You’ve had a few weeks of occasional throbbing headaches with nausea, vomiting, and increased sensitivity to loud noises. You’re likely experiencing migraine headaches, which usually throb on one side of the head. Nausea is a very common associated symptom. Many people note that headaches begin in response to certain triggers, like stress, menstruation, or strong smells. See here for more information.
A few times per year, you experience one or two days of intense nausea and vomiting. You may have the rare condition known as cyclic vomiting syndrome. Affected people have nausea and vomiting for several days, then go back to normal for a few weeks or months. The cycle then repeats indefinitely. Many people with this condition have a history of migraine headaches, and some of the treatments used for migraine may be helpful in this disorder. Before settling on this diagnosis, it’s important to look for other possible causes of nausea; therefore, your doctor will likely perform several tests. Although there are no great treatments for cyclic vomiting syndrome, antimigraine medications and antidepressants can be helpful.
Get to the E.R.
You have diabetes, and your sugar has been really high. When your body runs out of insulin, it becomes totally unable to process the sugar in your blood. Since your organs depend on sugar for energy, they begrudgingly turn to other sources of calories. Your blood sugar levels skyrocket, and the byproducts from those alternate energy sources (known as ketones) increase your blood’s acid level. The main symptoms include nausea, fatigue, belly pain, and deep breathing. You need an emergency infusion of insulin and intravenous fluids. Get to the E.R. as soon as possible.
You also have a severe headache. Migraine headaches often cause nausea and vomiting, as described in a previous section. If you don’t have a history of migraines, however, and are experiencing a new, severe headache associated with nausea, you may have increased pressure on your brain. The skull is a closed space that doesn’t have much spare room. As a result, the brain gets squeezed whenever there is brain swelling, bleeding around the brain, or a tumor inside the skull. Early symptoms are headache and nausea. As things worsen, you may become confused, tired, and experience vision problems. Ultimately, you can suffer severe brain injury or even death. Get help ASAP.
Your vomit is mostly blood. If you’ve just eaten a beet salad or huge bowl of tomato soup, your vomit will be stained red. If, on the other hand, your toilet water is swirling with a distinct, bright red fluid that appears different from the rest of your vomit, it’s probably blood. Most bleeding in your stomach or intestines just travels down with your stool to the natural exit. Severe bleeding into the stomach or the esophagus (the tube that connects your mouth to your stomach), however, will trigger the vomiting reflex and make even the vomiting scene from The Exorcist look tame. People with advanced liver disease are at the highest risk of this terrifying event, since they have fragile blood vessels in their esophagus and can’t clot blood normally.
You have severe belly pain. The combination of nausea and severe belly pain are typical for the many causes of an acute abdomen—basically, a belly that needs immediate attention, before life-threatening complications occur. The major culprits include blockage (obstruction) of the intestines and irritation of the pancreas (pancreatitis), gall bladder (cholecystitis), appendix (appendicitis), or part of the large intestine (diverticulitis). If you have an intestinal blockage, and the food can’t get through your system, it is instead sent back toward the entrance. As a result, your vomit may smell really gross—like feces—since it’s coming from deep down in your guts. There’s more information about all of these problems in the section on belly pain; however, the bottom line is that if the pain is severe, you should get prompt attention.
Part 4
Lady Parts
Lump in Your Breast
EDITED BY TIMOTHY RYNTZ, M.D.
Breast cancer affects one in eight women during their lifetime, so it’s reasonable to become worried if you notice a lump. The good news is that many lumps are not cancer. The bad news is that it sometimes takes multiple imaging tests and a biopsy (surgical removal of a small piece of breast tissue) to figure that out.
Women frequently ask if they should be routinely checking their breasts for lumps (and if so, how often). For many years, there was a heated argument among doctors regarding this issue. The final verdict from most professional medical groups is that routine, regular breast self-examination may cause more harm than good, because when compared to other screening techniques, it does not effectively distinguish between dangerous lumps and benign ones, but often results in additional, sometimes invasive tests that provide little benefit.
Nonetheless, you are likely familiar with the normal texture of your breasts, and even if you’re not performing regular checks, you may notice a lump or a change in the shape of one breast. If you do, what should happen next? Wait a week for an appointment with your doctor, or go to an E.R. and try to get an emergency mammogram?
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You injured your breast and now have a lump beneath a visible bruise. If you’ve bruised your breast, you may have a lump-like collection of blood beneath the surface. The key is to track the lump over the following week as the bruise fades. If the lump doesn’t get smaller, check in with your doctor. Sometimes breast injury causes a phenomenon known as fat necrosis in which damaged breast fat becomes solid. Unfortunately, further testing is often required to prove it isn’t cancer. After all, it’s possible that by sheer coincidence you have a tumor in the exact area that was injured.
Your breasts hurt and have a lumpy texture during your period. Like many women, you likely have numerous small cysts (fluid-filled areas) in your breasts that swell and become painful during your period. The tip-off is the fact that both breasts are affected and feel lumpy all over. Any really large or persistent lumps may require further evaluation with a breast ultrasound.
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You’re breastfeeding. You may have a blocked milk duct, which results in swelling of your milk-producing glands. This condition, known as galactocele, can feel like a tumor and occurs either during or shortly after the breastfeeding months. Your doctor will perform a mammogram and/or ultrasound to check for signs of cancer. To confirm the diagnosis, your doctor may insert a needle into the area to demonstrate that milk comes out. A galactocele itself is not dangerous and usually doesn’t require any further attention.
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Quick Consult
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How Often Do You Need a Mammogram?
Mammograms remain the subject of heated debate. Some professional medical organizations recommend they begin at age forty and get repeated every year. Others recommend they begin at age fifty (earlier if there is a family history of breast cancer) and get repeated every other year.
What could possibly be the downside of earlier and more frequent testing? Isn’t it always better to stay on top of things? Unfortunately, mammograms aren’t a perfect screening test. They can’t always clearly show if a lump is or isn’t cancer, and as a result, an abnormal mammogram frequently results in a biopsy. Also, a mammogram itself isn’t exactly a walk in the park, as it requires your breasts to get sandwiched between two sheets of hard plastic.
As a result, even though earlier and more frequent mammograms will detect cancers sooner, they also dramatically increase the likelihood of finding noncancers that wouldn’t otherwise have been noticed or caused problems. (In men, a comparable issue exists with prostate cancer screening.) You and your doctor will have to decide on the schedule that best suits your attitude and wishes.
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You have a painful, red lump near your nipple. You may have a breast infection, known as mastitis, which usually occurs in women who are breastfeeding. In some cases, the infection can produce a solid ball of bacteria and immune cells known as an abscess. The treatment is antibiotics and drainage of the abscess, if large enough. Sometimes the symptoms of nipple infection don’t improve with antibiotics and are actually
an early sign of breast cancer known as Paget disease of the breast. Your doctor may perform further testing to check for this diagnosis.
You have a lump that doesn’t match any of the previous descriptions, but you otherwise feel fine. Try to see your doctor in the next few days. Depending on your age and the overall consistency of your breasts, you likely need either a breast ultrasound or mammogram (possibly both). If those tests can’t prove beyond a reasonable doubt that the lump is nothing to fear, your doctor will schedule a biopsy. Don’t go to the emergency room just to check out a lump; mammograms aren’t performed there and you’ll be sent right back to your regular doctor.
Get to the E.R.
You have a red, swollen, painful breast along with fevers, chills, and/or lightheadedness. You may have a severe case of mastitis that requires urgent attention, possibly with intravenous fluids and antibiotics. If you can’t see your doctor within the next few hours, head to the E.R.
Nipple Discharge
EDITED BY TIMOTHY RYNTZ, M.D.
It’s the end of a long day, and you’re ready to finally chill out and unwind. You go home, drop your bag by the door, and head straight to the bedroom to shed your work clothes. You grab your softest pajamas and start tossing your clothes on the bed. You reach for the remote to turn on your favorite . . . whoa, what is that? Is that a stain in your bra? Is that blood? Do I have fucking breast cancer???
The breasts are sometimes more a curse than a gift. For much of their adult lives, many women tolerate backaches, annual mammograms, a constant background fear of cancer, and countless wandering, gawking eyes—just, as far as evolution is concerned, to provide a few months of milk to their newborn children.
But what if milk, or some other fluid, starts coming out of your nipple when there’s no baby at home? Should you just wait a few days to see if it goes away? Should you quickly get a mammogram or an ultrasound?
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Your partner keeps getting to second base. And staying there. If your nipples are repeatedly stimulated during sexual intercourse, your body may misinterpret that as a baby trying to get milk. As any economics major can tell you, supply responds to demand. When your brain’s milk area becomes stimulated it releases a hormone called prolactin, which promotes milky discharge from both breasts. (Get it? Promoting lactation.) Tell your partner to play with something else; we’ll leave the details to your creative mind. If the discharge continues for more than a week or two, see your doctor. If the discharge is from just one breast, it’s also more concerning for an abnormal growth in that breast, such as cancer.
You burned your bra during the sixties. And haven’t replaced it since. If your nipple is frequently moving around inside your shirt, rubbing up against the surrounding cloth, your brain can also misinterpret that as sucking from a hungry little one. (It’s a pretty primitive reflex.) Even a loose bra or nipple piercings can stimulate the nipples enough to get the milk pumping. Again, milky discharge should be coming out of both breasts, since the signals from the brain aren’t selective. If you change your wardrobe but the milk keeps flowing, see your doctor.
You recently had a chest surgery, burn, or other injury. If someone recently took a scalpel to your chest, the last thing you want to deal with is nipple discharge. Unfortunately, the wires in your nervous system may get crossed, with your brain misinterpreting pain in the chest as nipple sucking. (We swear we are not making this up.) As noted in the previous section, the brain’s milk area gets turned on, and you may notice white discharge coming from both breasts. Just keep your doctor abreast. (Sorry, we really couldn’t help that one.)
You’re pregnant. In the last few weeks of pregnancy, you may note milky discharge from both breasts as your hormones go into overdrive. Think of it as a normal warmup. Some women, however, note bloody discharge from their breasts. Although this finding is probably normal, resulting simply from rapid growth and engorgement of the breasts, you should mention it to your doctor.
Make an Appointment
You have discharge from one breast. This finding suggests a problem specific to that breast, rather than an issue in the brain’s milk command center. The possibilities range from insignificant growths to full-blown cancer. Depending on your age and past medical history, you’ll likely need a mammogram, breast ultrasound, or both. Your doctor may also inject some contrast material into your nipple so that the milk glands are clearly visible on the scans.
You have a rash or redness around one nipple. A crusted skin infection in or around the nipple may occasionally ooze a pus-like discharge. If you also have a high fever and lightheadedness, call your doctor right away (or visit an urgent care center), since the infection may have spread to your bloodstream. A much rarer but more concerning cause of nipple irritation is Paget’s disease, a type of breast cancer that starts as a raw, painful rash around the nipple and can also produce discharge. It can be hard to distinguish Paget’s from a skin infection, so your doctor will likely prescribe an antibacterial or steroid cream to treat the rash. If your rash doesn’t improve within a week, you may need a biopsy to check for signs of Paget’s disease.
You take medications for schizophrenia or chronic nausea and abdominal pain. The antipsychotics used to treat schizophrenia (such as haloperidol/Haldol, fluphenazine/Prolixin, and risperidone/Risperdal), along with a popular medication used to treat nausea (metoclopramide/Reglan), mess with normal signaling in the brain and cause high prolactin levels. Some people experience milky discharge from both nipples as a result. Let your doctor know, and if it’s really bothersome, you may be able to try a different dose or medication. (Please don’t change medications on your own.) If you have discharge from just one breast, you’ll need a more detailed evaluation for breast cancer.
You’re tired, constipated, and have been gaining weight. First of all, join the club. Second of all, if your symptoms really are new, you may have a problem with your thyroid. The thyroid gland helps regulate your body’s metabolism. When the thyroid poops out, your entire body slows down, and you often pick up a few pounds. In rare cases, the dysfunctional thyroid causes cross-talk with the brain’s milk area, resulting in prolactin release and milk production from both breasts. Your doctor will check your blood levels of thyroid hormone and prolactin.
You’re a man. It’s never normal for men to lactate. (The closest you can get is the fake breast Robert De Niro sported in Meet the Fockers.) If you notice nipple discharge, speak with your doctor for some blood tests and a breast ultrasound.
Not only are you not pregnant, but you’ve been trying to get pregnant and haven’t been able. Many women enjoy a brief period of infertility after childbirth, which results from high levels of prolactin. (Nature wants you to pace yourself.) Women who are not new mothers, however, may experience abnormally high prolactin levels, leading to irregular periods, infertility, and milk production. Although nipple stimulation and certain medications can cause high prolactin levels, as described earlier, another common cause is a tumor in the part of the brain that makes prolactin, known as the pituitary gland. If your prolactin levels are high for no apparent reason, your doctor will order an MRI of your brain to check for this diagnosis.
You have frequent headaches or tunnel vision. A pituitary tumor can produce prolactin and cause all of the symptoms described in the preceding section. If it’s big enough, it can also cause headaches and compress the nearby nerves connecting the brain to the eyes, causing tunnel vision. Because the tumor does not spread to other organ systems (it’s not malignant), you may be able to treat it with medications alone. If it remains large, however, you’ll need to have it removed. Since the pituitary gland is located on the bottom surface of the brain, a surgeon can usually extract the tumor through your nostril, without having to cut open your skull. Amazing, right?
Vaginal Bleeding and Discharge
EDITED BY TIMOTHY RYNTZ, M.D.
For better or worse, the uterus is the only organ that is supposed to bleed on a regular basis. For a
bout forty years, the uterus unburdens itself like clockwork, its monthly purge sometimes being greeted with annoyance, dread, or even relief (if you’ve been less than perfect about contraception).
In most women, a normal period occurs every four to six weeks and lasts four to seven days. Sometimes, however, Aunt Flo overstays her welcome, or a dam seems to break up there and the trickle becomes a gush. In other cases, blood shows up way off schedule and seemingly out of nowhere, or discharge appears that definitely isn’t blood. All of which makes you curse your luck and wonder what in the world is going on.
First, a quick review of the plumbing. Most vaginal bleeding originates from the uterus. The vagina leads to the uterus through the cervix, a small, ringlike opening. Each month, the wall of the uterus thickens in preparation for a possible pregnancy, but if your eggs get stood up once again, the uterus dumps the wall and starts over.
Sometimes abnormal growths occur and, not even knowing about the monthly routine, bleed off-schedule. Meanwhile, nonbloody discharge is often a sign of infection.
If you have abnormal bleeding or discharge, should you just wait a few days to see if it goes away? Put in a tampon and move on with your life? Rush to a gynecologist for a complete pelvic examination?
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Am I Dying Page 12