What Is Hemophilia? Symptoms, Causes, Diagnosis, and Treatment
Signs Your PAH Treatment Isn't Working
Pulmonary arterial hypertension (PAH) is a form of pulmonary hypertension that causes the small arteries of your lungs to thicken and narrow. This can lead to high blood pressure in your lungs.
While there's no cure for PAH, there are many treatment options that can help control your symptoms. It's important to work closely with the doctor to ensure your PAH treatment continues to work.
"Treatments range from medication all the way up to transplantation," says Richard N. Channick, MD, a pulmonologist at UCLA. Your treatment plan might include:
Vasodilators. Blood vessel dilators, called vasodilators, help relax and open your narrowed blood vessels to help blood flow. Your doctor may give you treatment through an intravenous (IV) infusion, under the skin, as a pill, or through inhalation. With inhalation, you'll breathe in the medication through a machine called a nebulizer.
Anticoagulant medications. These drugs can help prevent blood clots. The most common form is warfarin (Coumadin, Jantoven).
Diuretics. These are "water pills" that help get rid of extra fluid in your body.
Digoxin. This medication can help ease your symptoms, strengthen your heart muscle contractions, and slow down your heart rate.
Oxygen treatment. With this therapy, you'll inhale air that has a higher concentration of oxygen than normal air.
Surgery. In some cases, you may need surgery. There are a few different types, including pulmonary endarterectomy, balloon pulmonary angioplasty, atrial septostomy, and transplant.
There are other treatments less commonly used for PAH as well.
"We have this big list of potential medications that we can choose from. Which medications we choose and how we use them is also a very important topic," Channick says.
The main goal of treatment is to ease symptoms and slow the progression of your condition. If your PAH seems to be getting worse, you may need to explore new treatment options.
How Can You Tell if Your PAH Treatment Is Effective?"It doesn't matter as much how you are at day one; it's really how you're responding to therapies that will determine how you'll do long term," Channick says. There are a few different ways to measure the success of someone's PAH treatment:
Functional class. Doctors may simply ask how you're feeling with the current form of treatment. They'll have you rate your symptoms on a scale, which experts refer to as a functional class.
"The functional class ranges from one to four. One being the [person] has no limitations to activity, four means they get symptomatic even at rest or with minimal exertion, and two or three being in between," Channick says. "Their functional class can help us determine how they're going to do and whether they need additional therapy."
Exercise capacity. "We can measure that using what we call the '6-minute walk' test, or how far a patient can walk up and down a hallway in 6 minutes. It's a pretty strong measure of how a patient is doing," he says.
Other tests. "Then we have things that we measure more directly, such as blood tests, an echocardiogram to look at how the right ventricle is functioning, or in some cases, even doing a repeat heart catheterization," says Channick.
No matter which method your care team uses, it's important to check in with your doctor to let them know how you're doing. Every 3 to 4 months is ideal. Don't wait until you think your condition has gotten worse. It's easier for them to determine your risk level with regular appointments and tests.
"It's important that you come in regularly, regardless of the presence or absence of symptoms," says Channick. "We have many examples of [people] who felt like they were doing pretty well, but maybe they weren't doing as well as they thought."
Symptoms don't always tell the whole story, but it's still important to pay attention to how you're feeling.
"Are you noticing a decrease in you exercise tolerance? For example, things you could do a month ago, you're now no longer able to do," Channick says.
Weight changes are another potential warning sign.
"One of the problems with PAH that isn't responding to treatment is fluid retention. It may not always be apparent. People hide fluid in places they can't even see," Channick says. "Getting regular weight checks may help us prevent a real problem or even a need for hospitalization."
Your treatment may also not be working well if you notice other symptoms, like:
If one treatment doesn't control your symptoms, it's likely something else will.
"Most [people] start on two different medications. Then, we do risk profiling, and if they're not at a low risk, and they still have limitations, then we'll often add a third drug to the regimen," Channick says. "So they may end up on three different treatments for their pulmonary hypertension."
How you respond helps determine whether you're a good fit for infusions.
"It's generally thought that the infusions can help even when the pills or the other medicines aren't working. Ultimately, if none of that is working, then we consider lung transplantation," Channick says.
But that doesn't happen often.
"The majority of patients benefit from just the current therapies and don't need an extreme approach," Channick says. "Before these medical therapies, the average survival was less than 3 years with this condition. Now, we have long-term survivors. We still can do better, but we've certainly come a long way."
What Is Penis Shrinkage And Why Does It Happen?
Penis shrinkage can occur and is often due to age, medication side effects, or lifestyle habits, such as smoking or weight gain. It rarely requires treatment, and habit changes can often help.
Penis size can vary significantly between people, and certain lifestyle factors can affect it.
This article discusses the current research on average penis sizes, what may cause shrinkage, and available treatment options.
Research into average penis sizes is often impaired by inaccurate participant reporting, selection bias, and inadequate sample sizes. However, a 2020 review calculated that the average penis size was:
Older but more detailed research from BJU International found average penis size falls within the following ranges:
Penis shrinkage is widespread as men age, but there are many other reasons why a penis may shrink:
AgingAs people age, several bodily changes can impact penis function, especially the reaching and maintaining of erections. Notably, muscle cells in the erectile tubes inside the penis can weaken with age. The erectile tubes produce erections when engorged with blood, so less blood flow means smaller or fewer firm erections.
Furthermore, fatty deposits can build up in the arteries (atherosclerosis), causing reduced blood flow to the penis, and a natural reduction in testosterone can further decrease erection size and strength.
Learn more about erectile dysfunction and aging here.
Weight gainWeight gain, particularly around the stomach, may also impact perceived penis size.
Although a penis may appear smaller with weight gain, it has not shrunk. It looks smaller because the penis is attached to the abdominal wall, and when the belly expands, it pulls the penis inward. If a person loses weight, his penis will regain its shape and size.
Prostate surgeryResearch from 2014 found that penis shrinkage occurred in 15–68% of patients after cancerous prostate gland removal surgery (radical prostatectomy) may experience some penis shrinkage.
However, more recent reviews note that penile shrinkage rates tend to lessen the further on from surgery recovery a person gets. Researchers found that around 60% of patients regained full penis length at 12 months of recovery.
Peyronie's diseaseIn Peyronie's disease, fibrous scar tissue develops inside the penis, causing it to become curved during erection. Most of the time, a curved erection is not a reason for concern, but for some, the bend might be significant or painful.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Peyronie's affects up to 23% of natal males ages 40 to 70.
Peyronie's can cause a reduction in the length and circumference of a penis. Sometimes, Peyronie's goes away on its own; most of the time, however, it will either stay the same or worsen.
MedicationsStudies have found penile shrinkage and other sexual dysfunctions to be a side effect of finasteride, a common anti-baldness medication.
Some medications can also reduce blood flow to the penis, and affect sexual performance, including the strength and size of erections. These medicines include anti-hypertensives and selective serotonin reuptake inhibitors.
SmokingLimited research suggests a correlation between smoking and below-average penis size. However, further controlled studies are necessary to investigate this potential link fully.
Smoking is also associated with erectile dysfunction (ED), according to a 2017 study.
Chemicals from cigarette smoking can injure the blood vessels in the penis, preventing the penis from filling with blood and stretching. Regardless of the stimuli and the effect on the brain, if the blood vessels are damaged, the penis will not achieve an erection.
Most causes of penis shrinkage, such as smoking and weight gain, can be addressed by lifestyle changes. If medications are causing the penis to shrink, a medication adjustment can reverse the shrinkage.
For some men who experience penis shrinkage after prostate removal, the condition may improve on its own within a few months to a year. Penile rehabilitation (a form of physical therapy) after surgery can help men regain erectile function, and medications, such as Viagra and Cialis, can boost blood flow to the penis.
Treatment for Peyronie's disease focuses on removing scar tissue from inside the penis, either with medication, surgery, or ultrasound technology. Penis shrinkage is irreversible but repairing the curvature can help improve sexual function and reduce pain.
Most of the time, penis shrinkage is related to age, medication, or lifestyle habits, such as smoking or weight gain, and rarely requires treatment. Adopting more healthful lifestyle habits or changing medication can often reverse shrinkage and reduce other sexual problems.
Any person who is experiencing penis shrinkage, pain, or other sexual problems, or has concerns about cancer, should talk with their doctor. A doctor or urologist, can answer questions, reassure patients, and offer testing and treatment if necessary.
What To Know About Treatment-Resistant Depression
Standard treatments ease depression for a lot of people, but they don't work for everyone. At least 30% of those who try two or more antidepressants continue to have serious symptoms. That's called treatment-resistant depression.
If it happens to you, keep in mind that there are still ways to manage your depression. Talk to your doctor about all of your treatment choices.
"The most important point is not to give up," says John Krystal, MD, chair of the Department of Psychiatry at Yale School of Medicine and a pioneer in research on ketamine and depression. "There are so many of these options – current and emerging – that can really make a difference in a person's life."
What Is Treatment-Resistant Depression?Experts don't agree on one definition. But in general, it's a form of depression that doesn't improve after you try two antidepressants from different classes of drugs. "If you have to go to a third medication, that's the standard threshold," Krystal says.
For example, he says your doctor might diagnose you with treatment-resistant depression after you're first treated with a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine, and you don't respond. And next, you're treated with a serotonin-norepinephrine reuptake inhibitor (SNRI), such as venlafaxine or duloxetine, and you don't respond to that either.
"Medication acts as a kind of filter," Krystal says. "If you respond to it, then by definition, you don't have treatment-resistant depression."
How to Get a DiagnosisBefore you get a diagnosis of treatment-resistant depression, Krystal says you'll need to go through two rounds of antidepressant treatments. That typically means giving each antidepressant 6 to 8 weeks to work. And if the dose of your first antidepressants doesn't help, your doctor might raise the amount of the drug you take before you switch to a different medicine.
Crystal Clark, MD, an associate professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, says it's important to maximize the dose of each antidepressant.
"Sometimes we'll see that people have tried several [antidepressants] that haven't worked, but they've only tried half of the potential dose. That may not necessarily be a failed trial."
Your doctor might also look for hidden causes that could explain why your drug treatments aren't working. There are a "cluster of different reasons" why people don't respond to antidepressants, Krystal says, including things such as:
Outside issues can also play a role. "Some people don't respond [to antidepressants] because so much is going on in their life, and they experience such stress and turmoil that the resolution of their depression is masked or prevented," Krystal says.
What Causes Treatment-Resistant Depression?There are some theories about genetic and brain differences, Clark says, but there isn't a biomarker or other mechanism that can identify people who'll have treatment-resistant depression. "There's no definitive answer on that question."
Krystal says there are "many different pockets of people" who don't respond to antidepressants. Researchers are trying to figure out the biology behind why that is. This might lead to more personalized treatment down the road. "That strategy is called precision medicine," he says.
Experts are specifically looking into how this targeted approach might help certain groups, such as those who have treatment-resistant depression and lots of inflammation. Krystal says this includes people with conditions such as arthritis, asthma, heart disease, inflammatory bowel disease, and are overweight or have obesity.
In general, your odds of depression go up when you have ongoing inflammation. And Krystal says there's some evidence that the amount of inflammation you have can predict whether you'll respond to antidepressants. He says there's promising evidence that immunosuppressant medication, which blocks signals from pro-inflammatory cytokines, might help ease symptoms for certain people with treatment-resistant depression.
SymptomsThere isn't a specific set of symptoms that makes treatment-resistant depression different from other forms of depression. Experts agree it'd be a lot easier if that were the case. But Krystal says your antidepressant definitely isn't working if you wake up every morning and think, "I don't know how I'm going to get through the day."
Krystal says that if you have no joy, pleasure, or excitement in your life, "that's a good time to start talking to a therapist, counselor, or doctor about what's going on."
Here are some other questions to gauge whether your antidepressant is helping:
Antidepressants alone may not work very well. Seek help from a doctor who'll give you more choices. "I encourage people to make sure they're working with a psychiatrist who feels comfortable going through the gamut," Clark says. "Not just with oral therapies, but someone who has knowledge of some of the more advanced and novel treatments."
Treatment options for treatment-resistant depression include:
Adjunctive medication. Your doctor can add other drugs to go with your antidepressant. Everyone is different, but common choices may include antipsychotics, mood stabilizers, anti-anxiety medications, thyroid hormone, or other drugs. Your doctor may also suggest pharmacogenetic testing to check for specific genes that show how well you process certain antidepressants.
Talk therapy. There's evidence that psychotherapy can ease depression in some people who don't respond well to antidepressant drugs. "Yet, often, when we're talking about treatment-resistant depression, and thinking about interventions, we're not always including cognitive behavior therapy, family therapy, or supervised work therapy," Krystal says. These therapies may help:
Ketamine. Your doctor may suggest this drug to give you rapid relief from treatment-resistant depression. You'll take it in low doses through an IV. The FDA has approved a nasal spray form called esketamine (Spravato). Doctors typically recommend that you take an oral antidepressant along with esketamine or ketamine.
Brain stimulation. Your doctor might want you to go this route if nothing else works or your symptoms are really serious. These procedures include:
Tell your doctor if you don't feel 100% better. The goal for your treatment should be the same as other health conditions, Krystal says, such as cancer, heart attacks, or broken bones. "In other words, we don't go to an orthopedic surgeon and tell them, 'I broke my leg, but I want it to be 60% better.' We tell the orthopedic surgeon, 'I want my leg fixed.' "
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