Health News and Information

This is a malignant tumour of melanocytes, which are the melanin and pigment producing cells in the basal layer of the epidermis. It is by far the most dangerous and life-threatening form of all cancers. Two-thirds of all skin cancer deaths are attributable to it. Like other skin cancers, the frequency of melanomas appear to be increasing—and not because of better or earlier recognition.

Causes. The incidence is greatest where light-skinned Caucasians are exposed to large amounts of solar radiation. Unlike S.C.C.s or B.C.C.s, melanomas are not found predominantly on sun-exposed areas—one-third of tumours occur on the trunk. The greatest incidence in the world is in Queensland.

Occasionally a mole may undergo malignant change and become a melanoma. However, considering the number of moles in the population, this happens relatively rarely; melanomas of this origin account for probably less than one-third of melanomas.

Features. Melanomas may vary considerably in appearance. However they usually all have some degree of colour or pigmentation to them. This is usually not uniform, and the edges are commonly irregular. The pigmentation may range from tan through blue to black, or from between red and brown to blue and black. Sometimes a melanoma is quite flat and flush with the skin surface, or on the other hand it may appear as a raised lump.

Some of the characteristics that may be observed in a mole which should arouse suspicion are:

colour change—either becoming darker or more variable in colour size change—becoming larger or irregular in outline surface roughness, scales, ulceration, or bleeding itching or pain

Treatment. The treatment for melanomas is basically surgical excision. If the diagnosis is uncertain, this should be preceded by a biopsy. The surgery of melanomas is usually fairly extensive (that is! wide and deep) because of the poor prognoses for advanced cases. Usually, a fairly large margin of normal skin is taken out with the melanoma, and a skin graft applied. The more radical approach of the past, in which the lymph glands close to the affected skin were also removed, is no longer practised.

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To understand why, it is necessary to go back a few decades. In the 1950s and 1960s, oestrogen replacement therapy was used by women in the United States in a big way. By replacing their lost oestrogen they discovered they could be, as the phrase went, Teminine forever’. At its peak, up to 50 per cent of middle-class American menopausal women were taking oestrogen, often simply so that they would look and feel 20 years younger. Eternal youth and, of course, no more periods. Goodbye old age! Life could now be one long silver lining.

Until up popped that little black cloud. By the 1970s, doctors in the United States had begun to notice a worrying increase in the number of women on oestrogen replacement therapy who developed – and sometimes died of – cancer of the endometrium (the lining of the womb). Suddenly oestrogen therapy was getting a very bad press, and in a short space of time doctors no longer wanted to prescribe it, and women no longer wanted to take it. It seemed as if this wonderful era of eternal youth was over.

Research quickly got under way, and it was discovered that when a woman took oestrogen on its own the lining of the womb would build up each month and remain there instead being shed as a period in the normal way. Eventually, the lining of the womb would become abnormally thickened, and in some women it became cancerous. The solution was to add a form of the hormone progesterone to the oestrogen therapy every month, so that the lining of the womb did not build up, but was shed each month, as a ‘period’. (After the menopause, it is not a true period as it is not triggered by ovulation, nor does it mean you are fertile and could become pregnant; it is an artificial withdrawal bleed, produced when you stop taking each monthly course of progestogen.)

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When it comes to disorders affecting the uterus, the procedure known as dilatation and curettage (D and C) is grossly overused. There is now ample research indicating it has significant shortcomings, yet it continues to be carried out both to provide samples of tissue for further investigation and as a ‘treatment’ for women with menstrual irregularities. In fact, its ability to provide useful samples for diagnostic purposes is quite limited; and when used for treatment purposes it is very disappointing, reducing menstrual flow for only one cycle in most women. In 1991-92 in New South Wales alone, more than 35 000 D and Cs were performed, suggesting that the annual figure for this procedure in Australia probably exceeds 100000.

The D and C technique is usually carried out under a general anaesthetic in a day hospital or general hospital setting. During dilatation, the cervix is gently stretched open by inserting progressively larger instruments. This is followed by a curette in which the endometrium is gently scraped away using an elongated instrument with a scoop attachment.

An alternative diagnostic procedure that can be used when a detailed patient history, examination and laboratory tests have failed to reveal the cause of abnormal bleeding is hysteroscopy. A hysteroscope is basically a tubular instrument with a light at one end and an optical system for transmitting an image to a display monitor. It is inserted through the vagina and cervix to observe the inside of the uterus. After obtaining ultrasound images of the uterus and introducing gas to separate the pelvic organs, the cervical canal is gently stretched to allow the hysteroscope to pass into it. It is then possible to get a good view of the uterus in about 80% of patients. (In the remaining patients, the view may be obscured by heavy bleeding.) Of women with menstrual irregularities in whom the uterus can be observed, more than 60% have no apparent uterine abnormality. These women are spared a diagnostic curettage. The others may have fibroids, polyps, endometriosis, pre-cancerous changes or endometrial cancer. If any area of abnormality is identified, a sample can be removed, checked by a pathologist and, in many cases, destroyed on the spot by an instrument inserted through the hysteroscope.

Hysteroscopy is thus a useful diagnostic test which can be used as the basis for treatment. It can be carried out without hospital admission or general anaesthesia, a considerable benefit in the eyes of many women (particularly those who are elderly and have multiple medical problems). A study by the University of Adelaide and the Royal Adelaide Hospital suggests that Australia’s health budget could be reduced by at least $30 million a year if outpatient hysteroscopy (also called office hysteroscopy) was adopted instead of performing D and C procedures in day surgery units.9 This 1994 study quoted the cost of a hysteroscopy at about $100, while a D and C cost over $500 when carried out in a day surgery unit and over $1000 if an operating theatre and overnight stay were required.

Serious complications such as bowel perforation occur in less than 1% of patients having a hysteroscopy, but about 70% experience the discomfort of menstrual-type pain, sensations of dizziness, tremor, shoulder tip pain or nausea, which is often followed by vomiting. If doctors explain possible side-effects before the procedure starts, this can help to reduce anxiety in patients when they occur. As increasing numbers of gynaecologists become familiar with the technique of hysteroscopy, it is hoped that D and C will be used more selectively.

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There are two different kinds of sleep, and they alternate with each other throughout the night. During REM sleep dreams are experienced, and during NREM sleep there are few or no dreams at all. When we fall asleep we go through NREM sleep, then REM sleep; these two combine to form one sleep cycle and we have a few sleep cycles throughout the night In this chapter we are going to study NREM sleep in detail.

In NREM or non-REM sleep there is an absence of rapid eye movement as recorded by the electro-oculogram or EOG. The brain waves are also calmer, in contrast to those of REM sleep. During REM sleep, the brain waves are not much different from those of the awake state. However, during NREM sleep the brain waves are slow and big and are divided into four stages according to their frequency.

During NREM sleep the mind is in complete rest, and is passive, peaceful, and calm. In REM sleep, in contrast, the mind is active and explosive, and the whole brain is working to capacity. Some experts report a 40 per cent increase in the blood flow to the brain during REM sleep.

During NREM sleep, the breathing is slow and regular. The blood pressure is lower than when we are awake, and the heart rate is also slower as if we are in complete rest On the other hand, during REM sleep the breathing is very heavy, and irregular. The blood pressure can be sky-high and the heart rate can be as fast as if we had just finished a 100 m race. It has been observed that if a heart attack or stroke takes place during sleep at night, it occurs during the REM stage. However, the peak incidence of heart attacks is between 7 a.m. and 11 a.m. in the morning and not during sleep. So you can sleep easy.

What about the muscular system during sleep? During NREM sleep, the muscles are active and the muscular system is fully engaged with the brain. There are spontaneous movements in the body during NREM sleep. We turn over many times during the night. This movement is important. People who cannot move because of illness such as quadriplegia suffer from bedsores. They need to be turned by nursing staff continuously throughout the 24 hours. The reason is that if the body is not moving during sleep, the skin which is under pressure from the weight of the body will be blanched and the blood supply to that part of the skin will be insufficient. That area of skin will break down and slough off to form a bedsore. So it is important that the body turns automatically during sleep. Also, this turning and moving of the limbs prevents the stiff neck and joint pain that most people experience the morning after they have been drunk the night before.

During REM sleep the muscular system is disengaged, as if a jamming mechanism is preventing the body from moving. This prevents the physical acting out of dreams. REM sleep is also called ‘paradoxical sleep’; the brain is so active and yet, paradoxically, the body is completely paralyzed.

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