. This can start from our teens and gets worse as we grow older.
The amazing thing is how much it varies from person to person. If you look at two people, who have had identical jobs and identical stresses on their joints through their lifetimes, you could well find one with their joints in virtually pristine condition, and the other with visibly misshapen and painful joints which do not function normally.
Osteoarthrosis and osteoarthritis are terms which are used virtually interchangeably. Osteoarthrosis means a condition where the joints are affected by degeneration. Osteoarthritis implies the same, but the "itis" adds the meaning that the joints are red, hot, swollen, and painful (inflamed).
Most of the time people with this condition do not have inflamed joints, although they may well be painful and, to some extent, deformed. Thus, in truth, osteoarthrosis is probably a more accurate overall description of the condition. However as most people refer to the condition as osteoarthritis, this is the term used below.
Osteoarthritis is not usually a progressive and crippling arthritis in the way that some other forms, such as rheumatoid arthritis, can be. It may begin at a very young age, so do not worry too much that it means you are "over the hill". Changes of osteoarthritis have been found in the bones of teenagers.

Symptoms

The joints that are affected ache and you may feel or hear them crunching or cracking. The range of movement of the joints may be reduced, and they may become visibly knobbly.
Sometimes the pain gets worse, and the joint becomes swollen. This is usually short lived, and the symptoms return to how they were, but you should see your doctor.
Osteoarthritis is more likely to affect your hips or knees, and also the end joints on your fingers, but it can affect any joint.

Causes

The standard explanation for osteoarthritis is that it is a result of "wear and tear". This does account for a large percentage of the problem, but there are many examples of people who have had very similar lives, one of whom will have virtually perfect joints, while the other will have really quite severe osteoarthritis. Thus there must be an inbuilt susceptibility to or, on the other hand, protection against osteoarthritis.

Diagnosis

Diagnosis is usually made by the doctor from talking to, and examining, the patient. When a particular joint becomes worse, your doctor may arrange X-rays and blood tests, to confirm the diagnosis, and to help rule out the more aggressive types of inflammatory arthritis.

Treatment

For the most part treatment is to keep mobile and active, taking pain killers (analgesics) such as paracetamol or paracetamol based medications, and if necessary, especially when the joints are swollen, hot and more painful (inflamed), anti-inflammatory drugs, such as aspirin and ibuprofen.
You should speak to your doctor. He or she will advise appropriately, and prescribe if necessary. Physiotherapy techniques can also be helpful, both in the form of active treatment, and in the form of exercises which you can continue on your own.
The physiotherapist, and sometimes an occupational therapist may advise on aids and appliances to help you get around or to make certain activities easier, in the home or workplace. eg walking stick, rails near the bath, adaptations to taps and electrical plugs etc. Do not let this description worry you. Most people have a mild degree of osteoarthritis, and it is only when it is more troublesome that these sort of approaches are necessary or helpful.
There is evidence that a chemical called glucosamine may help in osteoarthritis. In the UK this is available over the counter, but as the evidence is mixed and seems to suggest better effects from one type of glucosamine than others, NICE does not recommend its use by the NHS.
Another recent addition to the treatments available is a cream to apply to the affected area, which is based on chilli peppers. This again has withstood medical scrutiny and been proven to be effective. You would have to discuss with your doctor whether it is appropriate for you.
If a particular joint or joints are causing problems, which the above methods are not containing, your doctor may refer you to a specialist. Sometimes treatments such as injections to the joint can help, but if the joint is very worn, the question of surgery may be raised.
There are operations to reduce the wear and tear on the joint, but the major procedure used these days is a joint replacement. Though other joints can be replaced, the hip is the replacement that has been going for longest, and in recent years knee replacements have also become widely used. Your family doctor and your specialist will discuss the pros and cons of these procedures.
It is wise not to embark on a joint replacement too soon, as we are living longer these days, and the replacement is likely to wear out or go wrong after a number of years. Subsequent options for further surgery are limited.
Having said that, people who have a joint replacement usually remark on the sudden loss of the severe pain they had before. One drawback can be that the joint is so much better that they do more and notice, as a result, that another part of them is holding them back, and needs attention!

Complementary medicine

There are a number of complementary medical approaches to osteoarthritis, including nutritional medicine, acupuncture, homoeopathy, and herbal medicine. The research evidence on the effectiveness of these is sometimes lacking and conflicting, but many patients find help from one or other of these approaches.

Prevention

Injuries involving the joints tend to lead to an increased risk of osteoarthritis affecting that joint in later life (usually many years later).

• Avoid being overweight. Excess weight increases the load on the joints.
• Remain active.
• Seek advice from your doctor or physiotherapist if you develop joint problems.

Sub-conjunctival haemorrhage

Sub-conjunctival haemorrhage is a leak of blood, from a blood vessel, over the white of the eye (sclera). It looks quite dramatic, but will not do you any serious harm. 

Symptoms

The main thing you will notice is a dramatic red patch over the white of one of your eyes. This is limited to the white of the eye. It usually comes on all of a sudden, with no apparent cause, although sometimes it accompanies an obvious injury.
Frequently you will not notice anything until you get a comment from someone else, or you get a surprise when you look in the mirror. Occasionally there is a slight irritation, stinging, or awareness of something not feeling right. It does not affect the vision. If you have a red eye and problems with your vision you should contact a doctor to look for other causes.
The blood, that has leaked from a tiny blood vessel, shows up dramatically on the white of the eye and may just spread across a segment of the white, or cover almost all of it.
The leaked blood is held in place over the white of the eye by a thin, clear membrane (the conjunctiva). The conjunctiva is fixed to the surface of the eye around the outside of the coloured ring on the eye (the iris) and therefore it is impossible for the blood from the haemorrhage to spread across the central part of the eye that we see through. That means that, although a sub-conjunctival haemorrhage looks dramatic, it cannot harm your vision.
The blood will stay there for some days, and slowly go through the same colours that a bruise does as it is absorbed by the body. It takes longer to change colour than a normal bruise, because the membrane is so thin that oxygen from the air can get to the blood to some degree.

Causes

Most times it is not clear what has caused the sub-conjunctival haemorrhage. It may be that a tiny blood vessel has burst with coughing or sneezing, or something has caught the surface of the eye.
If you have been banged on the eye or face it is clear what has caused the haemorrhage.
On rare occasions it is associated with a problem with the clotting of the blood eg in people taking anticoagulants or aspirin, or people with bleeding disorders.

Diagnosis

Most times you do not need to do anything about a sub-conjunctival haemorrhage.
If in any doubt, however, it may be worth discussing it with a doctor or nurse. This can usually be during routine hours.
Your doctor will make the diagnosis by a quick glance at the eye, but may want to check your blood pressure, and if there is any question about bruising and bleeding excessively in other parts of your body, may also arrange a blood test.
If the haemorrhage has been caused by an injury, especially something like a squash ball in the eye, your doctor will be taking a closer look at the eye to check for any other damage. In such cases it is well worth seeing a doctor more urgently, especially if the vision is affected. In these circumstances it may be better going to the Accident and Emergency Department at your local hospital.

Treatment

No treatment is needed for simple sub-conjunctival haemorrhage. It will settle in a few days. 

 

 

 

 

Thyrotoxicosis

Thyrotoxicosis (hyperthyroidism, Graves' disease) is a condition in which the thyroid gland produces excess thyroid hormone (thyroxine) which results in effects on the whole body. 

Symptoms

 

The thyroid gland, which is in the front of the neck, controls the rate of at which the body's cells work (the metabolic rate). In thyrotoxicosis, the rate of metabolism is increased, and this results in most of the symptoms:

• weight loss in spite of increased appetite
• rapid heart rate
• a fine tremor
• increased nervousness and emotional instability
• intolerance of heat, and excessive sweating
• staring, bulging eyes
• enlargement of the thyroid gland, which is at the front of the neck, at the level of the voice box 
  

Causes

Most often the cause seems to be the body developing an immune reaction against itself, in this case the parts of the thyroid cells which normally act as the receptors for thyroid stimulating hormone (TSH), which is the hormone coming from the gland hanging beneath the brain (the pituitary gland).
This hormone normally stimulates the thyroid to produce thyroxine, so antibodies bound on to these receptors cause production of thyroid hormone, and because it attaches to these receptors better than TSH would, more thyroxine than usual is produced.

 

Diagnosis

In the presence of symptoms such as some or all of those above, your doctor is likely to arrange for a blood test to check on the amount of thyroid hormone (thyroxine) and other tests, looking at other hormones which control or are produced by the thyroid gland. These tests are collectively known as thyroid function tests.
In thyrotoxicosis the level of thyroid hormone is elevated, and the hormone (thyroid stimulating hormone, TSH) that is produced by a gland hanging from the underside of the brain (pituitary gland) to drive the thyroid gland, is almost undetectable.
Especially if the thyroid gland is enlarged and has lumps in it, an ultrasound scan or a scan which involves the injection of radioactive technetium (⁹⁹Tc which tends to concentrate in the thyroid), a radio-isotope scan, may be arranged.

Treatment

Your doctor is likely to prescribe medication known as a thiourea drug (carbimazole, methimazole or propylthiouracil) that will reduce the output of hormone from the thyroid.
This starts off at quite a high dose, and the dose comes down slowly once the blood test returns to normal. Usually most people are able to come off the tablets after a year or two, but sometimes the tablets need to be continued for longer, or restarted.
Sometimes your doctor may prescribe another type of medication, a beta blocker, to overcome some of the worst symptoms of an over-active thyroid gland, while waiting for the specific treatment for the thyroid to take its effect.
Sometimes, in certain cases, a surgical procedure is recommended, to remove part of the thyroid gland. This is known as a partial thyroidectomy. Removing part of the overactive gland results in a drop in the amount of hormone that it produces.
Another treatment that is sometimes used is the injection of radioactive iodine (¹³¹I, a longer lasting isotope than is used for scanning) which is concentrated in the thyroid gland and results in damage to, and destruction of, some of the cells of the thyroid.

Thyroid eye disease

The effects of thyrotoxicosis on the eyes are usually minimal, but when more severe can lead to excessive bulging of the eyes and weakness of the eye muscles. In extreme cases this can put the vision at risk, and specialist treatment is required.

For most people with thyrotoxicosis all that is required is treatment to reduce the excessive levels of thyroid hormone.

 

 

 

 

Sprains and strains

Sprains and strains are a description of what happens to the muscles, and other non-bony structures connected to our bones, when they are put under excessive pressure or strain. The result is swelling, pain, bruising and loss or impairment of function of the affected area.

Symptoms

 

• The first thing you notice is pain, often severe. This is usually at the time of injury, eg "going over on your ankle" or twisting your knee, but some times the damage is done by repetitive and less major strains and the pain becomes apparent later and possibly even the following day.
• Swelling is often obvious, and this is usually very tender
• The area affected may be reddened and rather warmer than usual.
• Bruising usually appears, often away from the area most affected, as blood which is released from the damaged soft tissues (muscles, ligaments, and tendons) seeps out along the muscles and other structures before coming near the skin.
• Pain and swelling causes the part affected to be difficult to use normally. 
  

Diagnosis

If in doubt you should seek advice from a nurse, physiotherapist or a doctor. This may be available nearby at some sports clubs etc., or may come from your own doctor's team, or possibly the accident and emergency department at the hospital.
Most sprains and strains, although painful, can be dealt with by someone who knows first aid, but sometimes there is more extensive damage, eg a broken bone (fracture) or a complete rupture of a muscle or tendon. Sometimes even a straightforward sprain can lead to complications. So if in doubt seek professional advice.

Treatment

The cornerstones of treatment are said to be RICE:

• Rest of the part of the body which has been sprained.
• Ice packs to the affected part. To do this, put crushed ice in a plastic bag (or use a bag of frozen peas), and wrap it in a damp tea towel, to avoid ice burns, and apply that to the area for as long as you can. This helps reduce and minimise swelling, as well as helping with the pain.
• Compression, with a crepe bandage or a stockingette tubular bandage, can help reduce swelling and discomfort.
• Elevation. This means, for example, having a sprained ankle up on a stool, or a sprained wrist supported in a sling.

In addition to this, pain relief and some reduction in inflammation can be provided by taking a non-steroidal anti-inflammatory drug, such as ibuprofen, if you are not allergic to, or likely to be upset, by this. (If in doubt ask the pharmacist or your doctor.)
Straight pain relief (analgesia) can be provided by taking paracetamol.
Some people find an embrocation or liniment applied to the skin helps, but this should not be used on sensitive or broken skin.
Physiotherapy treatments can often help with recovery.
Occasionally, your doctor might suggest a steroid injection. This acts rather like an anti-inflammatory drug, and reduces swelling, pain and inflammation, but the body's natural healing mechanisms are still needed to mend the tissues, and this will usually take quite a few weeks.

 

 

WARTS AND VERRUCAS

Warts and verrucas are small thickened growths on the skin, which are caused by a virus. 

Symptoms

Warts are small growths of the skin, caused by a virus. They have a rather rough surface, and can be unsightly. They do not usually hurt, although they may itch. Warts may affect any part of the body, but are most commonly seen on the hands.
Warts on the feet are known as verrucas. Here the pressure from the body weight causes them to be flatter, but to grow into the skin more, and can cause pain, rather like walking on a dried pea.
Sometimes people have many warts or verrucas, while others only have one or two.

Causes

 It is a virus that causes warts and verrucas. It may be that they can be picked up from direct contact or in swimming pools or changing rooms, but warts and verrucas do not spread rapidly through a family, and it seems to be a question of being more susceptible at certain times in life. 

Diagnosis

 Your doctor, a chiropodist, podiatrist or nurse will be able to confirm the diagnosis, and it is unlikely that any tests will be needed. 

 

Treatment

Warts will heal on their own, given long enough, but this may take years. If treatment is needed there are a number various possibilities:

• Various paints and applications which contain one or more acid eg salicylic acid, and sometimes other chemicals. (Not for sensitive skin. Read the instruction leaflet.) Some of these need a plaster to cover them, while others contain a glue-like substance, which forms a seal of its own. It is important to rub down the area with a pumice stone or emery board once or twice a week, as the skin tends to heap up, protecting the underneath part of the wart or verruca.
  
• Liquid nitrogen can be used to freeze the wart or verruca. Nitrogen, the gas which makes up the majority of the air we breathe, is a liquid at temperatures below -196°C (-321°F). Only a tiny amount is applied, for a few seconds. This will be done by a health care professional.
  The area may be painful and red for a few days after being frozen, but when it settles, the wart or verruca has usually gone. Sometimes more than one application is needed.
  
• A treatment that was found to be helpful in a research project (published in Plastic & Reconstructive Surgery in 1981), involved the use of banana skin. The inner side of a fresh piece of banana skin is placed over the wart and held in place with tape. This is changed daily after washing the affected area. As with other treatments, you should rub down the area regularly with a pumice stone or an emery board.
  
• Another simple treatment that has been found to be effective is applying a piece of duct tape over the wart. You leave this on for 6 days then take it off, soak the area in water and clear off the dead skin with an emery board or pumice stone (as with the other treatments). Leave it open for 12 hours, then repeat the whole process again. This method seemed effective, painless and safe in the rather small medical trial which was published in the Archives of Pediatric and Adolescent Medicine.
  

Very occasionally the wart or verruca does not respond to any of these treatments, and your doctor may refer you to a specialist (dermatologist) to consider stronger treatments.
Warts on the genital areas (genital warts) need a specific type of treatment (usually a paint) and you should consult with your doctor if you have these. They can spread to sexual contacts, so unprotected sexual contact should be avoided until they have been treated.

 

 

Peptic ulcer

Peptic ulcer refers to an area of the stomach or duodenal lining which becomes eroded by the stomach acid. These are known as stomach and duodenal ulcers, collectively known as peptic ulcers.

Symptoms

 

You may notice no symptoms although you have an ulcer, but frequently they are associated with indigestion or pain in the upper abdomen or even lower chest. This pain may be worse before or after eating and frequently wakes you in the early hours of the morning. The pain may go to the back or sometimes be perceived elsewhere.
If an ulcer bleeds you may vomit blood or partially digested blood (which looks like coffee grounds) or pass black stools (melaena), which contain changed blood, when you go to the toilet. If any of these happen call the doctor immediately (even out of hours).

Causes

Many factors make you more likely to have an ulcer.

• It often seems to run in families.
• Smoking increases the risk.
• Heavy drinking.
• Certain drugs eg aspirin and other anti-inflammatory drugs.
• We now know that a large percentage of people who have ulcers have a germ (Helicobacter pylori) in their stomach which they probably picked up many years previously, which makes the ulcer more likely to occur and more difficult to heal. 
  

 

 

Diagnosis

Your doctor may treat you on the assumption of the diagnosis, but may well arrange either a barium meal X-ray or a visual inspection using a fibre-optic tube passed down the throat (upper gastrointestinal endoscopy). The endoscopy is preferred by the experts as they can see the lining of the stomach and duodenum and take biopsies which allow them to rule out more serious conditions as well as looking for the presence of Helicobacter pylori.
A simple blood test or a test which measures the chemicals in your breath may also be used to look for evidence of Helicobacter pylori.

Treatment and prevention

• If you smoke, stop.
• If you drink heavily, stop or cut down.
• Eat small meals regularly.
• Avoid any foods which seem to bring on pain.
• Try simple antacid mixtures or tablets to neutralise the acid. These will usually only ease the symptoms, although very high doses may eradicate an ulcer. NB high doses should not be used without due consultation with a doctor.
• Your doctor may prescribe a tablet which reduces the production of acid in the stomach. This is likely to cure an active ulcer.
• If you have Helicobacter pylori or your doctor has good grounds to think that you may have it, they may well prescribe a course of antibiotics (possibly two types) along with acid reducing tablets. This treatment is aimed at eradication of the bacteria, and as such is likely to cure the current ulcer and make it much less likely that further problems will occur. 

 

 

Migraine

Migraine is a form of headache which is severe and usually one sided, frequently associated with nausea and vomiting. This is sometimes preceded by warning symptoms which usually affect the eyesight and are known as an "aura". 

Symptoms

 

People sometimes feel not quite right prior to a migraine, for example depressed, unusually happy or hungry, and in addition may suffer from visual changes such as flashing, zig-zag lines, or a blind spot. Sometimes the symptoms are even more extreme. The headache is usually one sided although it is not invariably the same side. Quite quickly nausea and vomiting may follow. The bowels may also be affected and in children sometimes there is no headache but abdominal pain instead. 

Causes

Each person is different but there are some "trigger" factors which are commonly involved:

• tiredness
• physical exhaustion
• stress
• climatic change
• hormones, eg period time in women
• foods, eg caffeine, cheese, chocolate, red wine. 
  

 

Treatment and prevention

• Note down your attacks in a diary and try to spot any common triggering factors, and avoid them if possible.
• Try avoiding any food which seems implicated and at a later stage take a small trial dose of the food again to see whether it genuinely is involved.
• At the first symptom of an attack take a pain killer eg aspirin or paracetamol, even if this means waking yourself up when you notice symptoms while half asleep in the early hours of the morning. (Often by getting up time it is too late to abort the attack.)
• Most people find that it helps to lie down in a darkened room, in fact there may be little else you are able to do. In some instances migraine follows a period of rushing around over-stretching yourself, and it might be looked on as the body's way of slowing you down.
• Sometimes bathing your head in cold water or using a cold compress on the forehead is helpful.
• There are some over the counter preparations which contain a pain killer and a medication which stops nausea and vomiting (antiemetic). These are often even more effective than the pain killer alone, as migraine is associated with poor absorption from the stomach and a tendency for food and drink to stay in the stomach much longer than usual (prior to being sick).
• Your doctor may prescribe something along the lines of the above, or possibly one of the more modern specific antimigraine treatments, which work on one of the chemical pathways in the brain.
• If the attacks are frequent and disruptive, then your doctor may prescribe a drug to be taken daily as a preventative.
• Sometimes relaxation and meditation techniques may be helpful as may some of the complementary therapies. 
  

 

(Medial Epicondylitis) Golfer's Elbow

Golfer's Elbow or Medial Epicondylitis is a condition when the inner part of the elbow becomes painful and tender, usually as a result of a specific strain, overuse, or a direct bang. Sometimes no specific cause is found. 

Symptoms

The inner part of the elbow is painful and tender to touch. Movements of the elbow, and also movements which involve lifting, with the hand underneath, palm upwards, hurt.  

Causes

Although called golfer's elbow, medial epicondylitis is much more commonly seen in people who are over using their arm doing something else.
The most common cause is over use of the muscles which are attached to the bone at this part of the elbow. That is to say, the muscles which pull the palm of the hand towards the arm (the wrist flexors). All the flexor muscles of the hand attach to the elbow at the inner part (the medial epicondyle). If they are strained or over used they become inflamed, which means they are swollen, painful, and tender to touch.
Sometimes the inflammation is caused by a direct injury or bang. Sometimes, especially when the cause is direct injury or strain, the muscles are actually partially torn.
Rarely the inflammation comes on without any definite cause, and this may be due to an arthritis, rheumatism or gout. Sometimes the problem is partly or completely due to a neck problem, which is causing pain in the elbow via the nerves from the neck.

Diagnosis

Your doctor or physiotherapist will test for tenderness over or near to the bony bump on the inside of the elbow. He or she will also test to see whether the pain gets worse when you bend the palm towards the arm (flex the wrist) against resistance. In the event of both these signs being present, it is likely that you have golfer's elbow.
Your doctor may also examine your neck, as this may be the cause or part of the problem. After all many of the things that might strain your elbow might also put a strain on your neck.

Treatment

 

• Rest helps, with avoidance of the activities which over use the elbow.
• Physiotherapy treatments, which may include heat / ultrasound therapy.
• Use of anti inflammatory drugs and ordinary pain killers (analgesics).
• Your doctor may suggest an injection of a small dose of steroid to the affected area. This is not the sort of steroid banned for athletes. If used it can last for up to three months, and although it may need to be repeated you seldom need more than two or possibly three injections.