Sleep Disorders and Medical Drugs Treatment

Introduction

The light from the moon casts long shadows across your bedroom wall. Your spouse breathes softly beside you. You are wide awake once again at four a.m. Your frustration grows the longer you lie awake. You wonder how you will be able to function at work tomorrow with so little rest.

What is it?

Sleep disorders can be temporary or long-term problems and can affect the quantity or quality of sleep achieved. There are four recognized types of sleeping disorders:

• Extrinsic sleep disorders, caused by something outside of the body such as drug use or a poor sleep environment
• Intrinsic sleep disorders, caused by something within the body such as a physical or psychological ailment
• Dyssomnias, characterized by an abnormality in the amount, quality, or timing of sleep. For example, insomnia, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep disorders, which are disruptions in your regular daily biological clock such as jet lag or work shift changes
• Parasomnias, characterized by unusual physical occurrences during sleep such as sleepwalking, grinding teeth or bed-wetting

Insomnia, is defined as difficulty falling asleep, difficulty maintaining sleep or sleeping but not feeling rested. Insomnia can be caused by any one of the four types of sleep disorders mentioned above.

The National Institutes of Mental Health has identified three broad categories of insomnia. These include:

• Transient - insomnia lasting fewer than three days
• Short-term - lasting three days to three weeks
• Chronic - lasting more than three weeks

What causes it?

There are many elements about the mechanisms of sleep and wakefulness that scientists do not understand. What is known is that sleep is primarily controlled by two systems in the brain: one that induces sleep and sleep-related processes, and one that regulates sleep within a 24-hour cycle. This cycle, which corresponds to periods of light and darkness, is known as the circadian rhythm cycle. Researchers are discovering that this cycle is a process controlled by genes that are found in living creatures ranging from the lowly fruit fly to human beings.

Researchers know that as human beings we go through a variety of stages of sleep that can be measured by brain wave patterns. Sleep is divided into two phases: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. There are many cycles of NREM and REM sleep, each lasting between 70 and 120 minutes. Sleep disorders result from either internal abnormalities or external disturbances to these cycles. The feeling of having had enough sleep, or sleep satiety, is related to whether one has gone through all of the cycles of sleep, including both dreamless and REM sleep. We typically cycle through these stages multiple times per night.

The ongoing study of sleep disorders spans many medical fields, including neuroscience, genetics, physiology and psychology. Some of the mechanisms that play a role in sleep disorders are the subject of study at The National Center for Sleep Disorders Research. This center is situated within the National Heart, Lung, and Blood Institute - part of the National Institutes of Health (NIH) in Bethesda, Maryland. Research includes the study of the genes that play a role in narcolepsy (a condition characterized by brief attacks of deep sleep), how sleep disturbances affect the immune system, and the role of sleep/wake cycles in triggering heart attacks.

Who has it?

About 40 million people in the U.S. suffer from sleep problems every year. Insomnia is the most prevalent sleep complaint among adults in America. Insomnia is more common among the elderly and women.

Sleep apnea, a disruption of breathing during sleep, affects nearly 18 million people in the U.S. More than one billion dollars are spent each year on sleep medications in the United States.

What are the risk factors?

Most short-term sleep disorders are caused by one or more of the following factors:

• lifestyle changes, such as marriage, retirement, or unemployment
• stressful situations, such as the death of a loved one or job pressure
• physical disorders
• environment

Chronic sleep disorders have numerous possible causes. These include:

• medical conditions - especially those producing pain
• psychiatric conditions such as depression
• drug use (including alcohol, nicotine, or caffeine)
• environments that are not conducive to sleep

Many conditions that cause sleep disorders are associated with the elderly, which could explain why insomnia is 1.5 times more common in people older than age 65. In addition to physical conditions that disrupt sleep, elderly people tend to experience changes in sleep patterns leading to fewer hours of quality sleep per night.

Women, especially those who are postmenopausal, are more likely to suffer from sleep disorders than men. However, laboratory studies show that men are more likely to experience disrupted sleep patterns than women.

What are the symptoms?

The symptoms of sleep disorders include:

• difficulty or inability to fall asleep
• awaking early from sleep
• easy disruption of sleep
• fatigue or sleepiness
• anxiety
• lack of concentration
• irritability

How is it treated?

Lifestyle changes and proper sleep hygiene (click on the Helping Yourself box) may be helpful for short-term management of insomnia. Medications may also help relieve insomnia and re-establish regular sleep patterns. Management of chronic insomnia requires careful assessment of the underlying cause for the insomnia, as well as nonpharmacologic therapy and less frequent use of sedative-hypnotics to prevent tolerance and dependence.

Over-the-counter sleep aids that contain diphenhydramine (Benadryl), an antihistamine, may be helpful for short-term bouts of insomnia. Because the body can grow accustomed to antihistamine sleep aids, they often lose their effectiveness the more you take them. If you experience continued bouts of insomnia you should talk to your doctor to see if prescription medications are needed. Benzodiazepines are commonly used for the management of sleep disorders. Short-acting benzodiazepines are less likely than long-acting benzodiazepines to be associated with drowsiness or sluggishness the next morning. Benzodiazepines are only available with a prescription. They are controlled substances and do carry a potential for addiction if used inappropriately.

Other drugs used in the management of insomnia include unique agents called non-benzodiazepine sedative hypnotics. Examples include Ambien (zolpidem), Sonata (zaleplon), and Lunesta (eszopiclone).

Drug classes also considered sedative hypnotics are barbiturates and sedating antihistamines. The non-benzodiazepines and barbiturates are also controlled substances due to the potential for addiction.

A newer class of sedative hypnotics is also available. Rozerem (ramelteon), a melatonin receptor agonist, mimics the body's natural sleep promoting hormone, melatonin. This drug class is unique because it works with the body's natural circadian rhythm to promote sleep. These melatonin receptor agonists are not controlled substances and do not carry an addiction potential.

Natural remedies have been used for years to treat sleep disorders. One of the most popular "natural" remedies for insomnia has been melatonin, which can be obtained at most pharmacies and health food stores. Melatonin is a hormone that is known to be involved in the regulation of sleep and wakefulness. It has been shown that the ingestion of melatonin prior to bedtime will help individuals fall asleep. However, scientific data have failed to confirm that melatonin is useful in maintaining sleep.

Herbal products such as valerian, chamomile, kava kava, and others have also been promoted as natural remedies for insomnia. However, these herbals are not regulated by the Food and Drug Administration (FDA) and the effectiveness and safety of these products has not been documented in large clinical trials.

Drug classes used to treat Sleep Disorders

• Barbiturates
• Benzodiazepines
• Miscellaneous Sedatives and Hypnotics
  

Stroke and Medical Drugs Treatment

Introduction

Although death rates from stroke have declined over the recent years, it remains the third leading cause of death in the United States. On average, someone in the United States has a stroke every 40 seconds. And, every 3 to 4 minutes, someone dies of a stroke. Strokes can occur at any time, regardless of age, gender or race. Most stroke symptoms are not associated with pain, causing people to delay medical treatment. Signs and symptoms of stroke can range from difficulty with speech to sudden numbness or weakness in the face or limbs. During a stroke, two million brain cells die every minute, increasing the risk for permanent brain damage, disability and death. Therefore, it is important to recognize signs and symptoms of a stroke in order to seek immediate medical attention.

What is it?

There are two main types of strokes:

1. An ischemic stroke occurs when there is a decrease in the amount of blood and oxygen delivered to the brain as a result of blood clots or build up of fat in the blood vessels.
2. A hemorrhagic stroke occurs when a blood vessel ruptures, causing blood to leak into the brain.

About 87% of all strokes are ischemic in nature, with hemorrhagic stroke occurring only 13% of the time. Ischemic strokes are more common because there are more causes or risk factors associated with ischemic strokes, such as high cholesterol, heart disease, other heart conditions (such as heart failure), and high blood pressure. On the other hand, hemorrhagic strokes may occur when there is trauma to the head or high blood pressure, causing a rupture in a blood vessel.

Transient ischemic attacks (TIAs) are "mini strokes" that have stroke-like symptoms with no lasting damage. It occurs when the blood supply to the brain is temporarily interrupted. TIA symptoms, which usually occur suddenly, are similar to those of a full-blown ischemic stroke, but they do not last as long. Symptoms of a TIA may last for several minutes to 24 hours without leaving permanent effects. It is possible to have more than one TIA, and the recurrent signs and symptoms may be similar or different. People who have had a TIA are more likely to have a stroke than those who have not had a previous TIA.

TIAs occur before an ischemic stroke in about 15% of cases. After a TIA, the 90-day risk of experiencing a stroke is approximately 3% to 17%, but the risk is the highest within the first 30 days. Within one year of a TIA, up to one-fourth of people who have an ischemic or hemorrhagic stroke die.

What causes it?

Ischemic Strokes

There are two main causes of ischemic strokes:

1. Cerebral thrombosis: Thrombosis is the formation of a blood clot (or thrombus) at the blocked portion of a blood vessel. Atherosclerosis (hardening of the blood vessels as a result of fatty buildup and cholesterol plaques on the vessel wall) causes blood vessels to narrow and restrict blood flow, which can lead to the formation of a blood clot. If a blood clot develops in a blood vessel that supplies blood to the brain, the blood and oxygen supply to the brain can be diminished or completely blocked leading to an ischemic stroke.
2. Cerebral embolism: An embolism is a dislodged blood clot that forms at another site in the circulatory system, usually in the heart or in the large arteries in the upper chest and neck. The blood clot then traveles through the blood vessels and becomes wedged in an artery. In about 15% of all strokes, the emboli are blood clots that originally formed in the heart as a result of a rhythm disorder known as atrial fibrillation -- a rapid, irregular beat in the upper chambers of the heart (the atria). As a result of the irregular pumping, some blood may pool in the heart chamber and form a clot, which can then break off and travel to the brain as an emboli, causing an ischemic stroke.

Hemorrhagic Stroke

A hemorrhagic stroke occurs when a blood vessel that is weakened ruptures, causing blood to leak into the surrounding areas of the brain. Blood vessels usually rupture as a result of high blood pressure combined with arteriosclerosis (hardening of the blood vessels due to fatty buildup and cholesterol plaques on the vessel wall), which can place too much pressure on the blood vessel walls. The blood can accumulate and increase the pressure surrounding the brain tissue.

The two types of hemorrhagic strokes are:

1. An intracerebral hemorrhage occurs when a faulty blood vessel in the brain bursts, flooding the nearby areas of the brain. The most common sites are the basal ganglia (an area in the brain responsible for controlling voluntary movements and establishing postures), the cerebellum (an area in the brain that provides coordination of finely executed complex movements, including speech) the thalamus (an area in the brain that is the center of pain, touch, and temperature) and the pons (an area in the brain that acts as a relay station for messages in the brain and is important centers for regulating breathing).
2. A subarachnoid hemorrhage occurs when a blood vessel in the brain bursts, causing sudden bleeding into the space between the middle lining of the brain (the arachnoid membrane) and the brain itself. A subarachnoid hemorrhage causes sudden, severe pain in the head; a person may describe it as "the worst headache I have ever had."

Who has it?

As mentioned previously, stroke is the third leading cause of death in the United States and a leading cause of long-term disability. In 2006, the American Stroke Association estimated that in the United States nearly 157,000 people die from a stroke each year, and that cumulatively 4.6 million people survived a stroke. Each year, it is estimated that 795,000 people will experience a new or recurrent stroke.

Strokes can occur in both women and men and in all ethnic groups although certain groups are at higher risk for dying from strokes (see "What are the risk factors?"). African Americans have almost twice the risk of an initial stroke as compared with Caucasians. The incidences of strokes in males are greater than in women at younger ages, but not at older ages. In 2004, women accounted for 61% of U.S. stroke deaths.

What are the risk factors?

Risk factors are characteristics that may increase your chance for developing a condition. For ischemic and hemorrhagic stroke, risk factors include the following:

Risk factors that can not be changed or controlled:

• Age -- The risk for stroke doubles each decade after the age of 55.
• Gender -- Men have about a 30% higher risk for stroke than women do until the age of 55 years. After the age of 55 years, the risk is the same for men and women.
• Race -- Higher death rates from stroke occur in African Americans, Asian-Pacific Islanders, and Hispanics than in whites as a result of increased incidence of high blood pressure.
• Heredity -- The risk for stroke is greater if a parent, brother, or sister has a stroke or transient ischemic attack.

Risk factors that can be changed or that can be controlled:

• High blood pressure
• Heart disease
• TIAs
• Diabetes
• High cholesterol
• Atrial fibrillation
• Cigarette smoking
• Alcohol
• Illicit drug use
• Lifestyle factors - inactivity, obesity, poor diet and stress
• High estrogen oral contraceptives, especially in women over 35 years who smoke and women over 40 years who have hypertension or diabetes
• Sickle cell disease

What are the symptoms?

Ischemic stroke

General symptoms of an ischemic stroke include a sudden onset of the following:

• Numbness, weakness, or inability to move (paralysis) of face, arm, or leg, usually on one side of the body
• Trouble seeing in one or both eyes (such as dimness, blurring, double vision, or loss of vision)
• Confusion, trouble speaking or understanding
• Trouble walking, dizziness, loss of balance or coordination
• Severe headache with no known cause

Symptoms can develop suddenly (within minutes) and may also progress over hours to days. Symptoms of an ischemic stroke may be so minor that they often get ignored or go unnoticed, but medical attention should not be delayed.

TIA

General symptoms of TIA include sudden onset of the following:

• Numbness or weakness in the face or limbs
• Dimming or loss of vision in one eye
• Unexpected falls
• Unexplained dizziness
• Nausea
• Double vision
• Drowsiness

The difference between a TIA and an ischemic or hemorrhagic stroke is the duration of the symptoms; TIA symptoms usually disappear after 10 to 20 minutes and last no longer than 24 hours. For instance, a person experiencing a TIA may experience temporary numbness in the limbs, loss of vision or unexplained dizziness for a few minutes, or even up to 24 hours, but will likely recover the next day. On the other hand, a person who has an ischemic stroke may have numbness on one side of the body, loss of vision, headache or confusion, which will not disappear the next day. This would also apply to a person having a hemorrhagic stroke; they may experience a severe headache, changes in mental status or dizziness that will not disappear after 24 hours.

Hemorrhagic stroke

General symptoms of a hemorrhagic stroke include sudden onset of the following:

• Headache (severe and in a specific area)
• Nausea and vomiting
• Neck stiffness
• Dizziness
• Seizures
• Changes in mental state, such as irritability, confusion, and possibly, unconsciousness

Hemorrhagic strokes often occur during the daytime and during physical activity, but this is not always true. Symptoms of a hemorrhagic stroke typically begin suddenly (within seconds) and progress over several hours.

People with very high, uncontrolled blood pressure may have one or more symptoms before they have a hemorrhagic stroke, including the following:

• Severe headache in the back of the head or top of the neck
• Dizziness or fainting
• Tingling or numbness in an arm or leg, or an inability to move an arm or leg that comes and goes

How is it treated?

Strokes can be treated and 80% of strokes are preventable. At the moment, no treatment can cure a stroke, and most people will have some form of residual damage, which will vary from person to person. Residual damage can range from a slight limp to paralysis on one side of the body. Prevention will be the key to avoid further damage and subsequent strokes.

Prevention:

Antihypertensive agents: Reducing even mild to moderate blood pressure has been shown to lower the risk of stroke.

Cholesterol lowering agents: These agents -- "statins" like Zocor, Lipitor, Crestor, Lescol, Mevacor and Pravachol -- reduce the risk of stroke in people with existing coronary artery disease.

Treatment of Atrial Fibrillation (irregular heartbeat): The main goal of treatment for atrial fibrillation is to prevent blood clots from forming by first restoring and then maintaining normal heart rhythm.

Treatment for ischemic stroke:

Acute Treatment:

• An acute ischemic stroke is usually treated with a thrombolytic agent, which is considered to be a first-line treatment. Thrombolytics, sometimes called "clot busters," dissolve the blood clot that is blocking the flow of blood through the blood vessel. The use of thrombolytics may however, increase the risk of an intracranial hemorrhage (bleeding in the brain). Due to this increased risk for bleeding, there are several specific criteria that a person must meet before thrombolytic therapy can be given. One of the key criteria is that thrombolytics need to be administered within a certain time frame after stroke symptoms are initially recognized. Therefore, it is extremely important for the person or family members to recognize the symptoms of stroke and to seek medical attention immediately - - at the very least within 3 hours of the onset of stroke symptoms to qualify for thrombolytic therapy. Call 911 if you witness anyone having a stroke because time is of the essence.
• Aspirin is another important agent in the treatment of an acute ischemic stroke. Aspirin should be given more than 24 hours after the thrombolytic, but within 48 hours of symptoms. Early aspirin use has been shown to decrease long-term death and disability in stroke patients.

Chronic Treatment:

• After hospitalization, most patients will need to be placed on an antiplatelet or an anticoagulant, as well as other medications to control blood pressure and lower cholesterol to prevent another stroke. Anti-platelets and anticoagulants are important after a stroke because they interfere with the blood's ability to clot; this can prevent blood clots that may form in the heart or in the blood vessels, which will help reduce your chances of another stroke.
• Medications that prevent blood from clotting are also used in people who have had a TIA and are at risk for stroke.
• Carotid endarterectomy is a surgical procedure used to treat and prevent an acute ischemic stroke. This is an effective procedure in protecting against a first stroke in patients with severe stenosis (constriction or narrowing of a blood vessel by 70%-99%) of the main blood vessel in the brain.
• Angioplasty and stenting are common procedures used in some individuals to help widen the arteries. During the procedure, a catheter (a long, hollow tube) is inserted in an artery near the groin until it reaches the artery that is narrowed. A tiny balloon at the end of the catheter is inflated to flatten the fatty buildup against the wall of the artery. Afterwards, a wire mesh stent (small mesh tube) is placed in order to keep the artery open and prevent it from narrowing.

Treatment for hemorrhagic stroke:

• A cerebral hemorrhage is associated with extremely high death rates. It can be treated with either surgery or medical intervention and there is currently no medical consensus as to which treatment is best.
• Surgical treatment involves removing the large clot from the area. The blood clot (referred to as a hematoma) size and level of consciousness of the patient are critical. Patients who are awake and have small hematomas (less than 3 centimeters diameter or less than 20 mls) will usually improve without surgery, whereas comatose patients with large hematomas (greater than 6 centimeters diameter or greater than 80 mls) will usually do very poorly, regardless of management. The best candidates for surgery may be patients with moderate to large hematomas who are still awake or conscious.
• Medical treatment involves monitoring blood pressure while providing adequate blood flow to the brain. If increased pressure is suspected treatment with intravenous mannitol (which reduces the pressure and excess fluids by reducing the clot) with or without furosemide (a diuretic that reduces pressure and removes excess water) may be helpful.
• A subarachnoid hemorrhage can be treated with either surgery or medical treatment. Surgical treatment involves not only finding the site of the bleeding, but also stopping the bleeding in the brain. Currently, surgery in all patients in good neurological condition (meaning there are no other complications affecting the nervous system) would be the treatment of choice, if the site is surgically easy to get to and there are no other medical complications present. Medical treatment involves normalizing blood pressure, bedrest, analgesics (acetaminophen) to relieve headache and nimodipine (Nimotop) (to reduce pressure and decrease brain cell loss). Nimodipine has been shown to reduce death and hospitalizations.

Drug classes used to treat Stroke

• Antiplatelets
• Oral Anticoagulants
• Salicylates
• Thrombolytic Agents
  

What is on the horizon?

New therapy for prevention of TIAs and stroke includes a number of new and emerging interventions. Different strategies that restore blood flow to the brain, including longer-acting thrombolytics, anti-platelets and laser-guided clot removal are being researched. Therapies that help reverse the effects of an acute stroke are also being investigated. Researchers are also investigating the possibility of extending the time frame for administering thrombolytic therapy.

Smoking Cessation and Medical Drug Treatment

Introduction

Every day, more than 3,500 teenagers (<>

What is it?

Smoking is an addiction that currently affects approximately 47 million people in the United States. It has been identified by the American Lung Association as the most important source of preventable morbidity and early mortality worldwide. In the U.S., smoking is responsible for 1 in 5 deaths. Smoking costs the U.S. economy over $193 billion in health care costs and lost productivity each year.

A person who smokes often feels the compulsive need to light up that next cigarette. Many smokers cannot wait until their next cigarette to make the nicotine craving go away.

Tobacco smoke contains many compounds that are harmful to the body. Over 4,000 chemicals, including 60 that have been shown to cause cancer, have been found in tobacco and tobacco smoke. Smoking causes approximately one-third of all cancers, including 90% of all lung cancers. Other chemicals in the smoke cause lung and heart disease.

The following are just a few of the chemicals surprisingly found in cigarette smoke:

• Cyanide
• Benzene
• Formaldehyde
• Methanol (wood alcohol)
• Acetylene (fuel used in welding torches)
• Ammonia
• Poisonous gases including nitrous oxide and carbon monoxide

These chemicals inhaled by a smoker or nonsmoker (via second hand smoke?see below) are known to either cause or worsen the following health problems:

• Cancers: lung, oral, larynx (throat), esophageal, kidney, bladder, pancreas, stomach, colon
• Chronic Obstructive Pulmonary Disease (emphysema and chronic bronchitis)
• Chronic "smoker's cough"
• Asthma
• High blood pressure
• Heart disease
• Stroke
• Peptic ulcer disease
• Gastric Esophageal Reflux Disease (GERD or heartburn)
• Diabetes

Secondhand smoke, also called environmental tobacco smoke (ETS), is smoke inhaled by a person who is in an environment where tobacco smoke is being produced by another person. Secondhand smoke contains the same amount of cancer-causing chemicals as smoke inhaled directly by a smoker. In 1993, the U.S. Environmental Protection Agency determined that there is sufficient evidence that secondhand smoke causes cancer in humans. However, researchers are unsure at this time what amount of secondhand smoke exposure is needed to cause cancer. The current Surgeon General's Report concluded that scientific evidence indicates there is no risk-free level of exposure to secondhand smoke.

Additionally, a study was recently published that coined the term "third-hand smoke." The term is being used to describe the invisible yet toxic brew of gases and particles that cling to smokers' hair and clothing, even furniture cushions and carpeting that lingers long after second-hand smoke has cleared. Researchers have found that eleven of the compounds found in third-hand smoke are highly carcinogenic (may cause cancer). The study shows that increasing awareness of how third-hand smoke harms the health of children may encourage home smoking bans.

According to the Centers for Disease Control and Prevention (CDC), approximately 38,000 deaths occur each year among nonsmokers in the United States as a result of exposure to secondhand smoke. It has also been shown that persons living in a home with smokers are at the highest risk of developing cancer from secondhand smoke. According to the American Cancer Society, sitting in a nonsmoking section of a restaurant for two hours is equal to smoking one and a half cigarettes. In addition, a nonsmoker sitting behind a smoker in a bar for two hours breathes in the equivalent of four cigarettes.

What causes it?

Addiction to smoking is actually caused by the body's addiction to the primary ingredient in cigarette smoke, known as nicotine. Nicotine causes an addiction to smoking in three ways. First, small amounts of nicotine make a person feel pleasant and satisfied, causing the person to want to smoke even more. Secondly, nicotine affects the mood and behavior of a smoker by altering chemicals in the brain. Long-term brain changes induced by continued nicotine exposure result in addiction. Lastly, and often most importantly, withdrawal symptoms, such as nervousness, headaches, irritability, increased appetite, and difficulty sleeping, occur when a person refrains from smoking for a given period of time (usually about 24 hours).

Who has it?

Since tobacco use is an addiction that is self-initiated, anyone could become addicted to tobacco products. However, there are certain groups of people that are more prone to becoming addicted to nicotine. According to the most recent National Health Interview Survey from the Centers for Disease Control and Prevention and the National Center for Health Statistics, in the United States, an estimated 25.9 million men (23.9%) and 20.7 million women (18.1%) are smokers. Smoking is least prevalent among persons older than age 65 (10.0%) and most prevalent among persons 18 to 24 years of age (23.7%), although the prevalence for those 25 to 44 years of age is only just slightly lower (23.2%). Studies have shown that the prevalence of smoking is higher among persons with 9 to 11 years of education (32.6%) compared with persons with more than 16 years of education (7.1%).

Unfortunately, teenage smoking is on the rise. In 2003, approximately 3.6 million Americans 12 to 17 years of age smoked regularly. In 2007, 20% of high school students reported that they were current smokers. On a positive note, in recent years, the percentage of 8th grade students who admitted to smoking has declined from 21% (in 2002) to 9% (in 2003).

What are the risk factors?

Surveys have shown that young adults age 18 to 25 years have the greatest incidence of starting to use tobacco products. The younger you are when you begin smoking, the more likely you are to be an adult smoker. Almost 90% of adult smokers started at or before the age of 19. Teenage use of tobacco products is most often initiated by the need to be accepted by their peers who smoke and the need to feel like they fit in. Some teens have also reported that they began using tobacco products in order to rebel against their parents. Recent research has also shown that teenagers are the most resistant to antismoking messages and campaigns, because they do not fully understand the complications that smoking tobacco can initiate.

The pleasant feeling associated with nicotine use is often helpful to people who want to decrease their stress levels. Consequently, people who have high-stress work environments or difficult family situations may be more likely to use nicotine, at least on an occasional basis.

A few small studies have shown that persons are more likely to begin smoking if a parent smoked. Parents, the most influential role models in children, often dictate the positive and negative behaviors of their children.

What are the symptoms?

Symptoms of high nicotine addiction include but are not limited to:

• Nicotine craving within the first hour of waking
• Having difficulty refraining from smoking in places where it is forbidden
• Smoking more than ten cigarettes per day (although any nicotine use is unhealthy)
• Smoking even when very ill and unable to go to work or get out of bed

Nicotine withdrawal often occurs within 24 hours of refraining from nicotine use. Signs of nicotine withdrawal include:

• Depressed or elevated mood
• Insomnia
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased cravings
• Increased appetite or weight gain

The presence of at least four signs of withdrawal is needed to be diagnosed with nicotine withdrawal. It is important to continually self-monitor for these signs.

Why should you quit?

The US Surgeon General's Report of 1990 detailed a timeline as to how cessation from nicotine improves a person's health status. While this report is somewhat dated, it still holds true today.

• 20 minutes after the last cigarette: heart rate drops
• 12 hours after the last cigarette: the carbon monoxide level in the blood drops back to normal
• 2 weeks to 3 months after the last cigarette: circulation improves and lung function increases
• 1 to 9 months after the last cigarette: coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) begin to function normally again, increasing the ability to clean out the lungs and thus reduce the risk for lung infection
• 1 year after the last cigarette: risk of heart disease is decreased in half compared to a continuing smoker's risk
• 5 years after the last cigarette: risk for having a stroke is the same as a person who never smoked
• 10 years after the last cigarette: lung cancer death rate is about half of a continuing smoker. The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease as well.
• 15 years after the last cigarette: the risk of heart disease is the same as a person who never smoked.

Five stages of smoking cessation

There are five stages of smoking cessation. These stages can help a person determine how much further he/she must go in order to achieve complete smoking cessation.

1. Pre-contemplation: the person has no desire to quit
2. Contemplation: the person has a desire to quit but no quitting plan
3. Preparation: the person has a desire to quit within one month and has a quitting plan
4. Action: the person has quit for one day to six months
5. Maintenance: the person has quit for at least six months

Successful treatment of nicotine addiction is a continual process. An addiction is not like an infection where you take a medication and the infection completely resolves in a short amount of time. On average, a person tries to quit smoking eleven different times before becoming successful. Quitting "cold turkey" with no additional help is often only successful in persons who smoke infrequently. People who smoke greater than ten cigarettes per day often require medication and psychological therapy to aid them in successfully refraining from smoking on a permanent basis.

Multiple products are available to help you quit smoking including nicotine replacement aids (e.g. gums, patches) and medications such as Zyban, Chantix, and antidepressant medications. For individuals who are highly addicted to nicotine or who have smoked for many years, combination therapy (eg. nicotine patch plus Zyban) can be tried. However, it's best to try one therapy first and if that therapy fails, then proceed to combination therapy. Therapy needs to be tailored to the individual. Click on the drug class links below to learn more.

Additionally, non-drug therapy is the key to success with smoking cessation. Click on our "Helping Yourself" link above to learn helpful tips to stop smoking.

Finally, some people have found success with alternative therapies such as hypnosis.

Drug classes used to treat Smoking Cessation

• Alpha 4 Beta 2 Nicotinic Acetylcholine Receptor Agonist
• Alpha-2 Agonists
• Nicotine Replacement Therapy
• Tricyclic Antidepressants
• Zyban
  

What is on the horizon?

An experimental vaccine to help people quit smoking is currently being researched. This vaccine stimulates the body to produce nicotine antibodies that bind to any nicotine that enters a person's blood when he/she smokes. This nicotine/antibody complex is then too large to enter a person's brain, thus preventing the addictive effects of the nicotine from occurring. Small studies so far have reported the vaccine to be safe and well tolerated. However, the effectiveness of the vaccine in helping people to stop smoking has not yet been established. A recent study was just completed that evaluated the safety and efficacy of various dosing levels and dosing frequencies of a nicotine vaccine named NicVAX. The results have yet to be published. There are also two more studies in progress that are studying NicVAX. The vaccine will most likely be used in combination with other smoking cessation drug therapies. It is being considered as a smoking prevention vaccine for people who have never smoked before. The vaccine for the use in smoking prevention has yet to be studied. Once clinical studies of the vaccine for smoking cessation purposes are completed, FDA approval will be needed before manufacture of this vaccine can occur.

Research has pinpointed a specific molecule, the b2 subunit, of the nicotine receptor in the body as a critical component of nicotine addiction. This discovery identifies a potential site for targeting future drug therapy in smoking cessation.

Other recent research has shown that persons with decreased function of the liver enzyme CYP2A6 have a less likely chance of becoming addicted to nicotine. The creation of new medications that decrease function of this enzyme may promote improved smoking cessation.

Many smokers report that they miss the sensory aspects of smoking. Studies using sensory replacement therapy in these patients have shown some promise. Inhalation therapies containing ascorbic acid or citric acid have been tested, both increasing short-term rates of smoking cessation. Further studies of sensory replacement therapy in combination with FDA-approved smoking cessation drug therapy is warranted but has yet to be initiated.

Menopause and Medical Drugs Treatment

Introduction

As women reach their late forties or early fifties, their menstrual periods generally become much less frequent and then stop. Sometimes called the "change of life" or the "climacteric," menopause is the time when menstrual periods end. Some women see menopause as a time for celebration while others dread the physical signs of aging. Most women treat it as a normal stage of life.

What is it?

Menopause simply means the end of menstruation. Usually defined as not having had a menstrual period for 12 months in a row, menopause may be natural or it may occur after a hysterectomy (surgical removal of the uterus). In the United States, the average age of natural menopause is 51 years, but it may occur naturally at any time between the ages of about 45 and 55 years.

Menopause results from decreased production of the female sex hormones, estrogen and progesterone. After menopause, few eggs remain in the ovaries. As a result, both estrogen and progesterone levels fall. The extreme decline in hormone production is a major cause of symptoms, such as hot flashes and mood disorders, which frequently accompany the start of menopause. Lowered estrogen and progesterone levels also contribute to an increased risk for certain health problems, such as heart disease, osteoporosis, and urinary incontinence (the inability to control urine flow). When levels of both hormones decline, menstruation stops and fertility essentially ends, as well.

Perimenopause is the time just before and after the onset of menopause. It averages 4 years in length, but it may be much shorter or longer for individual women. Because women may still release eggs during perimenopause, they can still get pregnant. Common symptoms that may begin in perimenopause include:

• Changes in menstrual periods
• Hot flashes
• Insomnia
• Mood changes
• Night sweats

Postmenopause refers to the time after menopause. This is the time when some of the distress from the changes from menopause will start to fade. The symptoms described above may become milder, while energy levels and emotions stabilize.

What causes it?

Menopause is a natural part of the aging process for women. Each girl is born with a limited number of immature eggs in her ovaries. A complex balance of female hormones promotes the maturation and release of the eggs by the ovaries. With each menstrual period, some of the eggs are lost. As the number of eggs in the ovaries decreases, less estrogen is produced and menstrual periods usually become irregular before they stop completely. For most women, the process is gradual, but some women experience abrupt physical and emotional changes. For unknown reasons, some young women undergo menopause many years before expected. Women of any age enter menopause if the ovaries are removed surgically or if they are damaged (for example, by chemotherapy or radiation). In menopause caused by ovarian surgery or damage, the production of estrogen and progesterone drops suddenly.

Who has it?

All women will experience menopause. The average age is in the early fifties, but some women undergo menopausal changes much earlier or later in life. Emotional stress, certain illnesses, some medications, or excessive exercise can cause even very young women to stop menstruating temporarily. In rare cases, temporary cessation of the menstrual cycle may become permanent if the underlying cause is not corrected. Women who smoke cigarettes generally enter menopause a few years earlier than non-smokers.

What are the risk factors?

Risk factors are characteristics that make individuals more likely to develop a disease or condition. For menopause, the only risk factors are being female and approaching 50 years of age. However, younger women with certain risk factors can experience menopause earlier in life. For example, women who undergo surgical treatments such as hysterectomy (removal of the uterus), have genetic disorders that affect the ovaries, or who use certain types of cancer therapies may experience menopause at a younger age.

Menopause increases risk factors for other health conditions. When a woman stops producing female hormones naturally, she loses the protective effects of those hormones. For example, her rate of bone loss speeds up, making the development of osteoporosis causing broken bones more likely. Her risk of heart disease also increases, partly due to higher cholesterol levels that occur after the production of female hormones stops. Estrogen and progesterone were formerly prescribed widely to help prevent heart disease among postmenopausal women. However, the results of large studies have found they not only do not protect against heart disease, they may actually increase heart disease risk for some women. The American Heart Association (AHA) now recommends against the use of estrogen and progesterone if they are taken only to prevent heart disease. If hormones are taken to relieve the symptoms of menopause, some guidelines now suggest they be used no longer than needed - 5 years, at the most.

What are the symptoms?

Menopause is usually associated with distinctive symptoms. Although many women have very little trouble dealing with menopausal symptoms, about 40% of American women report symptoms that disrupt their normal functioning to some extent. Approximately 85% of women experience vasomotor symptoms - most often hot flashes. Vasomotor refers to the interactions of muscles and nerves that cause blood vessels to shrink and expand. Although the exact causes of vasomotor menopausal symptoms are not yet known, they are associated with disruption of the body's temperature regulation by changing hormone levels. Hot flashes are sudden, unprovoked feelings of heat, usually on the face, head, neck, and chest. They may be accompanied by rapid heartbeats, reddened skin, and/or heavy sweating. Typically beginning a year or more before menopause, individual hot flashes may last for a few seconds or for several minutes. They may occur singly or in groups. Only a few may occur per day or they may occur frequently. Hot flashes may happen at any time of the day or night, and they may persist for several years. Generally, both the length and the number of hot flashes decrease gradually until they eventually disappear for most women.

Other symptoms of menopause may include:

• Decreased interest in sexual intercourse
• Difficulty in concentrating
• Dry, thin, easily bruised skin
• Inability to control urine
• Insomnia
• Mood changes (such as anxiety, depression, and/or irritability)
• Night sweats
• Spotting (small amounts of blood from the vagina) and/or abnormal vaginal bleeding
• Thinning or lost hair
• Vaginal dryness
• Urinary Tract Infections
• Vaginal infections
• Waking up earlier than usual

How is it treated?

For nearly 50 years, the standard treatment for menopausal symptoms was replacing one or both of the major female hormones, estrogen and progesterone. Hormone replacement therapy, often abbreviated as "HRT," restores both estrogen and progesterone. Since estrogen alone may increase the risk of uterine cancer, HRT is prescribed for menopausal women who have not had surgery to remove the uterus. Progesterone decreases the risk of endometrial cancer and so, is said to "oppose" the uterine cancer-promoting side effects of the estrogen. Progesterone also regulates fluid balance, restores libido, and helps to build bone. Replacement of estrogen alone (estrogen replacement therapy or ERT) is often used for women who have had a hysterectomy (surgical removal of the uterus) since they no longer are at risk for uterine cancer. Therapy aimed at decreasing symptoms of menopause is usually given only for a short period of time. If hormone replacement therapy is used for prevention of osteoporosis, the therapy must be taken for longer. Although still used today, it is now known that in addition to the benefits of this therapy, there are risks involved. Based on the results of several trials, both the risks and benefits of hormone replacement must be weighed to determine if it is the best option for an individual. For some women, symptoms of menopause can be managed by making lifestyle changes. Read the section on Helping Yourself.

Two large, long-term studies and several smaller ones concentrated on defining the risks and benefits associated with ERT and HRT. In 1998, results from the Heart and Estrogen-Progestin Replacement Study (HERS) found no heart disease prevention benefit from HRT. Those findings were confirmed in a follow-up study (HERS II) that concluded in 2002. The good news, however, is this study showed that after an initial treatment period of 2 years with hormones, the risk of blood clots declined to a non-significant difference. Therefore, long-term there seems to be no increased risk of blood clots. The HERS II study also demonstrated that there were no differences between the hormone group and the placebo (inactive pill) group in the incidence of any types of cancer.

An even larger study, the Women's Health Initiative (WHI) sponsored by the National Heart, Lung and Blood Institute of the U.S. National Institutes of Health also examined the use of both ERT and HRT by thousands of women. The part of WHI that concerned HRT began in 1993 and ended in 2002 before the planned end date. It was stopped when higher rates of breast cancer, heart disease, stroke, and blood clots in the lungs were found in women who were taking HRT than in women taking a placebo. The study did find a decrease in hip fractures and colon cancer for those women taking HRT.

The estrogen-only part of the WHI, scheduled to end in 2005, was also stopped early (in February 2004) after results showed that estrogen apparently increased the risk of both stroke and dementia (decreased mental functioning). Benefits from treatment in this study included a reduction in fractures, conferring protection from osteoporosis. Neither part of WHI found any benefit for ERT or HRT in preventing heart disease.

The Women's International Study of Long Duration Oestrogen After Menopause (WISDOM) was a study performed in the United Kingdom, Australia, and New Zealand. The study was designed similarly to the Women's Health Initiative study. The trial was stopped early following the publication of results from the Women's Health Initiative study. Reports of results from the portion of the WISDOM study that was completed were consistent with those from the Women's Health Initiative. Older women beginning HRT many years after the start of menopause were at greater risk for cardiovascular events and blood clots. The investigators suggested that research is needed to assess the long-term risks and benefits of starting HRT in younger women, who may have different effects than older women starting HRT.

To investigate this issue, a substudy of the estrogen-only part of the Women's Health Initiative was recently undertaken. The results of this substudy demonstrated that younger postmenopausal women who had had a hysterectomy and who took ERT had significantly less buildup of calcium plaque in their arteries compared to those who did not take hormone therapy. This is good news for younger women who have had a hysterectomy and want to use short-term estrogen therapy to relieve the symptoms of menopause. However, more studies in this age group are needed, and it should be noted that these findings do not alter the previous recommendation that hormone therapy should not be used to prevent heart disease.

For those taking HRT or ERT, the lowest dose that is effective should be taken. Taking HRT or ERT may not be a good decision for some women, however. Other types of treatment may be more appropriate for women who:

• Have or have had breast cancer
• Have mothers or sisters who have or have had breast cancer or ovarian cancer
• Experience abnormal bleeding from the uterus
• Receive active treatment for blood clots in the legs

Another option for women who are at risk for certain types of cancer or have failed treatment with prescription estrogens and progesterone is bioidentical hormones. The terms "natural" or "bioidentical" hormone therapy are used to describe hormone treatment with individually compounded recipes of certain hormones in various dosage forms. Based on the results of a person's salivary or blood hormone levels, the final composition of the compounded dosage form is individualized to that specific person. It is important to consider that saliva testing has not been proven accurate or reliable, and blood testing only provides hormone levels present in the blood at the time of testing. This may be a problem because blood hormone levels can vary throughout the day. Also, the desired levels of these hormones in the blood and saliva are unknown.

Proponents claim that natural hormone therapy is better tolerated than manufactured products. Most manufactured oral hormone products require metabolism by the body to be broken down into a form that the body can use. Metabolites are left behind that your body does not use and are the likely culprits of causing side effects. Bioidentical hormones are chemically identical to the hormones which your body produces and do not require metabolism. However, there is no approved preparation method for these compounded products, and methods will differ from one pharmacist or pharmacy to another. This can result in patients receiving inconsistent amounts of medication. Currently this treatment option is not recommended over FDA-approved prescription products.

Drug classes used to treat Menopause

• Androgen and Estrogen Combinations
• Estrogens
• Estrogens - Vaginal
• Progestins
• Topical Estrogens
  

What is on the horizon?

The National Center for Complimentary and Alternative Medicine (NCCAM), a division of the U.S. National Institutes of Health, is currently conducting several clinical trials investigating the effectiveness and safety of natural menopause treatments. Black cohosh, soy and other isoflavones, and red clover are the primary agents being studied. However, clinical studies to date have failed to demonstrate positive results with these natural products.

Some evidence suggests that antidepressant drugs may help to control hot flashes. In small studies involving women with hot flashes, drugs known as selective-serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, and paroxetine, relieved hot flashes up to twice as well as placebo. Another type of antidepressant, venlafaxine, has also shown effectiveness. Possible side effects from antidepressants include constipation or diarrhea, dry mouth, insomnia, nausea, and sexual dysfunction. In addition, antidepressant drugs may interfere with the effectiveness of tamoxifen, a drug used to treat breast cancer.

Gabapentin, a drug used to control epileptic seizures and some types of pain, has also shown some promise for controlling hot flashes. A recent study has demonstrated that gabapentin appears to be as effective as estrogen in treating menopausal hot flashes. The exact mechanism of action in menopause is not completely understood, but it may help to normalize the body's temperature. In clinical and case studies of its use, women taking gabapentin reported reductions in other menopausal symptoms, such as mood changes and muscle aches, as well. Side effects, mainly dizziness, tiredness, and swelling in the hands or feet, were generally mild and appeared to be similar to those experienced by women taking estrogen only. Usually, side effects lessened after a few days of therapy. Gabapentin does not interfere with tamoxifen therapy for women who have breast cancer.

Also under study is the drug clonidine, which is commonly used to treat high blood pressure. Like gabapentin, clonidine can be used at the same time that tamoxifen is being taken. In case reports, clonidine relieved the length, number, and severity of hot flashes, at least mildly, for many women who were taking it. However the effects of clonidine on hot flashes wore off more quickly than anti-depressants or gabapentin. In addition to oral tablets, clonidine is available as a transdermal patch, which may be easier for some women to use. However, women taking clonidine experienced more problems with sleeping than women who were taking a placebo.

Hypertension (High Blood Pressure) and Medical Drugs Treatment

Introduction

You can't feel it. You can't see it. Nevertheless, your blood pressure may be high. If it is, you have hypertension, commonly called "the silent killer." You cannot afford to ignore it.

What is it?

In hypertension, also known as high blood pressure, blood is forced through the heart and vessels throughout the body with a greater force than is necessary. Over time, hypertension damages the heart and blood vessels. Eventually, untreated hypertension can lead to life-threatening health problems such as heart disease and strokes.

When your blood pressure is checked, two measurements--systolic and diastolic--are taken.

Systolic blood pressure represents the peak pumping pressure of your heart when it is fully contracted during a heartbeat.

Diastolic blood pressure represents the pressure in the heart when it is at rest between heartbeats. You may be diagnosed with hypertension if your systolic pressure is 140 or higher, and your diastolic is 90 or higher.

Normal blood pressure is defined as a systolic less than 120 and a diastolic less than 80 (or "less than 120 over 80"). "Pre-hypertension" is a new classification that impacts approximately 45 million American adults and is defined as a systolic of 120 to 139 and a diastolic of 80 to 89. Individuals who have pre-hypertension are on the brink of developing full blown hypertension.

Hypertension is defined as a systolic pressure of 140 or higher and/or a diastolic of 90 or higher. Hypertension is further classified by stages - stage 1 and stage 2 - depending on the systolic and diastolic pressure readings (see table below).

Hypertension is diagnosed when either the systolic or diastolic pressure is high or if both the systolic and diastolic pressures are high. To be diagnosed with hypertension, two or more properly measured blood pressure readings must be taken on each of two or more doctor's office visits and then the readings are averaged. This means it takes more than just one elevated blood pressure reading to be diagnosed with hypertension.

When the two blood pressure measurements fall into separate stages--for example a Stage 2 systolic reading, but a diastolic pressure in the normal range, the higher of the two is used for the classification. The higher part of the blood pressure measurement along with your personal risk for hypertension and other health conditions you may have, help your doctor determine the best treatment options for you. The table below lists the stages or classifications of hypertension.

	Systolic	Diastolic
Normal	Less than 120	Less than 80
Pre-hypertension	120 to 139	80 to 89
Stage 1	140 to 159	90 to 99
Stage 2	160 or higher	100 or higher

The higher the blood pressure, the more likely you are to experience a heart attack, stroke, heart failure or kidney disease.

What causes it?

Two main types of hypertension are recognized. By far the most common is Essential Hypertension, sometimes called Primary Hypertension. This is hypertension in which there is no identifiable cause. Ninety-five percent of all persons living with hypertension have essential hypertension. Although researchers have been unable to pinpoint its specific causes, several risk factors definitely increase an individual's chance of developing essential hypertension. Some of these risk factors are controllable. They include:

• Obesity
• High Salt Intake
• Smoking
• Lack of Exercise
• Emotional and/or Physical Stress

Risk factors that cannot be controlled are:

• Gender--Males are at a higher risk for hypertension at earlier ages than females.
• Age--The risk goes up for older women; more than half of women over the age of 60 have high blood pressure.
• Race--Hypertension and its complications are more common among people of African ancestry than among members of other ethnic groups. Not only does hypertension typically begin earlier among African-Americans; its complications are more frequent, and it leads to death more often.
• Family History of Hypertension--Risk is higher in people whose parents also have high blood pressure.

The other major type of hypertension, termed Secondary Hypertension, has an identifiable cause. It is due to disease. For example, kidney (renal) hypertension is due to high blood pressure within the arteries that supply blood to the kidneys. The underlying cause is kidney disease or conditions like atherosclerosis, which narrow or block the renal arteries. Secondary hypertension may also result from hormonal imbalances, particularly in the kidney's adrenal glands. Cushing's syndrome and pheochromocytoma (pronounced: "fee-oh-chrome-oh-sigh-toe-ma"), which is a tumor of the adrenal glands, are two of the conditions that can disrupt adrenal hormones and lead to secondary hypertension. Other causes of secondary hypertension include pregnancy, thyroid disease, and the use of some medications such as oral contraceptives and non-steroidal anti-inflammatory medications (NSAIDs).

Who has it?

According to estimates based on the Third National Health and Nutrition Examination Survey and on U.S. Census information, one-fourth of the general adult population in America has some degree of high blood pressure--a total of about 50 million people. Approximately 1 billion people worldwide have hypertension. Today it's estimated that there is a 19.3% prevalence of hypertension among white women, 24.4% among white men, 34.2% among black women, 35% among black men, 22% among Mexican-American women, and 25.2% among Mexican-American men.

Older persons also develop hypertension more often than younger individuals. Today it's estimated that in the older population (greater than 60 years of age), the prevalence of hypertension is 60%. As the population continues to age, it is expected that these numbers will also continue to increase. For unexplained reasons, people who live in the Southeastern part of the U.S. also seem to have higher rates of hypertension.

Approximately 45 million Americans have "prehypertension." These individuals are at increased risk for going on to develop hypertension.

What are the risk factors?

Risk factors are characteristics that may increase your chance for developing a condition. The more risk factors you have, the more likely you are to develop the condition. You are at increased risk for developing hypertension if you:

• Are 60 years of age or older
• Have a family history of hypertension
• Are of African-American descent
• Are overweight or obese
• Are a smoker
• Lack exercise or don't get enough physical activity
• Consume excessive amounts of alcohol (on a regular basis - defined as 3 or more drinks/day for a man or 2 or more drinks/day for a woman)
• Use oral contraceptives (birth control)
• Have a high salt intake and low potassium intake in your diet

What are the symptoms?

Hypertension (high blood pressure) usually has no symptoms. That is why it is termed "the silent killer." However, it can be accompanied by the following, especially if blood pressure gets very high:

• Headache
• Confusion
• Numbness or tingling in the hands and feet
• Severe shortness of breath

How is it treated?

The overall goal in treating hypertension is to prevent other health-related complications and death from hypertension-related complications. Treating and controlling your hypertension can help prevent damage to your heart, brain, kidneys, blood vessels, and eyes. For individuals who don't have other medical or health conditions such as diabetes or heart failure, typically the goal is to lower systolic blood pressure to less than 140 and the diastolic blood pressure to less than 90 ("less than 140 over 90"). For individuals with other medical conditions, blood pressure goals are lower and are determined by your doctor. For instance, the blood pressure goal for most people with diabetes is a systolic less than 130 and a diastolic less than 80 ("less than 130 over 80").

For individuals who have pre-hypertension, it is critical to adopt a healthy lifestyle to prevent high blood pressure. These lifestyle modifications include weight reduction, eating a healthy diet (called the "DASH" eating plan), increasing your amount of physical activity, and limiting alcoholic beverages. You can get more information about lifestyle modifications in the Helping Yourself section above.

For individuals with hypertension, lifestyle modifications as mentioned above are important but many times, medications will also be needed to adequately manage blood pressure. Many types of drugs are used to lower blood pressure. The initial drug choice is determined by your stage of hypertension (or how high your blood pressure is) and whether you have other health conditions that would affect the drug choice. (See the table below titled, "Options for Individualizing Antihypertensive Therapy" for more information.)

Options for Individualizing Antihypertensive Drug Therapy
If you have:	Then your doctor may prescribe one of the following:
Diabetes mellitus	ACE Inhibitors, ARBs, Diuretics, Beta Blockers, Calcium Channel Blockers
Heart failure	Diuretics, Beta Blockers, ACE Inhibitors, ARBs, spironolactone
Heart attack	Beta Blockers, ACE Inhibitors, spironolactone
Isolated systolic hypertension (elevated systolic only)	Diuretics, certain Long-acting Calcium Channel Blockers
Kidney Disease	ACE Inhibitors, ARBs
Recurrent Stroke Prevention	Diuretics, ACE Inhibitors

For hypertension that isn't controlled by diet and exercise, new treatment guidelines for hypertension recommend that most patients be started on a thiazide-type diuretic, unless there is a compelling need for a different class of medications.

Thiazide diuretics are useful in achieving blood pressure control. They have been proven to enhance effectiveness of other antihypertensive medications when used in combination, and are typically more affordable than other antihypertensive medications.

Patients with Stage 1 hypertension are generally started on a thiazide-type diuretic, but ACE Inhibitors, angiotensin II receptor blockers (ARBs), beta blockers, calcium channel blockers, or combinations of different classes can also be considered. Patients diagnosed with Stage 2 hypertension typically need a combination of two drugs usually consisting of a thiazide diuretic along with an ACE Inhibitor, an ARB, a beta blocker or a calcium channel blocker to adequately lower their blood pressure. However, the treatment guidelines are meant only to be a guide. Your healthcare provider is in the best position to design a drug therapy regimen to manage your hypertension.

If the initial drug regimen does not achieve the goal blood pressure, your healthcare provider may change your regimen by increasing your dosage or by adding additional antihypertensive medications until your goal blood pressure is achieved. Many patients eventually require two or more drugs to effectively control their blood pressure. Some patients may even require four or five medications to control their blood pressure.

It is important to remember that everyone can respond to antihypertensive medications differently. What works for others may not work for you and vice versa. It is sometimes necessary for a doctor to prescribe different antihypertensive medications until the best regimen for you is found.

More severe hypertension may require the use of drugs called "vasodilators", which widen arteries, allowing blood to flow more easily and thus, lowering blood pressure. Oral vasodilators, such as hydralazine and minoxidil, are often used together with diuretics and other drugs that reduce fluid retention. Clonidine, another type of antihypertensive, may also be utilized.

Hypertension is typically a lifelong condition. However, some patients-- especially those who have made lifestyle modifications such as losing weight-- may be able to modify their antihypertensive medication regimen after hypertension has been controlled for at least one year. In so-called "Step-Down" therapy the number of drugs being used, their dosages, or both are gradually reduced to see if blood pressure remains controlled. The goal is to maintain blood pressure control using the lowest dosage of the least number of medications possible. The key though is to keep blood pressure at or under goal. Not all patients are able to "Step Down" from their antihypertensive therapy.

Drug classes used to treat Hypertension (High Blood Pressure)

• ACE-Inhibitor and Calcium Channel Blocker Combination
• ACE-Inhibitor and Diuretic Combination
• ACE-Inhibitors
• Alpha Blockers
• Alpha-2 Agonists
• Angiotensin II Receptor Blocker and Diuretic Combinations
• Angiotensin II Receptor Blockers
• Beta Blockers
• Calcium Channel Blockers
• Combined Alpha and Beta Blockers
• Diuretics
• Renin Inhibitors

What is on the horizon?

Research is ongoing to better understand hypertension and how it develops. Researchers performed a study on newborns and found that healthy babies who had a "preferential response" to salt taste and who had at least one grandparent with a history of high blood pressure had blood pressures that averaged 5 millimeters of mercury (mmHg) or more higher than babies who had an aversive or neutral response to salt. Hypertension experts have long known that salt intake is linked to high blood pressure in some adults, especially those who are considered salt-sensitive, meaning that even low levels of salt trigger increases in blood pressure. While it is premature to suggest that neonatal testing can identify individuals at risk for adult hypertension, this research has spawned further investigation.

Researchers have also found that treating high blood pressure with medications not only lowers blood pressure but also makes the heart work better.

Researchers are also investigating a new class of drugs called vasopeptidase inhibitors. An investigational drug in this class called omapatrilat, was shown in one study to reduce blood pressure better than the well-known ACE inhibitors and appears to reverse some of the blood vessel stiffness thought to be an inevitable part of aging and a contributing factor to hypertension. Research continues on this drug class.

Researchers are also looking for a vaccine that would protect individuals against essential hypertension.

Hormonal Contraception/Birth Control and Medical Drugs Treatment♦

Introduction

Contraception (preventing pregnancy) has been attempted for thousands of years. Over the centuries, contraceptive methods have varied greatly from ways we would consider bizarre to methods quite similar to what we use today. For example, in ancient Egypt, crocodile dung and honey were put in the vagina to prevent conception. In some African countries, women used okra pods as vaginal pouches similar to the female condoms now in use. From dung to seedpods, the effectiveness of traditional contraceptive methods is quite questionable. Although today's methods of birth control can be more complicated to use, they are undeniably more reliable and certainly more appealing.

Over the next 25 years, the world's population is estimated to exceed 8 billion individuals. At more than 40%, this increase represents the largest population growth ever seen over such a short time period. Governments as well as individuals are taking action to keep a huge growth in population from overwhelming resources. Without using some form of family planning, however, approximately 80% of women age 35 to 39 and 91% of women age 20 to 24 would become pregnant at least once during a 5-year period. Even more significant to overall population growth, one out of ten women age 15 to 19 will become pregnant each year, despite a consistent decline in the teen birth rate. Far more likely to live in poverty, babies born to teen-aged mothers are often low in birth weight, which contributes not only to higher infant death rates, but also to greater risk of lifelong health problems. Although estimates vary over a large range, as many as 60% of all pregnancies are believed to be unplanned. Worldwide, unplanned children are more likely to die before the age of one year.

Efforts to control population growth take many forms from governmental limits on the number of children per family to individual decisions about contraceptive methods. Hormonal contraception is just one method of birth control now used to help keep population growth in check and minimize the number of unwanted pregnancies. By far, the most popular method of limiting family size in the United States is oral hormonal contraception taken by the female partner. Since the U.S. Food and Drug Administration (FDA) approved the first modern contraceptive, Enovid 10, in 1960, major advances have been made in hormonal contraception. Available in several different dosage forms, today's hormonal contraceptives are formulated to reduce side effects and increase convenience while maintaining effectiveness.

Important Note: Hormonal contraceptives, in any form, do not provide protection against the spread of sexually transmitted infections (STIs), such as AIDS, gonorrhea, or syphilis (just to name a few).

What is it?

Hormonal contraception is one approach to birth control. It may be accomplished through various methods, which all involve interference with normal sex hormone function in the body. Hormonal contraception for men is under study, but existing hormonal contraception is used almost exclusively by women. Currently-available hormonal contraceptives disrupt the normal menstrual cycle by altering the levels of the female hormones, mainly estrogen and/or progesterone. By changing the amounts of estrogen, progesterone, or both; hormonal contraceptives interfere with the release, fertilization, and/or implantation of human eggs.

Combination contraceptives contain both a synthetic estrogen (usually one known as ethinyl estradiol) and any one of several progestins (synthetic progesterones). Typically, they are taken or used for 3 weeks per month usually being discontinued during the week of the menstrual period. Among the general types of hormonal contraceptives that contain both an estrogen and a progestin are:

Combined oral contraceptive pills (COCs - also known as birth-control pills, OCs, or the "pill") Usually packaged in a compact-like case that holds a one-month supply (either 21 pills that contain active hormones or 21 active pills and 7 inactive placebo "sugar pills"), COCs may be:

• monophasic (all the pills contain the same amounts of both estrogen and progestin)
• biphasic (two different dose levels of the hormones are taken during separate parts of the menstrual cycle)
• triphasic (three different amounts of hormones are used in an effort to better match the normal menstrual cycle and minimize side effects)

Contraceptive patches - adhesive bandage-like squares that stick to the skin and release hormones for one week

Injectable estrogen and progestin combinations (no longer available in the US) - continuous hormone release from once-monthly injections

Vaginal rings - soft circles of vinyl that are saturated with estrogen and a progestin. Inserted once a month into the vagina, they release hormones for 3 weeks before being removed.

Progestin-only contraceptives work mainly by keeping sperm from reaching an egg. They include the following kinds of products:

Injectable progestins - usually oil-based products that release a progestin gradually over one to 3 months after a single injection

Intrauterine devices (IUDs) - certain brands contain reserves of a progestin that releases slowly as long as the IUD is in place

Progestin-only pills (also called POPs or "minipills") - tablets taken orally every day

Progestin implants (not currently available in the United States) -progestin-filled rubber or plastic tubes that release a progestin slowly for much longer times (up to 5 years) after being inserted under the skin

What causes it?

Although preventing pregnancy is usually not considered to be a health condition, hormonal contraceptives do represent one of the few drug classes that are widely used by healthy individuals.

How Does Hormonal Contraception Work?

Hormonal contraception upsets normal female hormonal cycles in the human body. Generally, additional amounts of one or two female hormones are used to disrupt the balance of hormones that is needed for pregnancy to occur.

Estrogens:

• prevent ovulation (the release of eggs from the ovaries)
• affect the time needed for an egg to travel through the fallopian tubes, thus interfering with precise timing needed for fertilization
• interfere with the implantation of a fertilized egg on the wall of the uterus

Progestins:

• prevent ovulation (the release of eggs from the ovaries)
• affect the time needed for an egg to travel through the fallopian tubes, thus interfering with precise timing needed for fertilization
• increase the amount and thickness of mucus at the cervix (the opening of the uterus), thereby decreasing sperm entry to and passage through the vagina
• decrease the ability of sperm to fertilize an egg
• interfere with the implantation of a fertilized egg on the wall of the uterus

Who has it?

Currently, all forms of hormonal contraceptives are for use only by women, although several non-hormonal contraceptives (such as condoms) exist for use by men and women.

What are the risk factors?

Certain conditions require careful attention by a healthcare provider when hormonal contraceptives are used. Click on the links below to read about contraindications (reasons not to use certain kinds of hormonal contraceptives) and precautions (reasons to be careful when using certain kinds of hormonal contraceptives) associated with each hormonal contraceptive. Women who have any of the following conditions should discuss the use of hormonal contraception with a doctor before beginning to use it.

• Injectable Estrogen and Progestin Combination (No longer available in the US)
• Contraceptive Patch
• Injectable Progestin
• Progestin-only Pill
• Combination Oral Contraceptive (COC)
• Vagina Ring
• Progestin Implant (not currently available in the US)
• Intrauterine Device (IUD)

What are the symptoms?

Since hormonal contraception is not a health condition, it has no symptoms. It is not absolutely foolproof, however. Pregnancy may occur even when hormonal contraceptives are used correctly and consistently. Women who are using a contraceptive, but who think they may be pregnant, should contact a doctor right away. Hormonal contraceptives should NOT be used during pregnancy. Common signs and symptoms of pregnancy may include:

• Amenorrhea (absence of menstruation)
• Breast tenderness and enlargement
• Darkened nipples
• Frequent urination
• Increased appetite
• Morning sickness (nausea and vomiting, typically early in the day)
• Weight gain

How is it treated?

Many types of hormonal and non-hormonal contraceptives are available.

What are the advantages and disadvantages of non-hormonal contraceptive methods?

Non-hormonal Contraceptive Methods Comparison

Method	Advantages	Disadvantages
Abstinence	No cost No side effects Acceptable for individuals who cannot use other forms of contraception Fertility is not affected	Advance planning required Commitment from both partners required
Cervical Cap	Relatively inexpensive Can be inserted several hours before intercourse Only small amounts of spermicide are required Protects for up to 48 hours Fertility is not affected	Prescription required Advance planning required Must be fitted by a doctor Comes in limited sizes-may not fit all women May be difficult to insert and/or remove Latex may cause allergic reactions May move during intercourse Should not be removed for 6 to 8 hours after intercourse Effectiveness reduced after childbirth Cannot be used during menstrual periods
Condom, Female	Relatively inexpensive Non-prescription, relatively easy to obtain Can be inserted just before intercourse or up to 8 hours in advance Protects against STIs (including HIV/AIDS) Provides protection for 48 hours Polyurethane is non-allergic Can be used with oil-based lubricants Fertility is not affected	More expensive than male condoms High failure rate, may break during use Awkward to use One time use
Condom, Male	Inexpensive Non-prescription, easy to obtain Latex type helps to protect against STIs including HIV/AIDS Fertility is not affected	Poor acceptance Relatively high failure rate, may break during use Cannot be applied in advance Can interrupt intercourse One-time use Latex type may cause allergic reactions Lamb-skin type does not protect against STIs Effectiveness reduced by oil-based lubricants
Diaphragm with Spermicide	Relatively inexpensive Can be inserted up to 6 hours before intercourse Helps to protect against STIs, including HIV/AIDS Fertility is not affected	Prescription required Must be fitted by a doctor Must be refitted if weight changes more than 10 pounds Effectiveness reduced by: frequent intercourse oil-based lubricants Increases risk for: toxic shock syndrome (TSS) urinary tract infections vaginal yeast infections
Natural Methods*	No cost No side effects Acceptable for individuals who cannot use other forms of contraception Fertility is not affected	High failure rate Advance planning required No protection against STIs May be complicated and time-consuming Commitment from both partners required
Spermicides Alone	Inexpensive Non-prescription, easy to obtain May offer some protection against certain STIs Fertility is not affected	High failure rate Cannot be applied in advance One-time use - must reapply before each act of intercourse No protection against HIV/AIDS Messy Possibly irritating to either partner
Sponge	Inexpensive Non-prescription Easy to insert and remove Fertility is not affected	No protection against STIs Fairly high failure rate when used alone
Tubal Ligation	Very low failure rate	Expensive Outpatient surgery required No protection against STIs Permanent
Vasectomy	Very low failure rate	Expensive In-office surgery required No protection against STIs Fertility difficult or impossible to restore
Withdrawal	No cost No side effects Acceptable for individuals who cannot use other forms of contraception Fertility is not affected	High failure rate Advance planning required No protection against STIs Commitment from both partners required

*Natural Methods include measuring body temperature, tracking menstrual cycles on the calendar, or determining the thickness of cervical mucus

How do hormonal contraceptives compare in cost?

General Cost of Hormonal Contraceptives
(All costs are based on retail prices that were in effect on July 1, 2007)

TABLE KEY:

$ = $0 to $50

$$ = $51 to $100

$$$ = $101 to $150

$$$$ = $151 to $200

$$$$$ = $201+

	Type of Contraceptive	Average Cost Range per Month
Combined Estrogen and Progestin	COC-monophasic*	$
	COC-biphasic*	$
	COC-triphasic*	$
	COC-91-day*	$ to $$$ (3-month supply)
	Contraceptive patch	$$
	Injectable estrogen and progestin combination	No longer available in U.S.
	Vaginal ring	$
Progestin Only	Injectable progestin*	$$ (3-month supply)
	Progestin-containing IUD **	$$$$$
	Progestin-only Pill*	$ to $$
	Progestin Implant	Not currently available in the U.S.

* A generic form may be available.
**The IUD must be inserted by a physician and additional fees for this service may apply and will vary according to physician.

What are the types of non-hormonal contraceptives?

Abstinence (not having sexual intercourse)

Cervical Cap (a small, cup-shaped latex device that is fitted into the entrance of the vagina to block the passage of sperm)

Condom, Female (a thin, stretchy pouch that fits inside the vagina and keeps sperm from entering the uterus)

Condom, Male (a thin, but strong covering that fits over the penis to prevent sperm from entering the vagina)

Copper IUD (a small T-shaped device wrapped in a copper wire that is inserted into the uterus and may be effective for up to 10 years depending on the device).

Diaphragm (a flexible, rubber device that is held against the opening of the uterus by a spring to prevent sperm from getting into the uterus)

Natural methods (such as measuring body temperature, tracking menstrual cycles on the calendar, or determining the thickness of cervical mucus)

Spermicide (vaginally-inserted chemicals that inactivate sperm - often used in combination with other forms of contraception such as cervical caps, condoms, diaphragms, sponges, and withdrawal)

Sponge (a thick, soft cushion of polyurethane foam that is inserted into the vagina to block the passage of sperm into the uterus)

Tubal ligation or female sterilization (commonly known as tied tubes - a permanent surgical procedure in which the fallopian tubes are cut or blocked so that eggs cannot enter the fallopian tubes and sperm cannot reach the eggs to fertilize them)

Vasectomy or male sterilization (a surgical procedure in which the vas deferens, which are the tubes through which sperm travel, are cut or blocked, so that sperm cannot leave the male body)

Withdrawal (also called coitus interruptus or pulling out taking the penis out of the vagina before sperm is released)

What is Emergency Contraception?

Whether it is the result of a broken condom or a sexual assault, unprotected (without contraception) sexual intercourse may occur. To avoid a possible unwanted pregnancy, emergency contraception may be utilized. Although emergency contraception is often called the ?morning after? pill, it is not a method to use routinely. It should be restricted to just what the name indicates - emergencies.

Currently several methods are used for emergency contraception. The most common methods work by preventing conception. Another way is to force the elimination of a fertilized egg.

In 1999, the FDA approved for use in the United States a contraceptive that is used only to prevent conception in an emergency situation. Under the brand name Plan B, the product has 2 tablets containing the progestin, levonorgestrel. Depending on the time of the woman?s cycle when it is taken, it prevents conception by interfering with ovulation, fertilization, and/or implantation. To use it, the first dose should be taken as soon as possible. A second dose is then taken 12 hours after the first dose. According to study results, Plan B may be up to 95% effective, if the first dose is taken within the first 24 hours and the second dose is taken on time. If the first dose is delayed until 72 hours, effectiveness decreases to about 89%. After 72 hours, effectiveness decreases significantly. In August 2006, the FDA made Plan B a non-prescription product for women who are 18 years old or older. Because it is still a prescription drug for younger women, Plan B will be kept behind the pharmacy counter.

Taking high doses of certain regular COCs may also prevent conception after unprotected sex. Like Plan B, however, this method also loses effectiveness if it is not started quickly. Each dose consists of 2 to 4 tablets of certain COC brands. A woman who needs to use this method, which may also be called the Yuzpe Method (pronounced Yoo-zep-ee), should check with a physician or pharmacist for recommendations on the brand of COC to use and the number of tablets to take. As with Plan B, the first dose of the COC should be taken as soon as possible within 72 hours. A second dose is then taken 12 hours after the first dose.

Common side effects from either Plan B or high doses of COCs may include breast tenderness, headache, nausea, pain in the abdomen, and tiredness. Because many women using Plan B or high dose COC also experience vomiting, an anti-nausea drug may be recommended before taking the first dose. If vomiting occurs within one hour of taking the COC, the dose should be repeated. Neither Plan B nor high doses of a COC can end a pregnancy if a fertilized egg has already implanted in the uterus.

For emergency use, a copper IUD can also prevent fertilization and/or implantation if it is inserted no later than 5 to 7 days after the incident. It is left in place at least until the start of the next menstrual period, but it may be left in place for 5 years or longer, if it is chosen as continuing contraception. With pregnancy prevention nearing 100%, inserting an IUD is more effective for emergency situations than taking oral forms of emergency contraception. IUDs are much more expensive, though, and they have to be inserted, checked, and removed by a doctor. They are not recommended for women who may have or who may have been exposed to an STI. IUDs may cause abdominal cramping and vaginal bleeding in the first few days or weeks after their insertion.

Another method of emergency contraception ends a pregnancy. Sometimes known as a "medical abortion", this method requires that two different drugs be taken. First, one 600 mg dose of mifepristone (Mifeprex) is taken as soon as possible within 49 days of the missed menstrual period. Two days later, one 400 microgram dose of misoprostol (Cytotec) must be taken. Mifepristone, commonly known as RU-486, blocks the effects of progesterone, which is necessary to maintain a pregnancy. Misoprostol belongs to a group of drugs known as prostaglandins, which cause the uterus to tighten. Usually, uterine contents (such as a fertilized egg) are forced out of the uterus. Women who use this form of emergency contraception must follow-up with a physician 14 days after taking misoprostol to determine whether the treatment was effective. Mifepristone/misoprostol is available only through specific physicians who must be able to perform abortive surgery if the treatment is ineffective.

Women with an IUD in place, those taking medications to prevent blood clotting, and those who have taken certain steroid medications for long periods of time cannot use mifepristone/misoprostol. This method also should not be used for women who have or have ever had:

• Adrenal gland dysfunction
• Allergic reactions to mifepristone or misoprostol
• Bleeding disorders
• Ectopic pregnancy (a fertilized egg that has implanted outside the uterus)
• Tubal pregnancy (a fertilized egg that has implanted inside the fallopian tube)

Between 80% and 90% of women who use mifepristone/misoprostol experience abdominal cramps and/or heavy vaginal bleeding. Other common side effects from mifepristone/misoprostol include diarrhea, dizziness, headaches, nausea, and tiredness.

What are the types of hormonal contraception?

Combination oral contraceptives (COCs) contain both an estrogen (usually one called ethinyl estradiol) and a progestin. Different brands may have varying amounts of estrogen and the progestin may be different. In general, lower doses of estrogen cause fewer side effects, so most currently-available COCs contain smaller amounts of estrogen than earlier versions. In addition, the products may have constant or varying amounts of the progestin component - making the pills either monophasic, biphasic, or triphasic. Monophasic COCs have the same amount of the estrogen and the same amount of the progestin in each pill throughout the cycle. Biphasic pills have the same amount of the estrogen, but have two different doses of the progestin at different parts of the menstrual cycle. Triphasic COCs, which are made to mimic the natural changes in hormone levels, have a constant dose of the estrogen with three different amounts of the progestin. Most COCs are prepackaged in compact-like cases that contain either 21 or 28 pills. Women who use the 21-day packs do not take a pill during their menstrual periods. The 28-day packs contain 21 active pills and seven inactive placebo (sugar) pills that are included as reminders so that the individual taking the pills does not forget to start a new pack on time.

A newly-approved COC (Seasonale) introduces a new dosing schedule that is more convenient for women using it. Intended to be taken daily for 12 weeks, the "extended-cycle" COC is then discontinued for one week. As a result, the user has only four periods a year instead of one a month.

Another newly approved COC (Yaz) is taken for 24 days instead of 21 days. This is done to help shorten menstruation as well as possibly decrease side effects due to decreased hormonal fluctuation.

Estrogen containing drugs may increase your chances of developing heart disease. This is especially true if you are a smoker, have diabetes, high cholesterol, or a history of heart disease in your family. A recent study found that even low dose estrogen containing oral contraceptives can increase a woman's risk for a heart attack or stroke. You should always talk with your physician to see if a particular form of birth control is right for you.

Contraceptive patches release hormones through the skin. One patch is applied by the user each week for 3 weeks every month, skipping the fourth week usually the week that menstruation occurs. They are convenient for women who cannot remember to take pills.

Injectable estrogen and progestin combinations are given into a muscle of the arm, thigh, or buttock by a qualified health care professional. They must be injected once a month between days one and 5 of the menstrual cycle. Injectable combination hormonal contraception offers another effective alternative for women who may have difficulty remembering to take pills. Unfortunately, injectable estrogen and progestin combinations are no longer available in the U.S.

Vaginal rings are inserted by the user. After releasing hormones for 3 weeks, they are removed and discarded. A new vaginal ring is then inserted possibly during the menstrual period. Similar to hormonal injections or patches, vaginal rings provide an alternative for women who have difficulty remembering to take pills.

Injectable progestin has been used for contraception since the 1960's, even though it was not FDA-approved for contraception until 1992. Given by injection into an arm or buttock muscle, it must be administered by a health care professional. It is given once every 3 months between days one and 5 of the menstrual cycle. A very effective long-term contraceptive, progestin injection may be an especially good choice for women who are breast-feeding, who have a history of seizures, who should avoid estrogens, who may forget to take pills, or who do not want to use other methods.

Intrauterine devices (IUDs) are small "T"-shaped devices, which may be filled with a progestin. In addition to releasing a progestin, IUDs are believed to cause minor uterine inflammation, change the chemical environment of the uterus, and ? possibly ? interfere with sperm movement. All these effects may destroy the egg or sperm and they may also prevent implantation. IUDs are inserted through the vagina by a qualified health professional. Good candidates for an IUD are women who have a history of seizures, who should avoid estrogens, who have trouble remembering to take pills, who do not want to use other methods, or who want long-term contraception that is not permanent. However, women who use IUDs may have higher risk for both pelvic inflammatory disease (PID) and ectopic pregnancy (a fertilized egg that has implanted outside the uterus).

Progestin-only pills, also called "POPs" or "minipills" offer an alternative to COCs for women who are breast-feeding, smokers over the age of 35, women who have or who have had breast cancer, and other women who cannot take estrogens. They must be taken every day with no breaks during periods. To be as effective as possible, progestin-only pills need to be taken at the same time each day.

Progestin-only implants are not currently available in the United States, although they are used commonly in other parts of the world. They consist of up to six small tubes that contain a progestin. Inserted under the skin on the inside part of the upper arm, the tubes release a constant amount of medication. Their insertion and removal are minor surgical procedures that must be done by a doctor with special training. Insertion is usually done between days one and 7 of the menstrual cycle or after a negative pregnancy test. Progestin-only implants may be removed at any time over a period of one to 5 years depending on the brand and the number of tubes that are inserted.

How effective are various methods of contraception?

Except for total abstinence (never having sex at all), no form of contraception is 100% effective – even if it is used perfectly. Failure rates (the percentage of pregnancies that occur among women who are using each type of contraception) are typically higher during the first year that an individual uses a particular type of contraceptive. Additionally, effectiveness may be influenced by social or economic factors, such as body weight, ethnicity, income level, location, marital status, and frequency of sexual intercourse. For comparison, about 85% of fertile (able to become pregnant) women who do not use any form of contraception may be expected to become pregnant in any one year.

Contraceptive Effectiveness Comparison

Method	Failure Rate
Hormonal Methods
COC	0.1% to 3%
Contraceptive Patch	0.3% to 1%
Injectable Estrogen and Progestin (no longer available in U.S.)	Less than 1%
Vaginal Ring	0.3% to 1%
Injectable Progestin	0.3% to 3%
IUD	1% to 4%
Progestin-only Pill	0.5% to 5%
Progestin Implant (not currently available in the U.S.)	1.5% to 9.3%
Non-hormonal Methods
Abstinence (Continual)	0
Abstinence (Occasional)	Up to 25%
Cervical cap	8% to18%*
Condom, Female	3% to 12%
Condom, Male	3% to 21%
Diaphragm (with spermicide)	2% to 18%
Natural Methods**	1% to 25%
Spermicide Alone	15% to 29%
Sponge	14% to 28%
Tubal Ligation	0.5% to 0.6%
Vasectomy	0.1% to 0.2%
Withdrawal	4% to 27%

*Failure rates for the cervical cap may reach 30% for women who have had children
**Natural Methods include measuring body temperature, tracking menstrual cycles on the calendar, or determining the thickness of cervical mucus

What is on the horizon?

Currently, several pharmaceutical companies are developing other new combinations, dosing schedules, and formulations of estrogen and/or progestin pills. Generally, the proposed new products are intended to lower the chance of side effects. New progestins that may provide both contraception and additional benefits, such as helping to lower high cholesterol levels, are also being investigated. Potentially, some of these newer contraceptives may be appropriate for women with irregular periods and other women who cannot use COCs that are currently on the market. Other research focuses on completely new delivery methods, such as an estrogen/progestin nasal spray, that would give women more options for combination hormonal contraception.

Other investigation centers on hormonal contraceptives for men. In much the same way that hormonal contraception works for women, changing normal amounts of androgens (male hormones) disrupts a man's fertility. For example, increasing amounts of the male hormone, testosterone; introducing a progestin (a female hormone); or both drastically decreases the production of sperm and/or causes the sperm that are produced to be unable to fertilize an egg. Injections, implants, or pills are the dosage forms most studied for male contraception.

Non-hormonal contraceptives in development include:

Immunocontraception (contraceptive vaccines) By stimulating the body's immune system to produce antibodies against cells or chemicals that are essential to fertilization, various stages of conception may be prevented. Antibodies are natural proteins that are produced by the immune system to attack specific foreign substances in the body. Among the potential antibody targets that have been studied as immunocontraception are sperm, female and male hormones, and the zona pellucida (a membrane that surrounds human eggs). In studies of humans, antibody response has not been consistent, however, and producing enough antibodies to be effective may take a long time. How long the vaccine will remain effective is not clear, and once antibodies are produced, restoring fertility may be difficult or impossible.

N-butyldeoxygalactonojirimycin (NB-DNJ) A drug already being used to treat a genetic disease, NB-DNJ also blocks the production of sperm. In laboratory studies, male mice that were given NB-DNJ stopped producing sperm, eventually becoming sterile after their pre-existing sperm supplies were exhausted. Men taking NB-DNJ also stopped making new sperm. Their inability to fertilize an egg continued for as long as the drug was administered; but gradually returned to normal after the drug was stopped - over about three weeks for mice; about six weeks for humans.

Spermicide/Anti-infectant Combinations Chemicals that kill or disable sperm and also eliminate bacteria, viruses, and other agents that cause sexually-transmitted infections would not only provide contraception, they would also help to control the spread of diseases such as AIDS and other sexually transmitted infections.

Contraceptive Gel In very early stages of testing is a gel that hardens into a permanent, but possibly removable barrier after being inserted into the fallopian tubes. It forms a solid plug that prevents eggs from entering the uterus and sperm from reaching eggs. In animal studies, it has been effective and easy to insert. However, no human studies have been conducted, yet.