Articles on Medical Diseases and Conditions

Month: July 2009

  • Sexual relationships: Difficulties with erections

    First, it may be helpful just to explain a little of the ‘mechanics’ of an erection. The penis is made up of the ‘urethra’, which runs through it and carries both urine from the bladder and semen from the testes, and which is surrounded by the ‘prostate gland’. On the underside of the penis, and running along its length, is a mass of spongy tissue called the corpus spongiosum. Alongside this spongy tissue are two ‘chambers’ called the ‘corpora cavernosa’ in which millions of tiny pockets fill up with blood during an erection. Special cells in the penis limit the flow of blood into these pockets most of the time, for otherwise there would be a perpetual erection! When these special cells ‘relax’, they allow the pockets to fill with blood, and thus the penis becomes erect, and when they ‘contract’ the blood is expelled and the erection subsides. A range of enzymes and other chemical substances work together to facilitate blood flow into and out of the penis.
    Erections may not occur, either because of vascular problems, i.e. problems in the blood supply to penis, or, and much more likely in MS, problems in the control of erections through the nervous system, which controls the process of erection and ejaculation.
    Managing erectile problems in principle involves attempting to deal with the problems in the nervous system; dealing with problems in the vascular system, and in addition dealing with psychological and related issues. For many men with MS with erectile problems, drugs like Viagra have appeared to provide an immediate and helpful way forward.

    Viagra and other help for erections

    The introduction of Viagra was a breakthrough in the management of erection problems. Two more drugs, Cialis and Levitra, have now been added to the options available. It is important to explain how this type of drug works. They do not repair any of the nervous system damage caused by MS. Essentially they act on the vascular problems in MS, by assisting the penis to fill with blood. They do this by breaking down an enzyme (a chemical messenger in the blood) that is preventing or seriously slowing down the process of engorgement of the penis. By magnifying the effectiveness of the erectile process, even where this was previously weak or virtually non-existent, erections can be maintained as long as the drug effect lasts. These drugs may be able to help such problems in many men with MS; indeed, there is very strong evidence that men with erection difficulties caused by Multiple Sclerosis are likely to benefit from them.
    At present they are taken orally (by mouth) and, because of the relatively slow digestive process, it may be an hour or two before the drugs produce their ef fects – certainly an issue in planning sexual activity. Viagra, Cialis and Levitra affect not just the penile area, but have potential ef fects all over the body, so there may be some side ef fects elsewhere. Your cardiovascular health will be carefully assessed before they are prescribed. Not everyone will benefit, although firmer, more frequent and longer lasting erections have been found in two-thirds to four-fifths of men who used Viagra.
    Because the drugs are costly, and the demand is assumed to be large, the Department of Health has been extremely circumspect about those who can be prescribed them. However, MS is now one of the designated medical conditions by the Department of Health for which these drugs can be prescribed, and so there should be fewer difficulties in obtaining them on these grounds, although there may still be local variations in supply plus, of course, any clinical reasons for their non-prescription.
    Currently there are a number of other drugs under development, which promise similar overall effectiveness to that of Viagra, but with a greater immediacy and convenience of use. In particular the aim has been to ensure as far as possible that spontaneity can be preserved in relation to sexual activities. The forms in which Viagra can be used are also being developed and before long there will be several different ways in which it can be administered.

    Side effects
    With the publicity for these drugs have come reports of some potentially dangerous and unpredictable effects. We need to clarify the position.
    We have already noted that they work on the vascular system. Most reports have centred on vascular incidents, such as deaths from heart attacks. There are several points that need to be made here. In the population at large, impotence and erection problems increase with age, and so statistically much of the demand has come from older men. However, cardiovascular problems – heart disease and high blood pressure – also increase with age. Although these drugs have been found to enhance erectile function in those with such problems, men who are taking medications such as organic nitrates, which reduce blood pressure, e.g. nitroglycerin (trade names Nitro-bid, Nitrostat), isosorbide dinitrate (trade names Isordil, Sorbitrate), pentaerythritol tetranitrate (trade names Penitrol, Peritrate), and erythrityl tetranitrate (trade name Cardilate), may well suffer a dangerous further drop in blood pressure by taking such drugs. Such medications are also likely to be prescribed more to older men. In addition, and a rather obvious point, sexual activity, and particularly sexual intercourse, involves vigorous exercise, and men who have undertaken almost no exercise for several years, perhaps with an underlying undiagnosed cardiac problem, may find themselves in difficulty – as in undertaking any vigorous activity without prior preparation. The doctor prescribing these drugs will understand these problems. However, because many men with MS are in younger age groups than those in which major problems have occurred, it is likely that the difficulties will be found to be fewer amongst most men with MS.

    Other help available

    Even if the nerve pathways from the brain to the penis are damaged in the middle or upper parts of the spinal cord, the pathways in the lower part of the spinal cord may still be intact. If this is the case, stimulating your penis directly, most helpfully with a vibrator, could result in an erection. You could also induce an erection by placing the (non-erect) penis in your partner’s well-lubricated vagina – with your partner sitting astride you. However, it is important that this is undertaken carefully, for if sensation levels are low, your penis might be damaged by being folded over, without this problem or any subsequent injury, being realized at the time.
    There are a range of devices used in treating men’s erectile problems, although many of them are now being replaced with Viagra or other related drugs, because they are less intrusive and more effective.

    Vacuum pumps
    The least intrusive of these options is the vacuum pump, which should be available to you on prescription. A tube is placed over the flaccid penis, sealed at the bottom round the base of the penis, and air is pumped out either manually or by a battery-operated pump. This causes blood to enter the penis and for it to become erect. A band is then slipped from the bottom of the pump around the bottom of the penis, the pump removed and the penis then stays erect with the blood trapped inside. It is important not to keep the band round the base of the penis for longer than 30 minutes, and the placing of the band round the bottom of the penis may require some dexterity.

    Injections, prostheses and aids
    Other more intrusive forms of erectile assistance include penile injections that relax the smooth muscle normally inhibiting blood flow into the penis, thus allowing an erection; or penile prostheses that can be inserted surgically that allow an erection to take place with various forms of mechanical assistance.
    There are a wide range of issues and concerns relating to the use of penile injections and prostheses, and both require an exceedingly well- organized and planned approach to sexual activity, and intercourse in particular, which some have found difficult to reconcile with anticipated emotions and feelings. If Viagra, Cialis or Levitra are not available, then you should seek a referral from your GP or neurologist to a physician specializing in these other techniques.
    There are also a number of artificial aids that do not require medical consultation or prescription, and these may include latex or similar penises, some of which are hollow and can incorporate a flaccid penis. Vibrators and other aids in the form of a penis are also available in sex shops or by mail order.

  • Sexual relationships: Problems for women

    In general women’s sexual problems are cantered on a lack of desire, arousal and orgasm. Lack of desire is the chief complaint among women. A woman’s lack of sexual interest is often tied to her relationship with her partner. It can also be triggered by family concerns, illness or death, financial or job worries, childcare responsibilities, managing a career and children, previous or current physical and emotional abuse, fatigue and depression – as well as by the MS itself. Thus the issue is often trying to deal with a range of factors in managing sexual problems. Nonetheless there is a particular set of problems that may occur as a result of the Multiple Sclerosis, particularly cantered on arousal, and subsequent problems of lubrication.
    The process of sexual arousal is similar in women to that in men: in women the engorgement of the sexual organs (the clitoris and the inner and outer labia round the vagina), and lubrication by internal secretions, occur. For many women such a process is not just an aid to sexual intercourse, but also a considerable aid to sexual pleasure. In MS nervous system control of the process of engorgement is likely to fail – parallel to the process of erection in men. Furthermore, sensations in the breast and genital area may be also affected.
    The usual – and it must be said – still relatively common view in such circumstances is that artificial lubrication, through the use of a lubricant such as K-Y Jelly, is sufficient to deal with problems such as vaginal dryness but, whilst such lubrication can help sexual intercourse, it may well not deal with the complex range of other issues that surround sexual arousal and fulfilment in women.

    Exercises for women

    Although there are several possible causes of your loss of sexual drive, and thus several possible approaches to managing the difficulty, as far as some of the physical components are concerned, the female orgasm involves – amongst other things – the contraction of several sets of muscles around the vagina. There is increasing evidence that exercising these muscles can assist in providing the conditions for better sexual responsiveness. Relevant exercises involve periodically squeezing and then releasing the pubococcygeus muscle – the one that starts and stops urination in mid flow – several times a day if possible. This can help tone the muscles, and possibly enhance vaginal sensations, which may help responsiveness.
    If you have no partner, or indeed wish to attempt to do something yourself to enhance your sexual life, then there are a range of things you might try, including the use of fantasy, or sexually explicit books or magazines, and physical exploration of yourself. Some women use vibrators to provide additional physical stimulation. Although it is difficult to create sexual sensations to order, using one or other of these might help you to regain some of your libido – even if this requires more imagination than usual! Remember that some women without MS do not have perfect and completely satisfying sexual lives!

    Viagra, Cialis and Levitra for women

    In principle, these drugs could help to enhance sexual pleasure by promoting the engorgement of the clitoris and the inner and outer labia. Until relatively recently, although there are reports of individual women who have found Viagra helpful, there have been few systematic studies of women’s sexual response using the drug, and none in relation to women with Multiple Sclerosis. Women may feel that this again shows very particular gender priorities in the testing of such drugs.
    However, although a number of studies show that women tend to report more sexual problems then men, there is less evidence that a drug such as Viagra will assist with many of their problems. By and large, the major problems for many women are concerned with desire and arousal, rather than with the engorgement of their sexual organs alone. In particular, as it has been graphically put, often ‘the most important sex organ for women is between the ears, not in the genitals’. Thus it is not at all clear that many women as might be expected will be helped by the physical effects of such drugs alone, although it is important to note, for some women with MS in particular, the local genital effects of such a drug might be beneficial when there are difficulties, for example, with lubrication. Nonetheless many drug companies over the last two years or so have begun the development and testing of drugs, which potentially may have a range of effects on women’s sexual desire, in addition to similar effects to those of Viagra.

  • Sexual relationships

    Many people are diagnosed with MS at a time when they are, or may be about to become, sexually active in their relationships. The issues associated with how best to manage sexual activity and MS have in the past often proved difficult to discuss with others. However, increasingly, both doctors and other health professionals concerned with MS are aware of the importance of such issues and are able to offer helpful support and advice. In this chapter, we address some of the common worries that men and women with MS, and their partners, may have. Multiple sclerosis – the ‘at your fingertips’ guide contains more information on this subject. We start with a discussion about problems with erections, common issues affecting men with MS, and their sexual relationships.

  • A Diagnosis of High Blood Pressure

    If your doctor diagnoses you as having hypertension, your ?rst reaction may be surprise, because you feel ?ne. That is not unusual. High blood pressure usually has no symptoms, and many people go for years with- out knowing they have it. Your heart, brain, and kidneys can handle increased pressure for a long time, and you can live for many years with- out any symptoms or discomfort. But getting treatment to lower your blood pressure is extremely important, because hypertension is a major risk factor for serious disease.
    High blood pressure can affect your body in six main ways:
    • Atherosclerosis Uncontrolled high blood pressure can cause the walls of the arteries to thicken and become less ?exible. Fatty deposits are more likely to form on the rigid walls, and the chan- nel in the artery narrows.
    • Stroke If a blood clot forms and lodges in a stiffened artery trav- eling toward your brain, it can cause a stroke. If the clot is in an artery that supplies blood to your heart, it can cause a heart attack. High blood pressure may also cause a stroke if a weakened blood vessel ruptures.
    • Aortic aneurysm High blood pressure contributes to the widening of a weakened aorta, and an aortic aneurysm can be fatal if untreated.
    • Enlarged heart High blood pressure forces your heart to work harder. Over time, the muscle thickens and stiffens, or the heart muscle may enlarge and weaken. As it weakens, it pumps less ef?- ciently, and you will feel weak and tired more often. Fluid may back up and congest the lung tissue.
    • Kidney damage The kidneys ?lter waste products from the blood. If the vessels of the kidneys are thickened and damaged,

    your kidneys will begin to fail, causing waste to build up in the bloodstream. Treatment for kid- ney failure requires dialysis, a mechanical means of ?ltering the blood.
    • Eye damage If you have diabetes, high blood pressure can cause the capillaries in your eyes to bleed. This condition, called retinopathy, can eventually lead to blindness.

    These potential complications of blood pressure are genuinely alarming, but remember, blood pressure can be significantly lowered with treatment. The great decreases in death from heart disease and stroke in this country in recent years are partly the result of success- ful treatment of high blood pressure, speci?cally:
    • The incidence of stroke can be reduced by 35 to
    50 percent.
    • The incidence of heart attack can be decreased by
    20 to 25 percent.
    • The incidence of heart failure can be decreased by more than 50 percent.

    The Silent Disease

    Some people think that high blood pressure causes symptoms such as nervousness, sweating, or difficulty sleeping. None of these is a symptom of hypertension, and these are not necessarily related. Many people who look and feel perfectly fit have high blood pressure, while some peo- ple who are overweight, smoke, or show other risk factors for heart disease have normal blood pressure. That’s why the only way to know for sure if you have high blood pressure is to be tested.
    A person with severe, un- treated high blood pressure may have headaches, dizziness, or nosebleeds, but probably not until the condition has reached an advanced, life-threatening stage. Again, even many people with uncontrolled high blood pressure still do not have any of these symptoms. Getting tested and getting treatment are the only answers.

  • Factors That Increase Your Risk for High Blood Pressure

    The vast majority of people—90 to 95 percent—with high blood pres- sure have a type called essential or primary hypertension, which means that the exact cause or causes are unknown. In other people, high blood pressure may occur because of an underlying problem such as a blood vessel abnormality, kidney disease, or thyroid disease.
    However, there are well-known factors that increase your risk of developing high blood pressure or tend to worsen an existing condition. If one or more of these risk factors applies to you, you are at greater risk.
    You may have these factors contributing to hypertension, some of which are not within your control:
    • Gender Men are somewhat more likely to develop high blood pressure until age 70 than women, but after age 70 women are at greater risk.
    • Race Blacks develop high blood pressure more often than whites, and it tends to develop earlier and be more severe.
    • Family history If your parents or siblings have high blood pressure, you are more likely to develop it.
    • Age Generally, the likelihood that you have high blood pressure increases as you age. However, it is not a normal part of aging, and some people never develop it. Men tend to develop it after age
    . Women are more likely to have it after menopause. Other factors are within your control:
    • Weight As your body weight increases, your blood pressure rises.
    • Lack of exercise An inactive lifestyle increases your likelihood of being overweight and of having high blood pressure.
    • Salt Many people with high blood pressure are sensitive to salt;
    eating too much salt raises blood pressure in most people.

    • Unhealthy diet A diet low in fruits and vegetables or high in fat increases your risk of developing high blood pressure.
    • Drinking too much alcohol Heavy regular intake of alcohol can increase blood pressure signi?cantly.
    • Medication Over-the-counter decongestants and nutritional supplements may increase blood pressure. Birth control pills may also increase blood pressure in some women.

  • Measuring Blood Pressure

    Because your heart pumps in pulses, your blood pressure naturally rises and falls with each surge, even when you are at rest. Blood pressure peaks when the heart’s ventricles contract (the pumping or systolic phase) and falls to its lowest level after the contractions (the resting or diastolic phase). To accurately assess blood pressure, you need a reading for both phases, systolic and diastolic.
    You have probably had your blood pressure measured many times—just about every time you have any kind of a physical checkup. The familiar instrument your doctor uses, the blood pressure cuff and pressure gauge, has an unfamiliar name: sphygmomanometer.

    This instrument works by measuring how high the pressure in an artery in your arm can raise a column of mercury, so the measurement is expressed in millimeters of mercury (mm Hg). The reading is always expressed with the sys- tolic (pumping) pressure on the top and the diastolic (resting) pressure on the bottom. A healthy reading in an adult is less than 120/80 mm Hg.

    6

    Checking your blood pressure
    If you have been diagnosed with high blood pressure, your doctor will encourage you to acquire and use a device for monitoring your own blood pressure at home. This is especially important if you are taking new medica- tions or if your drug dose has been changed.

    Healthy adults should have their blood pressure checked at least every two years. If you have not had it checked recently, make an appointment to do so soon. It is an easy, pain- less, and inexpensive test. You can have a reli- able blood pressure check in many different settings—a hospital clinic, a nurse’s office, a company clinic. You may be tempted to consult the free blood pressure testing units that you see at some drugstores or shopping malls, but you should not rely on them alone. They may not be checked regularly for accuracy, and they may suffer from wear and tear. If you try out one of these machines, record the reading and then compare it with a read- ing from your doctor’s of?ce.
    When you know you are going to have your blood pressure checked, you can do several things to help ensure an accurate reading:
    • Do not drink coffee or smoke 30 minutes before the check; both caffeine and nicotine raise your blood pressure temporarily.
    • Try to arrive at your doctor’s of?ce at least 5 minutes before the check and sit comfortably, so you are not feeling hurried.
    • Wear short sleeves.
    Some people have a response called “white-coat hypertension,” which means that their blood pressure actually rises when they are undergoing a checkup. This phenomenon is quite common. If you or your doctor thinks you may be responding this way, you can try having your blood pressure checked in another setting, or you can buy a blood pressure device to do your own reading at home (see page 55). Your doctor can compare your home and of?ce readings to get a clearer idea of your average blood pressure.

    If your doctor is concerned about your blood pressure, he or she will initially take measurements on several different days, because there are so many normal variations. It is not unusual to have a high measure- ment on a single day and then have it return to normal when you are tested again. Your doctor will probably not diagnose you as having high blood pressure unless your measurement is high on two or more read- ings taken at separate visits.
    If your readings are 120/80 mm Hg or greater over several different days, your doctor will evaluate your condition in other ways. He or she will take a detailed medical history to determine if you have other risk factors for heart disease or stroke. He or she may use an instrument called an ophthalmoscope to look at the blood vessels in your eyes. This is the only place in your body where a doctor can directly look at your blood vessels to see if they are damaged. Thickened, narrowed, or burst vessels in the eyes can be another indication of high blood pressure.

    If your doctor diagnoses high blood pressure, he or she may order several tests. These tests are used to determine if there is an underlying cause of high blood pressure, to detect any organ damage, to assess other risk factors for heart disease, and to identify other conditions that might affect the course of treatment.
    In addition to conducting blood tests, your doctor also might order a chest X-ray (see page
    128) to check the size and condition of your heart and lungs. An electrocardiogram (ECG; see page 122) may provide evidence about whether your heart is enlarged and if there is any damage to the heart muscle. It is not uncommon to have a routine ECG in the doc- tor’s office that reveals signs of an enlarged heart or a previously unknown heart attack.
    You may have blood and urine tests to deter- mine if your kidneys are working properly or if there are any underlying problems causing the blood pressure to rise. In rare cases, people may have an intravenous pyelography, a procedure that examines kidney function by injecting a harmless dye into an artery and watching its passage on an X-ray screen. A few people may need more advanced tests to evaluate blood ?ow, such as an MRI (magnetic resonance imaging; see page 141), a nuclear scan stress test (see page 135), or a coronary angiogram echocardiogram.

    How Blood Pressure
    Testing Works

    The instrument used to test your blood pressure has four parts: an inflatable cuff, a pump, a pressure gauge, and a stethoscope. When you have a checkup, the tester wraps the cuff around your arm and inflates it so that the pressure in the cuff is higher than the pressure in your artery. The flow of blood is momentarily stopped and your heart- beat is inaudible through the stetho- scope. As the cuff deflates, the tester checks the pressure gauge as soon as he or she hears your heartbeat again. At this moment, the pressure in the cuff is the same as the pressure in your artery, and the reading is your systolic pres- sure. As the cuff deflates further, the tester listens for the moment the sound of the heartbeat disappears again— when the cuff pressure goes below the resting pressure in your artery. This reading is your diastolic pressure.

  • Just What Is Blood Pressure?

    As your heart pumps blood through your arteries, the moving blood exerts pressure against the arterial walls. This force is measured as blood pressure. Your blood pressure rises normally in response to many everyday in?uences, such as exercise, caffeine, medications, or stressful situations, and then returns to a normal level. But if the pressure in your arteries is consistently higher than is healthy, your heart needs to work harder and your blood vessels and heart can become damaged.
    Blood pressure is determined by the force of the heart as it contracts (systole) and the resistance of the main arteries and smaller arteries (called arterioles) to blood ?ow. The other force is diastole or relax- ation. Healthy arterioles are muscular and highly elastic and stretch eas- ily as blood is pumped into them. Their ready squeezing action keeps blood moving. When the heart is pumping more blood, as during exer- cise, many of the arterioles expand to accommodate greater blood ?ow. Healthy arteries are also wide open, clear of any buildup or obstruction so that blood can ?ow freely. Diseased arteries lose their elasticity, and pressure rises.

  • High Blood Pressure

    Today, high blood pressure (hypertension) is probably the most modi?able common major risk factor for heart disease and stroke in
    the United States. About one out of every three American adults has high blood pressure, and the numbers are increasing as our country ages and becomes more overweight. High blood pressure can cause damage to the heart, blood vessels, and, over time, the kidneys.
    Current ?ndings suggest that high blood pressure is an even more widespread health problem than previously understood. Today, at age 55, even a person who does not yet have high blood pressure has about a 90 percent chance of developing it at some point in his or her life. Further- more, recent evidence shows that the damage to arteries that leads to heart disease, stroke, and other major problems begins at blood pressure levels that doctors once considered normal. Independent of other risk factors such as high blood cholesterol level or being overweight, the higher your blood pressure, the higher your chance of heart disease or stroke.
    About one third of Americans who have high blood pressure don’t know it. Hypertension is often called the silent killer because by itself it does not cause symptoms, but over time it can cause stroke, heart attack, and kidney failure, any of which can be fatal. Most people who know they have the condition still do not have it under control; that is, their blood pressure levels are higher than is considered healthy.

    These numbers make clear how important it is to get your blood pressure checked, and to start as early as possible to prevent or treat the development of high blood pressure. The very good news is that it’s easy to be tested and treated. Even better, high blood pressure is largely preventable.

  • Medications to Lower Your Cholesterol

    If a healthful diet, regular exercise, and weight loss do not bring your total cholesterol or LDL levels down to your target, your doctor may prescribe a cholesterol-lowering medication, or a combination of more than one. You also may need to take these drugs if you have even mod- erately high cholesterol and also have a medical condition such as heart disease, thyroid disease (hypothyroidism), diabetes, or kidney disease. Your doctor will consider your age and family history as well as your risk status (see box, page 21) to determine what target cholesterol level is appropriate for you, and whether drugs are needed.
    If you are at high risk or very high risk, your doctor may recommend drugs to lower your LDL cholesterol aggressively, to less than 70 mg/dL. If you are at moderate risk, drugs will probably be recom- mended if your LDL is higher than 130. On the other hand, drug ther- apy is not necessarily appropriate for everyone—for example, for frail elderly people who have high cholesterol levels but who do not have heart disease or diabetes.
    It is important to discuss your medical history and lifestyle with your doctor before you begin taking cholesterol-lowering medications. Tell him or her about any other medications, vitamins, or herbal supple- ments you are taking. (Some drugs can interact with one another in a harmful way.) You and your doctor will also need to talk about what other illnesses you have, particularly if you have had liver problems, diabetes, gout, ulcers, or kidney or gallbladder disease, because some cholesterol-lowering medications can make these problems worse.

    There are ?ve main types of cholesterol-lowering drugs, each with a different method of action in your body.
    • Statins (or HMG CoA reductase inhibitors). The most com- monly prescribed cholesterol-lowering drugs are statins, which block the activity of an enzyme (HMG CoA reductase) in your body that helps you make cholesterol. As your cholesterol produc- tion slows down, your liver makes more LDL receptors. These receptors attract LDL particles in your blood and further lower your LDL levels. In addition to lowering cholesterol levels, statins may have other positive effects such as reducing in?ammation and improving the working of the cells that line the blood vessels. Many people can take statins without dif?culty, but the drugs can cause side effects in some people such as constipation, abdominal pain, or cramps. These side effects are likely to lessen or disappear the longer you take the drug. Statins are usually taken at bedtime, because the body produces more cholesterol in the evening. If you develop any muscle cramps or muscle weakness, alert your physi- cian because this might represent a more serious side effect. Mus- cle aches affect both sides of the body and commonly occur in large muscle groups such as those in the shoulders and the thighs. While taking statins, you need to have a blood test periodically to make sure your liver is not being affected by the drugs. Examples of statins include lovastatin, pravastatin, simvastatin, atorvastatin, and rosuvastatin.

    • Bile acid sequestrants (or resins). Your liver uses cholesterol to produce bile, an acid involved in the digestive process. These drugs bind chemically to bile in the intestine, preventing the bile from being reabsorbed; the bile is subsequently eliminated from the body in the stool. Your liver responds by using more choles- terol, which is a building block of bile, to make more bile. As a result, less cholesterol is left to enter your bloodstream. Bile acid sequestrants may have side effects such as constipation, stomach bloating, upset stomach, or heartburn. Examples of bile acid sequestrants are cholestyramine, colestipol, and colesevelam.

    • Nicotinic acid (niacin). This product is a form of vitamin B that slows the liver’s production of certain components of LDL. It also can lower triglycerides and raise HDL. Possible side effects of nicotinic acid include ?ushing, upset stomach, a gout attack, or abnormal heart rhythms. The ?ushing can be reduced by taking an aspirin 30 minutes before taking the nicotinic acid. If niacin is prescribed, it should be started at low doses and increased gradu- ally. Alcohol should not be consumed for two hours after taking niacin because of a possible increase in ?ushing. Episodes of ?ush- ing may be curbed with a chewable adult-dose aspirin or liquid ibuprofen (like aspirin, a nonsteroidal in?ammatory product).

    • Fibric acid derivatives (or fibrates). These drugs inhibit the production of the particles that may contain triglycerides and also stimulate enzymes that break down fats. Fibric acid derivatives may be prescribed to lower your triglycerides. They can cause side effects such as upset stomach, vomiting, gas, or headache, and they may increase the risk of gallstones. Examples of ?brates include gem?brozil and feno?brate.

    • Cholesterol absorption inhibitors. This is a newer class of drugs that inhibits the uptake of cholesterol by the small intestine. Eze- timibe is the ?rst drug developed in this category, and it can be given with any statin. Currently, the statin drug simvastatin is manufac- tured with ezetimibe in a combination pill. Ezetimibe is often pre- scribed for people with high cholesterol levels who cannot take a statin. Side effects may include stomach pain, feeling tired, or aller- gic reactions such as swelling in your throat. Inform your doctor promptly if these side effects occur.

    You may not have any side effects at all from your medications, or you may experience some that are not mentioned here. Be sure to tell your doctor immediately if you think you might be experiencing side effects from the drugs you are taking. But don’t stop taking them without checking with your doctor ?rst; going off medication abruptly can make your condition worse. These drugs should not be used during pregnancy (with the exception of bile acid sequestrants) because the effects on developing fetuses are not yet known.

  • Eating to Control Your Cholesterol

    Choosing foods that are low in saturated fats, trans fats, and cholesterol can lower your cholesterol. You might think that cholesterol in food is the major contributor to elevated blood cholesterol, but that is not the case. The biggest culprits are saturated fats and trans fats. The ?rst step toward lowering your cholesterol through diet is to understand the different types of fats in foods and their impact on blood cholesterol.

    Fats That Raise Cholesterol

    Two types of fats are known to raise your cholesterol: saturated fats and trans fats. If you have high cholesterol, current guidelines recommend that you limit your intake of saturated and trans fats to total no more than 7 percent of the total calories you consume in one day. Saturated fats, which your body uses to make bad LDL cholesterol, mostly come from animal products. Beef, veal, lamb, pork, and whole-milk dairy products including butter, cream, milk, and cheeses are all high in sat- urated fat. Plant sources of saturated fats include tropical oils (coconut, palm, and palm kernel oils) and cocoa butter. These foods are also high in dietary cholesterol. However, the fat in cocoa butter appears to be more neutral and less likely to raise LDL levels.
    Trans fat or trans fatty acid is an unsaturated fat, but it can also raise your LDL levels and lower your HDL levels. Trans fats are made when hydrogen is added to vegetable oils to make them solid and longer last- ing. Trans fats are widely used in commercial baking (crackers, cookies, and cakes) and in restaurants, particularly for frying. They also occur naturally in some foods such as meat and whole milk. Recently the Food and Drug Administration mandated that the amount of trans fatty acids in any prepared food product be spelled out on the food label (see sam- ple label on page 94). Also recently, the American Heart Association recommended that people limit their consumption of trans fatty acids to no more than 1 percent of their total calories each day. However, a label may state “0 g trans fat” but still contain up to 0.5 g of trans fats per serving, so to be con?dent you are controlling the amount of trans fats, make sure the label says the product contains no hydrogenated oil or “partially hydrogenated oil.” The New York City Department of Health recently banned the use of trans fats in restaurants in the city.

    Fats That Lower Cholesterol

    Some fats may actually lower your cholesterol. Both polyunsaturated and monounsaturated fats alike have qualities that help lower your cho- lesterol. They are both good substitutes for saturated or trans fats, but you still need to moderate your intake of fats in order to keep down your total calorie intake. To lower your cholesterol, your intake of all fats combined should be 25 to 35 percent of your total calorie intake per day.
    Monounsaturated fats are found in oils and fruits, such as olive oil and avocadoes. In your body, these fats help your body’s cells resist absorption of fat and cholesterol and slow the buildup of plaque in your arteries. Polyunsaturated fats are found in many nuts and seeds, corn, and soybeans and their oils. It is important to recognize that canola oil has the lowest content of saturated fat among the various pressed oils that are available.
    Foods rich in omega-3 polyunsaturated fats may be especially health- ful, reducing your risk of coronary artery disease, high triglycerides, blood clotting, abnormal heart rhythms, and sudden death. The American Heart Association recommends that you eat at least two servings of baked or grilled ?sh, preferably fatty ?sh, each week. Omega-3 fats or fatty acids are found in ?sh, especially fatty ?sh such as sardines, mackerel, lake trout, salmon, and albacore tuna. However, concerns about the high levels of mercury in mackerel, sword?sh, and tuna have led experts to recommend that adults limit themselves to eating no more than one serving of these ?sh per week. A fetus may be especially vulnerable to mercury, so doctors often recommend that pregnant women limit their consumption of mercury-containing ?sh even more. As an alternative to ?sh, several plant sources are rich in omega-3 fats, including ?axseed and ?axseed oil, soy- bean oil, and walnuts. Soy, though high in total fat, is very low in saturated fat and might have a bene?cial effect on lipids. Soy may be consumed in various forms including tofu, soy milk, and edamame beans.

    Dietary Cholesterol

    Cholesterol is found exclusively in animal-based products. Red meat, whole-milk dairy products, egg yolks, and organ meats are especially high in cholesterol. To lower cholesterol, current guidelines recom- mend that you limit your cholesterol intake to less than 300 milligrams per day, on average. Keep in mind that plant-based foods— fruits, vegetables, grains, nuts, and seeds—don’t raise your cholesterol level, so you can eat more of them.

    Fiber

    Eaten as part of a diet low in fat and saturated fats, ?ber can help lower your cholesterol. A high-?ber diet is linked to lower death rates from coronary artery disease and heart attack.

    Soluble ?ber (a type of ?ber that is partially broken down in your intestine) effectively lowers cholesterol about 5 percent by chemically binding to cholesterol-based substances to remove them from the bloodstream. Adding more ?ber to your diet is one means of enhancing the effects of your overall cholesterol-lowering diet. Soluble ?ber is found in oatmeal and oat bran, beans, peas, barley, citrus fruits, straw- berries, and apples. By contrast, the insoluble ?ber found in wheat products has no cholesterol-lowering effects.

    Plant Stanols and Sterols

    Your doctor may recommend that you start using soft margarines con- taining plant stanols and sterols. These substances are the plant equiva- lent of cholesterol, and they may significantly reduce your body’s absorption of dietary cholesterol from other sources. Margarines con- taining these substances are available at most grocery stores. Liquid mar- garine, spray margarine, or soft margarine in tubs are recommended over hardened margarines in sticks, because those contain hydrogenated fat or trans fat.

    Alcohol and Cholesterol

    You may have read about some studies suggesting that moderate use of alcohol may actually raise your good HDL cholesterol. However, the bene?ts are not clear enough to recommend that you start drinking alcohol if you don’t drink now. People who drink in moderation—one drink a day for women, two drinks a day for men, on average—have a lower risk of heart disease than nondrinkers. But drinking in higher amounts is dangerous to your cardiovascular health in many ways, con- tributing to your risk of developing high blood pressure, obesity, and stroke. Also, for women, more than one alcoholic drink per day increases the chances of breast cancer.