Dysfunctional Uterine Bleeding

(Australia—Australian Family Physician, May 1998, p. 371.) Dysfunctional uterine bleeding is particularly common around menarche and during the perimenopausal period. Once other causes of abnormal bleeding have been eliminated, bleeding can usually be managed by manipulation of the hormonal control of menstruation. The most simple treatment is combined oral contraception, which should re-establish regular and lighter periods. Progesterone alone effectively suppresses bleeding, leading to amenorrhea. Progesterone may also be given during part of the cycle to control flow in regular periods. Gonadotrophin analogs suppress ovarian function and lead to premature menopause. Prostaglandin synthetase inhibitors such as naproxen and mefenamic acid reduce abnormal bleeding by up to 50 percent and can provide effective, simple therapy. In Scandinavian trials, fibrinolytic inhibitors such as tranexamic acid and aminocaproic acid have been reported to decrease flow in cases of severe menorrhagia. Endometrial ablation or surgery are rarely indicated for uncomplicated cases of dysfunctional uterine bleeding.

Hiatal Hernia

(Australia—Australian Family Physician, June 1998, p. 481.) The two types of hiatal hernia are the sliding type and the rolling type. In the sliding type, the gastroesophageal junction migrates into the chest. In the rolling type, the junction remains in the abdomen, but the fundus and upper body of the stomach migrate upward. Rolling hiatal hernia is much less common and is not typically associated with dyspeptic symptoms. Sliding hiatal hernia is frequently associated with gastroesophageal reflux disease and is characterized by heartburn, regurgitation, belching, bloating, cough and asthma. In severe cases, dysphagia and painful swallowing may occur. Endoscopy has largely replaced barium studies in the diagnosis and assessment of hiatal hernia. Manometry and esophageal pH testing may provide useful information. Treatment is indicated if symptoms become problematic. Weight reduction, diet modification, raising the head of the bed and reduction of alcohol, caffeine and nicotine intake are all recommended. A number of antireflux therapies are available, ranging from simple antacids to histamine H₂-receptor antagonists and proton pump inhibitors, and therapy should be individualized to control symptoms. Surgery should be considered in severe and resistant cases of hiatal hernia. Several laparoscopic and open procedures are available, each with specific indications and complications.

Etiology and Management of Snoring

(Great Britain—The Practitioner, June 1998, p. 458.) As the tone of the upper airway musculature decreases during sleep, narrowing of the airway can result in snoring. Snoring may be caused or exacerbated by many conditions, including retropharyngeal fat, space-occupying lesions of the upper airway (including the tonsils and tongue), recession of the lower jaw, conditions such as hypothyroidism that thicken tissues, and use of alcohol or drugs that relax muscle tone. Narrowing of the upper airway may be exacerbated by supine body position and by deep rapid eye movement (REM) sleep. Snoring is associated with hypoxia during sleep that leads to arousal. The combination of poor sleep and nocturnal hypoxia has been blamed for many adverse effects, including impaired work performance and hypertension. Patients should be counseled about weight loss, sleeping position and use of alcohol or sedative drugs. Severe cases of snoring may require nasal continuous positive airway pressure during sleep to ensure a patent upper airway. Orthodontic devices that hold the jaw forward during sleep, tonsillectomy and palatal surgery are not usually helpful. Tricyclic antidepressants that suppress REM sleep were previously used for excessive snoring, but this therapy has generally been discontinued because of side effects.

Carpet Layer's Knee

(Australia—Australian Family Physician, May 1998, p. 415.) Acute infection of the prepatellar bursa is usually associated with sustained pressure or repeated trauma to the knee. Persons with occupations that place them at increased risk for this disorder include carpet layers, gardeners, bricklayers and plumbers. The bursa is tender and may have significant swelling and signs of infection. The location of the swelling and the lack of pain on joint movement help differentiate prepatellar bursitis from septic arthritis of the knee. Turbid fluid containing leukocytes and organisms is obtained on aspiration. The usual infecting organism is Staphylococcus aureus or Streptococcus pyogenes. Drainage provides some symptom relief, but appropriate antibiotic therapy is required in dosages sufficient to penetrate the bursa. Antibiotic therapy is usually necessary for up to three weeks to control infection.