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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Joseph Y. Allen, MD, FAAP
Many patients with panic disorder exhibit only mild levels of avoidance; at the opposite extreme are patients who will not leave the house without a trusted companion birth control gain weight buy 0.18mg alesse overnight delivery. Patients also present with significant variation in their profiles of panicrelated apprehension birth control for estrogen purchase alesse 0.18 mg without prescription, which seem to fall into one or more of several major foci of concern birth control 1950s order alesse 0.18mg without prescription. Sensitivity to these individual differences in the elements of panic disorder is essential for two reasons birth control breastfeeding buy alesse 0.18 mg visa. First birth control pills ovarian cysts purchase 0.18mg alesse overnight delivery, it is important for the patient to feel that the psychiatrist understands his or her individual experience of panic symptoms birth control for women yoga discount alesse 0.18mg on-line. Second, treatment selection, delivery, and response may be influenced by the particular constellation of symptoms of a given patient. It may be helpful for patients to monitor their panic symptoms using techniques such as keeping a daily diary, in order to gather information regarding the relationship of panic symptoms to internal stimuli. Such monitoring can reveal triggers of panic symptoms that may be the focus of subsequent intervention. In addition, it is extremely important when formulating the treatment plan to address the presence of any of the many psychiatric and medical conditions that frequently co-occur with panic disorder. Continuing evaluation and management of co-occurring conditions are a crucial part of the treatment plan. In some individuals, treatment of cooccurring conditions may be required before interventions for panic disorder can become successful. For example, patients with serious substance use disorders may need detoxification before it is possible to institute treatment for panic disorder. However, total abstinence should not usually be a condition of initiating panic disorder treatment, especially if the substance use appears to be triggered by panic disorder symptoms. Evaluating the safety of the patient A careful assessment of suicide risk is an essential element of the evaluation of all patients with panic disorder. Panic disorder has been shown to be associated with an elevated risk of suicidal ideation and behavior, even after controlling for the effects of co-occurring conditions (44). The assessment should include 1) identification of specific psychiatric symptoms known to be associated with suicide attempts or suicide, which include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychosis, mood disorders, and substance use disorders; 2) assessment of past suicidal behavior, including the intent and lethality of self-injurious acts; 3) family history of suicide and mental illness; 4) current stressors such as recent losses, poor social support, family dysfunction, physical illnesses, chronic pain, or financial, legal, occupational, or relationship problems; 5) potential protective factors such as positive reasons for living. Usually, panic attacks are controlled first, but subthreshold panic attacks, anticipatory anxiety, and agoraphobic avoidance often continue and require further treatment (47). The psychiatrist should continue to monitor the status of all of the symptoms with which the patient originally presented and should monitor the effectiveness of the treatment plan on an ongoing basis. Many illnesses, including depression and substance use disorders, co-occur with panic disorder at higher rates than are seen in the general population (33). Other resources provide detailed information about rating scales that may help with ongoing measurement of the severity of panic disorder symptoms and symptoms of co-occurring conditions (48, 49). Many other rating scales for anxiety, panic symptoms, and agoraphobia are available. Psychiatrists may refer to clinical handbooks to find other appropriate measures of panic symptoms as well as measures of common co-occurring illnesses. These handbooks offer descriptions of various rating scales along with information about reliability and validity, administration and scoring, and instructions about how to obtain each scale (48, 49). Before instructing patients to monitor panic symptoms, the psychiatrist should discuss the potential costs. Evaluating types and severity of functional impairment the degree of functional impairment varies considerably among patients with panic disorder. While panic attack frequency and severity contribute to functional impairment, so do the extent of anticipatory anxiety and agoraphobic avoidance. In particular, agoraphobic avoidance can lead to considerable dysfunction in both work and social domains. Levels of agoraphobic avoidance and apprehension have been shown to be stronger predictors of functional impairment and quality of life than frequency of panic attacks (46). Even after panic attacks have subsided, the patient may continue to have significant functional limitations that should be addressed in treatment. Establishing goals for treatment the ultimate goals of first-line treatments for panic disorder are reducing the frequency and intensity of panic attacks, anticipatory anxiety, and agoraphobic avoidance, optimally with full remission of symptoms and attainment of a premorbid level of functioning. Treatment of co-occurring psychiatric disorders when they are present is an additional goal. For example, in the case of pharmacotherapy the initial objectives include educating the patient about panic disorder and medication treatment (including medication side effects), selecting an appropriate starting dose of medication, titrating up to a therapeutic dose, promoting adherence to the medication regimen, and recommending and reinforcing positive behavioral changes. When any psychosocial treatment is pursued, a coherent explanation of how that treatment is thought to influence panic disorder should be provided to the patient. The conceptual model of panic pertinent to the type of therapy or therapies being deployed, principles of treatment, and expected outcomes should be made explicit to the patient. Treatment of panic disorder should also include substantial effort to alleviate or minimize functional impairment that may be associated with panic attacks, associated anxiety, and agoraphobic avoidance. In addressing such functional impairment, it is critical to determine how patients define satisfactory outcomes and desirable levels of functioning for themselves, but also to assist patients who Copyright 2010, American Psychiatric Association. Practice Guideline for the Treatment of Patients With Panic Disorder ment of symptoms than by using retrospective report) of this assessment strategy (54). Providing education to the patient and, when appropriate, to the family Once the diagnosis of panic disorder is made, the patient should be informed of the diagnosis and educated about panic disorder, its clinical course, and its complications. The psychiatrist should convey hope and reasonable expectations for how treatment will influence the course of the disorder. Regardless of the treatment modality selected, it is important to inform the patient that in almost all cases the physical sensations that characterize panic attacks are not acutely dangerous and will abate. Many patients with panic disorder believe they are suffering from a disorder of an organ system other than the central nervous system. Educating both the family and the patient and emphasizing that panic disorder is a real illness requiring support and treatment can be crucial. Regardless of the method of treatment selected, successful therapies of panic disorder usually begin by explaining to the patient that the attacks themselves are not life-threatening. By helping the patient realize that these symptoms are neither life-threatening nor uncommon, education alone may relieve some of the symptoms of panic disorder. In addition to receiving education provided by the treating psychiatrist, patients and their families may benefit from access to organizations and to materials that promote understanding of anxiety disorders and other mental health problems (see Appendix). As with other therapeutic communication, cultural and language differences may need to be considered and accommodated in imparting information about panic disorder to patients and their families. A patient who is homebound because of panic disorder, for example, may have assumed all of the household chores for the family. Remission of this kind of agoraphobic avoidance might lead the patient to engage in more activities outside of the home and create a potential for conflict in the family system. Without recognizing this, family members might tacitly undermine a potentially successful treatment to avoid disrupting their ingrained patterns. Patient education also includes general promotion of healthy behaviors such as exercise, good sleep hygiene, and decreased use of caffeine, tobacco, alcohol, and other potentially deleterious substances. Preliminary evidence suggests that aerobic exercise may benefit individuals with panic symptoms (5659). Given the myriad health benefits of exercise, even if benefits for panic disorder are largely unproven, psychiatrists should consider recommending aerobic exercise. However, in doing so the psychiatrist should consider that fears of physical exertion are common in patients with panic disorder and that exercise may actually trigger panic attacks in some patients (although most patients can tolerate exercise without difficulty) (60). In these individuals, the psychiatrist may wish to incorporate exercise into the treatment regimen more gradually, as the patient experiences symptom relief and develops coping skills for panic symptoms. When co-occurring tobacco use is present, smoking cessation interventions may be useful adjuncts to standard treatments for panic disorder. Epidemiologic data suggest that daily smoking increases risk for panic attacks and panic disorder. Thus, smoking may be a causal or exacerbating factor in some individuals with panic disorder. Psychiatric management may also involve educating nonpsychiatric health care professionals about panic disorder, including the ability of panic attacks to masquerade as other general medical conditions and strategies for assisting patients who are convinced that panic attacks represent serious abnormalities of other organ systems. It is important to ensure that a general medical evaluation has been done (either by the psychiatrist or by another physician) to rule out medical causes of panic symptoms. By the time a psychiatrist is consulted, many patients with panic disorder may already have undergone medical testing, which the psychiatrist should review. Generally, physicians should test thyroid-stimulating hormone levels to rule out thyroid disease and obtain a substance use history (including caffeine, nicotine, alcohol, and other potentially deleterious substances) to rule out overuse, abuse, or dependence that could be causing or exacerbating symptoms of panic disorder. If cardiac symptoms are prominent, an electrocardiogram may be warranted, and if seizures are suspected the physician should refer the patient to a neurologist for evaluation. In fact, attempting to diagnose and treat a variety of nonspecific somatic symptoms may delay initiation of treatment for the panic disorder itself. However, with some patients it may be therapeutic and enhance the therapeutic alliance to undertake assessment that will disconfirm other causative sources for the panic attacks. Therefore, the extent of assessment for medical causes of panic attacks will vary according to the individual patient. Recognition of these possibilities guides the psychiatrist to adopt a stance that encourages the patient to articulate his or her fears. It is also helpful to inform the patient that response is not likely to be immediate and that there may even be an initial increase in anxiety as treatment begins. Patients should be educated that relapses may occur during the course of recovery but that these events do not typically indicate that treatment will be ineffective over time. The psychiatrist should indicate how the patient could obtain help in the event of a severe relapse. For example, the patient might be afraid of somatic sensations that accompany medication use or be afraid to complete an exposure to a feared situation. Agoraphobic avoidance might also cause patients to miss sessions because of fears of leaving the house or traveling. Psychiatrists should acknowledge the possibility that anxiety might sometimes interfere with adherence to treatment and should help patients plan ahead to minimize this possibility. For example, for a patient who fears driving, initially arrangements could be made for a family member to drive the patient to sessions. Family members or other trusted individuals also may play other helpful roles in improving treatment adherence, such as reminding the patient to take medication at scheduled times or giving the patient positive reinforcement for confronting situations previously avoided. Adherence may be limited not only by the disorder but also by practical issues such as scheduling conflicts, lack of transportation or child care, or insufficient financial resources. With regard to scheduling, transportation, and child care issues, it is useful to identify these potential obstacles at an early juncture and help the patient generate possible solutions. Pharmaceutical companies may provide free medications for patients with severe financial limitations, with the exact criteria differing from company to company. Information on patient assistance programs is available from the web site of the Partnership for Prescription Assistance. Finally, incomplete adherence may reflect issues in the psychiatrist-patient relationship. If adherence is not improved by measures such as discussing fears, providing reassurance and nonpunitive acceptance, providing education, and mobilizing family support, it may indicate more com- 10. Enhancing treatment adherence the treatment of panic disorder involves confronting many things that the patient fears. Patients are often afraid of medically adverse events; hence, they fear taking medications and can be very sensitive to somatic sensations induced by them. The short-term intensification of anxiety in association with standard treatments for panic disorder may decrease adherence. For example, some patients may miss or arrive Copyright 2010, American Psychiatric Association. Working with the patient to address early signs of relapse Studies have shown that panic disorder is often a chronic illness, especially for patients with agoraphobia (61, 62). Symptom exacerbation can occur even while the patient is undergoing treatment and may indicate the need for reevaluation of the treatment plan. Because such exacerbations can be disconcerting, the patient and, when appropriate, the family should be reassured that fluctuations in symptom levels can occur during treatment before an acceptable level of remission is reached. Although treatment works for most patients to reduce the burden of panic disorder, patients may continue to have lingering symptoms, including occasional panic attacks and residual avoidance. Other problems, such as a depressive episode, could also develop and require specific attention. Patients should be instructed that panic disorder may recur and that, if it does, it is important to initiate treatment quickly to reduce the likelihood of complications such as agoraphobic avoidance (63). The patient should be assured that he or she is welcome to contact the psychiatrist and that resuming treatment almost always results in improvement. Rarely, hospitalization or partial hospitalization is required in very severe cases of panic disorder with agoraphobia when administration of outpatient treatment has been ineffective or is impractical. For example, a housebound patient may require more intensive and closely supervised treatment in the initial phase of therapy than that provided by outpatient care (64, 65). Home visits are another option for severely agoraphobic patients who are limited in their ability to travel or leave the house. A particular form of psychodynamic psychotherapy called panicfocused psychodynamic psychotherapy (145) has also been shown to be effective in a randomized controlled trial (146), suggesting that under certain circumstances. Other psychosocial treatments for patients with panic disorder have either been found equivalent to placebo conditions. There is insufficient evidence to recommend any proven efficacious psychosocial or pharmacological intervention over another or to recommend a combination of treatments over monotherapy. Advantages of pharmacotherapy include ready availability and the need for less effort by the patient for treatment to take effect. Disadvantages include risks of adverse effects, with roughly 10%20% of patients in clinical trials of common medications for panic disorder specifically citing medication side effects as a reason for dropping out of the trial. Discontinuation symptoms can be an additional disadvantage, necessitating that patients taper medication slowly if a decision is made to stop medication.
Syndromes
Effects of five-year treatment with testosterone undecanoate on metabolic and hormonal parameters in ageing men with metabolic syndrome birth control ratings buy alesse 0.18mg amex. Plasma levels of dihydrotestosterone remain in the normal range in men treated with long-acting parenteral testosterone undecanoate birth control pills other uses purchase 0.18mg alesse with amex. The efficacy and safety of testosterone undecanoate (Nebido) in testosterone deficiency syndrome in Korean: a multicenter prospective study birth control migraines effective alesse 0.18mg. Treatment of 161 men with symptomatic late onset hypogonadism with long-acting parenteral testosterone undecanoate: effects on body composition birth control in the 1920s generic 0.18 mg alesse amex, lipids birth control pills 50 mcg estrogen 0.18 mg alesse with visa, and psychosexual complaints birth control pills 8 years 0.18 mg alesse with amex. Comparison of long-acting testosterone undecanoate formulation versus testosterone enanthate on sexual function and mood in hypogonadal men. Comparison of a new long-acting testosterone undecanoate formulation vs testosterone enanthate for intramuscular androgen therapy in male hypogonadism. A four-year efficacy and safety study of the long-acting parenteral testosterone undecanoate. Timetable of effects of testosterone administration to hypogonadal men on variables of sex and mood. Influence of testosterone replacement therapy on metabolic disorders in male patients with type 2 diabetes mellitus and androgen deficiency. Effect of testosterone treatment on glucose metabolism in men with type 2 diabetes: a randomized controlled trial. Effect of testosterone treatment on constitutional and sexual symptoms in men with type 2 diabetes in a randomized, placebo-controlled clinical trial. Effects of testosterone undecanoate replacement and withdrawal on cardio-metabolic, hormonal and body composition outcomes in severely obese hypogonadal men: a pilot study. An exploratory study of the effects of 12 month administration of the novel long-acting testosterone undecanoate on measures of sexual function and the metabolic syndrome. Improvement of the diabetic foot upon testosterone administration to hypogonadal men with peripheral arterial disease. Testosterone replacement therapy with long-acting testosterone undecanoate improves sexual function and quality-of-life parameters vs. Efficacy and safety of two different testosterone undecanoate formulations in hypogonadal men with metabolic syndrome. Effects of testosterone supplementation on markers of the metabolic syndrome and inflammation in hypogonadal men with the metabolic syndrome: the double-blinded placebocontrolled Moscow study. Concurrent improvement of the metabolic syndrome and lower urinary tract symptoms upon normalisation of plasma testosterone levels in hypogonadal elderly men. Improvement of the metabolic syndrome and of non-alcoholic liver steatosis upon treatment of hypogonadal elderly men with parenteral testosterone undecanoate. Beneficial effects of 2 years of administration of parenteral testosterone undecanoate on the metabolic syndrome and on non-alcoholic liver steatosis and C-reactive protein. A safety study of administration of parenteral testosterone undecanoate to elderly men over minimally 24 months. Effects of testosterone undecanoate on cardiovascular risk factors and atherosclerosis in middle-aged men with late-onset hypogonadism and metabolic syndrome: results from a 24-month, randomized, double-blind, placebo-controlled study. Hypogonadal obese men with and without diabetes mellitus type 2 lose weight and show improvement in cardiovascular risk factors when treated with testosterone: an observational study. Effects of long-term testosterone therapy on patients with "diabesity": results of observational studies of pooled analyses in obese hypogonadal men with type 2 diabetes. Long-term testosterone therapy in hypogonadal men ameliorates elements of the metabolic syndrome: an observational, long-term registry study. Effects of testosterone treatment on body composition in males with testosterone deficiency syndrome. Effects of testosterone treatment on bone mineral density in men with testosterone deficiency syndrome. Testosterone therapy increases muscle mass in men with cirrhosis and low testosterone: A randomised controlled trial. Effects of testosterone treatment on body fat and lean mass in obese men on a hypocaloric diet: a randomised controlled trial. Effect of testosterone replacement therapy on bone mineral density in patients with Klinefelter syndrome. Long-term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health-related quality of life. Elderly men over 65 years of age with late-onset hypogonadism benefit as much from testosterone treatment as do younger men. Effects of 5-year treatment with testosterone undecanoate on lower urinary tract symptoms in obese men with hypogonadism and metabolic syndrome. Could Testosterone Replacement Therapy in Hypogonadal Men Ameliorate Anemia, a Cardiovascular Risk Factor? Testosterone therapy has positive effects on anthropometric measures, metabolic syndrome components (obesity, lipid profile, Diabetes Mellitus control) and blood indices, liver enzymes, prostate health indicators in elderly hypogonadal men. Long-Term Testosterone Therapy Improves Cardiometabolic Function and Reduces Risk of Cardiovascular Disease in Men with Hypogonadism. Effects of 8-Year Treatment of Long-Acting Testosterone Undecanoate on Metabolic Parameters, Urinary Symptoms, Bone Mineral Density, and Sexual Function in Men With Late-Onset Hypogonadism. Effects of intermission and resumption of long-term testosterone replacement therapy on body weight and metabolic parameters in hypogonadal in middle-aged and elderly men. Effects of testosterone replacement therapy withdrawal and re-treatment in hypogonadal elderly men upon obesity, voiding function and prostate safety parameters. Improvement of sexual function in men with late-onset hypogonadism treated with testosterone only. RigiScan data under long-term testosterone therapy: improving long-term blood circulation of penile arteries, penile length and girth, erectile function, and nocturnal penile tumescence and duration. Effects of testosterone supplementation on depressive symptoms and sexual dysfunction in hypogonadal men with the metabolic syndrome. Testosterone Undecanoate improves Sexual Function in Men with Type 2 diabetes and Severe Hypogonadism: Results from a 30 week randomized placebo controlled study. A prospective, multicenter study on efficacy of long-acting testosterone undecanoate, if desired in combination with vardenafil, in late onset hypogonadal patients with erectile dysfunction. Symptomatic response to testosterone treatment in dieting obese men with low testosterone levels in a randomized, placebo-controlled clinical trial. A dose-response study of testosterone on sexual dysfunction and features of the metabolic syndrome using testosterone gel and parenteral testosterone undecanoate. Effects of testosterone gel followed by parenteral testosterone undecanoate on sexual dysfunction and on features of the metabolic syndrome. Testosterone replacement therapy improves the health-related quality of life of men diagnosed with late-onset hypogonadism. Increased sexual desire with exogenous testosterone administration in men with obstructive sleep apnea: a randomized placebo-controlled study. Testosterone undecanoate improves erectile dysfunction in hypogonadal men with the metabolic syndrome refractory to treatment with phosphodiesterase type 5 inhibitors alone. The efficacy of combination treatment with injectable testosterone undecanoate and daily tadalafil for erectile dysfunction with testosterone deficiency syndrome. Testosterone undecanoate restores erectile function in a subset of patients with venous leakage: a series of case reports. Testosterone improves erectile function in hypogonadal patients with venous leakage. A randomized, double-blind, placebo-controlled trial on the effect of long-acting testosterone treatment as assessed by the Aging Male Symptoms scale. Effect of long-acting testosterone undecanoate treatment on quality of life in men with testosterone deficiency syndrome: a double blind randomized controlled trial. Effects of two-year testosterone replacement therapy on cognition, emotions and quality of life in young and middle-aged hypogonadal men. Beneficial effects of testosterone administration on symptoms of the lower urinary tract in men with late-onset hypogonadism: a pilot study. Testosterone replacement alone for testosterone deficiency syndrome improves moderate lower urinary tract symptoms: one year follow-up. Lower urinary tract symptoms improve with testosterone replacement therapy in men with late-onset hypogonadism: 5-year prospective, observational and longitudinal registry study. Intramuscular testosterone undecanoate: pharmacokinetic aspects of a novel testosterone formulation during long-term treatment of men with hypogonadism. Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate. Incidence of prostate cancer in hypogonadal men receiving testosterone therapy: observations from 5-year median followup of 3 registries. The effect of testosterone treatment on prostate histology and apoptosis in men with late-onset hypogonadism. Retrospective investigation of testosterone undecanoate depot for the long-term treatment of male hypogonadism in clinical practice. Long-acting testosterone injections for treatment of testosterone deficiency after brachytherapy for prostate cancer. Complications of injectable testosterone undecanoate in routine clinical practice. Body compositional and cardiometabolic effects of testosterone therapy in obese men with severe obstructive sleep apnoea: a randomised placebo-controlled trial. Effects of testosterone therapy on sleep and breathing in obese men with severe obstructive sleep apnoea: a randomized placebo-controlled trial. The effects of testosterone on ventilatory responses in men with obstructive sleep apnea: a randomised, placebo-controlled trial. Anaphylaxis triggered by benzyl benzoate in a preparation of depot testosterone undecanoate. Long-acting intramuscular testosterone undecanoate for treatment of femaleto-male transgender individuals. Safety aspects of 36 months of administration of long-acting intramuscular testosterone undecanoate for treatment of female-to-male transgender individuals. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. Effects of Three Different Testosterone Formulations in Female-to-Male Transsexual Persons. Long-term administration of testosterone undecanoate every 3 months for testosterone supplementation in female-to-male transsexuals. Short- and long-term clinical skin effects of testosterone treatment in trans men. Pubertal induction in adult males with isolated hypogonadotropic hypogonadism using long-acting intramuscular testosterone undecanoate 1-g depot (Nebido). The role of long-acting parenteral testosterone undecanoate compound in the induction of secondary sexual characteristics in males with hypogonadotropic hypogonadism. Effects of testosterone on the Q-T interval in older men and older women with chronic heart failure. Effect of long-acting testosterone treatment on functional exercise capacity, skeletal muscle performance, insulin resistance, and baroreflex sensitivity in elderly patients with chronic heart failure a double-blind, placebo-controlled, randomized study. Effects of short-term testosterone administration on variables of the metabolic syndrome, in particular aldosterone. Long-term benefits of testosterone replacement therapy on angina threshold and atheroma in men. Men with testosterone deficiency and a history of cardiovascular diseases benefit from long-term testosterone therapy: observational, real-life data from a registry study. Effect of Exercise Training and Testosterone Replacement on Skeletal Muscle Wasting in Patients With Heart Failure With Testosterone Deficiency. Effects of long-term testosterone replacement therapy, with a temporary intermission, on glycemic control of nine hypogonadal men with type 1 diabetes mellitus - a series of case reports. Testosterone undecanoate improves lipid profile in patients with type 1 diabetes and hypogonadotrophic hypogonadism. Hypogonadal men with psoriasis benefit from long-term testosterone replacement therapy - a series of 15 case reports. Name of the medicinal product Nebido 1000 mg/4 mL solution for injection Geriatric patients Limited data do not suggest the need for a dosage adjustment in elderly patients (see section 4. Patients with hepatic impairment No formal studies have been performed in patients with hepatic impairment. The use of Nebido is contraindicated in men with past or present liver tumours (see section 4. Patients with renal impairment No formal studies have been performed in patients with renal impairment. Qualitative and quantitative composition Each ml solution for injection contains 250 mg testosterone undecanoate corresponding to 157. Each ampoule / vial with 4 ml solution for injection contains 1000 mg testosterone undecanoate. Care should be taken to inject Nebido deeply into the gluteal muscle following the usual precautions for intramuscular administration. The contents of an ampoule / vial are to be injected intramuscularly immediately after opening. Injections with this frequency are capable of maintaining sufficient testosterone levels and do not lead to accumulation. Start of treatment Serum testosterone levels should be measured before start and during initiation of treatment. Depending on serum testosterone levels and clinical symptoms, the first injection interval may be reduced to a minimum of 6 weeks as compared to the recommended range of 10 to 14 weeks for maintenance. With this loading dose, sufficient steady state testosterone levels may be achieved more rapidly. Maintenance and individualisation of treatment the injection interval should be within the recommended range of 10 to 14 weeks. Careful monitoring of serum testosterone levels is required during maintenance of treatment. Measurements should be performed at the end of an injection interval and clinical symptoms considered.
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If you are concerned about this birth control 6 month shot buy alesse 0.18 mg free shipping, ask your doctor to help you find out this information birth control zovia side effects buy discount alesse 0.18mg on-line. Should I try to get my child excused from gym class so he does not have to change in front of the other kids in the locker room? If your child does not feel comfortable changing in front of the other classmates birth control 5 year injection purchase alesse 0.18 mg on line, work with the school to see to it that your child has access to a private shower or changing space birth control pills and pregnancy order alesse 0.18mg free shipping. Here we will cover some of the basic points birth control pills with iron discount alesse 0.18mg line, but look to Chapter 3 How to Talk with Others [page 39] for ways to talk with and help your child birth control pill womens liberation purchase alesse 0.18mg fast delivery. Keep in mind almost all children are teased at some point in their lives by peers. Kids get teased for being what others consider too tall, too short, too thin, or too chubby. There is a chance that your child will be teased because he looks or acts unusual for his gender or sex. One of the best things you can do for your child is to sit, listen, give hugs, and repeat back what your child has told you so that he knows he has been heard by you. It can help to remind your child that lots of kids get teased about numerous things and that sometimes kids can be very mean, even cruel. Your child, like other children who are teased, will have to work through his pain and grief. With support from you and other resources suggested in this book, you can help to ease your child through the process of growing up. Your child may benefit from help from a counselor in learning how to develop the skills to deflect teasing. Your school should have systems in place for helping all children feel accepted and welcomed. If the child was indeed bullying, then sanctions will be put into place to limit inappropriate behavior. Most schools also try to increase diversity awareness and education to the school at large. Regular programming about diversity can help your child and others develop the verbal tools they need to combat people who want to discriminate against them for being in a minority. The aspects of your sex include your "sex chromosomes" (which we will talk more about in a moment), some of your genes which are not on your "sex chromosomes," and your sex parts, like your ovaries or testicles, your vagina, clitoris, penis, scrotum, and so on. Sex hormones are another aspect of your sex; sex hormones are the chemical messengers in your body that move through the blood. From the time we are conceived until the time we die, our bodies pass through many steps of sex development. Sex development starts right at conception, goes through the time in the womb, and continues through early childhood, adolescence, adulthood, and late adulthood. So that is one time when sex development happens-when, long before birth, the proto-gonads differentiate to become ovaries or testes. The egg and the sperm usually each contain 23 chromosomes, little bits of matter that contain genes. We do know this: Between one in 1500 and one in 2000 children are born with noticeable "genital ambiguity," meaning genitals that do not look like the types common in either females or males. It is hard for a lot of people to talk about sex anatomy, especially when it involves children. You may have heard people talk about "hermaphrodites" (a mythological being with a full set of male and a full set of female parts), but that is not what we are talking about. Humans cannot have a full set of male and female parts; it is not physically possible. The top two images show how all people start off about seven weeks after conception with the same basic set of reproductive structures. After that point, genitals start to differentiate into male-type, female-type, or in-between types. If the fetus has an unusual level of certain hormones, or an unusually high or low ability to respond to them, then an in-between genital appearance can result. As airline flight attendants say, "In the case of an emergency, put on your own oxygen mask before attempting to help your child. If you do not know the answer, either ask your physician or refer to Chapter 7 Other Resources (Where to Learn More) [page 99]. There is no reason to keep the truth and your feelings all bottled up with those in your close circle. Peer support groups are listed in the section called "Support Groups and Diagnosis-Specific Information" [page 100]. Do teach your child to tell you if anyone touches him or her in a way that is uncomfortable or painful. Constantly bringing up these issues when your child does not want to talk about them may make the issues seem bigger than they should be. Tell him or her who will be at the appointment, what will happen at the appointment, and why you are taking him or her to the doctor. Ask your child whether he or she has any questions or concerns about the appointment. When you make your list, on the paper some leave room under each item so you can take notes at the appointment. Here is a short-form list of the questions discussed in Chapter 3 How to Talk with Others [page 39]. You might want to draw from some of these questions when you make up your advance list. Would you please give my name and number to other parents who have been through something similar, and ask them to call me? Would you please give me a referral to a psychologist, psychiatrist, and/or social worker who has experience dealing with gender issues and birth anomalies, so I can get someone experienced to help me with my mixed emotions? Can we wait until my child can make the decision about whether to have cosmetic genital surgeries? Can we wait until my child can decide whether this is the right choice for him or her? It does not matter if their children have exactly what mine does, I just want to be supportive of parents in similar situations. Here are some ideas they suggest: Record-keeping Go to a place like Target or OfficeMax and get a metal or plastic file-box that can hold lots of papers. Then make a file for each of these things, and file this material as you get it: · medical records (including lab results, copies of x-rays, etc. It can really help your parent-child relationship to have your child understand your decisions and the tough position you were sometimes in. When we first asked adults to write for this, we asked them "What do you wish your parents had known? In fact, one of them (Cindy Stone) writes about how her father sexually abused her. But do think about what they have to say that might help you be a good and well parent to your child. I can assure you that I know exactly what you are going through, and I assure you, you are not alone! My husband and I were living in Hong Kong when we gave birth to our child and were given the news. We felt so alone being so far away from our family and friends and only having each other for comfort while we made arrangements to fly back to the States for all the testing that needed to be done. He wanted the cosmetic surgery and only let our closest family members know what was going on. I was so afraid of how angry he would be that I only allowed myself to tell him the morning of the surgery when it was time for me to sign the consent forms. I did allow the doctors to remove her gonads, and I still wonder whether or not this was the right thing to do. Our daughter is almost four years old and I am convinced more and more that my daughter will one day announce she is a boy. Go with your gut and do not allow anyone to pressure you into doing something you do not feel is right. It took over a year for my husband to open up and, while I wish he spent the countless hours I spend dealing with support groups and research, I am thankful that he loves our daughter and trusts me to know what is right for our daughter. I have learned more from my support group then I have learned from all the doctors combined. Please know that everything you are feeling right now will diminish and there will be days when you will completely forget that your child is different. Of course, as your child grows older, new emotions will emerge and you will face more conflicts. However your love for your child will only grow and you will realize that taking a deep breath and sharing your thoughts and emotions will get you through. I immediately called her pediatrician who asked me to bring in Angela the next day. She made an appointment for us to go straight to a pediatric endocrinologist without going home. Always, always get a second opinion, or ask yourself, "Is this surgery really necessary? It is difficult to understand whether my son is "intersexed" or basically male with hypospadias from progesterone in utero. It seems like sexuality is on a spectrum and if his genitals are not fully developed, neither is his gender identity. There are probably more babies being diagnosed in utero due to amniocentesis than ever before. Although these moms will be presented with way too much information about what could go wrong, most of these same moms will give birth to perfectly healthy boys. I chose to opt out of an amnio because of the high risk of miscarriage associated with the test. After a difficult pregnancy, with the last three months confined more or less to bed rest, Dana was born. Well, no fewer than nine pediatricians made their way to my room over the next several hours. By mid-day (when we were finally alone) I had a chance to get a good look at her, and promptly asked for a chromosomal analysis. After several physical examination, the existence of external gonads were ruled out. Finally, alone with my baby, I slowly absorbed the fact that it looked as though she had little tiny penis, no scrotum and no vagina! It was only after a lengthy ultrasound the next morning, when doctors discovered a teeny-tiny uterus, that I felt comfortable signing the birth certificate confirming her gender. In light of all we have learned these last few years, this may or may not be important to her. The decision to move ahead with further surgery will be completely hers, based on what she decides is right for her. I loved you, and kept you by my side as if you were the most fragile piece of china, and I made certain that your life was filled with the most wonderful experiences and kissed your boo-boos and made the monsters under your bed go away. Your confidence as a parent and your level of acceptance will determine how well your child adjusts to his or her own unique situation. Allow yourself to enjoy the mind-numbing normality of your day-to-day existence as no one else has. It is in these moments that you get to leave behind the delivery room and focus on the here and now and the reality of the beautiful child who just made a terrible mess of his lunch and whose nose is running and who is, at that moment, just like every other child that has ever been or will ever be. What I learned foremost is the importance of listening to and carefully observing your child. I was in an emotional turmoil because I knew this was not the appropriate surgery for this child. In preparing the child for surgery I took him to the library and we looked at pictures of unclothed boys and girls. When I showed him what he would look like after surgery he looked very frightened. It is very important that your child have a psychological evaluation before surgery or treatments where there are any doubts or questions. I was criticized by some people for listening to a small child, but I am so grateful that I did. You should make careful notes of how your child interacts within the family, school, etc. Although it is rare, you should emotionally prepare yourself that there may be a gender change. In my unique experience with this child, the gender he presented changed back and forth four times in six months. This was most unusual, but be prepared and, if you run into confusion, do seek counseling for yourself. This has been very important, because I have had to share them with another medical team to proceed in caring for him. Finally, I would like to say: enjoy this special child you have been entrusted to care for. I can see him, if given the chance, becoming an engineer or working in the trucking business. Focus on the joy of one day seeing your child succeed in accomplishing his or her dream.
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