Sleep is one of those things that should come naturally. And for many of us, it does. For some individuals, however, getting a good night’s sleep can be a struggle that leads to drowsiness, an inability to focus, and low energy during the day. Over a long period of time, lack of sleep may lead to an increased risk of depression and heart trouble. You may have trouble falling asleep and/or sleeping through the night, wake up earlier than desired, or feel tired upon awakening. These symptoms may be classified by their duration: transient (less than 1 week), short term (1-3 weeks), or chronic (more than 3 weeks). If you have chronic insomnia with daily symptoms and you are waking several times each night, or if your insomnia is caused by other medical conditions, see your health care provider (HCP) for treatment. See Table 1 for medical conditions that cause insomnia. If your insomnia can be classified as short term, several changes in lifestyle may be helpful.

The first step is to get in sync with your body’s natural sleep-wake cycle by following these practices:

		Set and stick to a bedtime schedule. Go to bed at about the same time every night and wake up at the same time every day to set your body’s internal clock. This includes weekends and holidays.

		Avoid late-day naps. Late afternoon naps can make falling asleep or staying asleep at night more difficult. If you do take naps, avoid napping after 3 pm and limit them to 15 to 20 minutes.

		Don’t sleep in on weekends. If your weekend and weekday sleep schedules differ, you may find your natural sleep-wake cycle is easily disturbed.

Melatonin, the naturally occurring hormone that makes you feel sleepy at night, is controlled by daylight, darkness, and the amount of light your eyes are exposed to. Melatonin levels are lowest during the day because your eyes detect large amounts of light through specialized cells of the retina. During the nighttime hours, melatonin levels peak, inducing physiological changes that promote sleep, such as decreased body temperature and respiration rate. In addition to sunlight, artificial lighting can be bright enough to prevent the release of melatonin, which can interfere with the sleep-wake cycle.

Here are some simple tips for optimizing the sleep-wake cycle:

		Spend more daytime hours outside or in lightfilled rooms. Exposure to sunlight during the day will help you fall asleep later on when it’s time for bed because light inhibition of melatonin production stimulates wakefulness and alertness throughout the day. Get outside early in the morning or have your breakfast near a sunny window. During the day, exercise outside or take your dog for a walk and open curtains and blinds in your house and workplace to expose yourself to plenty of light.

		Make your bedroom dark for better sleep. Block all sources of artificial light, including street lamps or outside house lights with heavy curtains or blinds, and cover up the glow from light-emitting electronics and bright alarm clocks.

Consider these other factors that affect sleep:

		Limit caffeine, tea, and nicotine before bedtime. In addition, avoid drinking large amounts of liquids in the evening because it may cause you to have to get up several times during the night to use the restroom. Although alcohol may make you feel tired at first, it may actually compromise the quality of your sleep and should be avoided, especially if you have been having trouble getting a good night’s sleep.

		Create a comfortable sleeping environment and pay attention to the temperature, noise and light in your room, as the bedroom environment can have a significant influence on sleep quality and quantity. This may mean reducing the temperature, turning off the TV, and avoiding computers, iPads, TVs, or work in the bedroom. The bedroom should be reserved for sleep.

		Get ready for bed with a regular routine. Engage in relaxing activities in the hours just before bed, such as light reading and listening to soothing music.

		Make sure your bed is comfortable and use it only for sleep. Avoid watching TV or working in bed.

		Exercise regularly. If timed right, exercise helps promote restful sleep. Engage in strenuous exercise (jogging, swimming, brisk walking, etc.) during the day, especially the day after a bad night’s sleep. However, you need to pay attention to what time you exercise. If you exercise too late in the day, you may have difficulty falling asleep. Try to finish exercising at least 3 hours before bed; however, a gentle stretching routine before bed can also help you to relax and induce sleep.

		Avoid heavy meals within 2 to 4 hours of bedtime. If your body is working to digest a large meal, your sleep may be disturbed— although a little food in your stomach may help you sleep. If you must eat before bed, try to limit your meal to a light snack and avoid protein-rich, high-fat foods near bedtime. See Table 2 for a list of foods to avoid for a good night’s sleep.

		If possible, avoid medications that disrupt sleep. Certain commonly used prescription and OTC medicines contain ingredients that can make it difficult to fall asleep, cause more awakenings during the night, and affect the quality of your sleep. These ingredients include decongestants, steroids, and caffeine in headache medicines. Antihistamines and prescription medications including betablockers, alpha-blockers, asthma treatments, and antidepressants can also affect sleep. If you have trouble sleeping, talk to your pharmacist to see whether any drugs you’re taking might be disrupting your sleep and whether they can be taken at other times in the day. Don’t stop taking prescription drugs or adjust your dosing schedule without talking to your pharmacist or HCP first.

If you’re still having trouble sleeping, you may be tempted to reach for a supplement or an OTC sleep aid. So when is it time to try a sleep aid? The answer is different for every individual because sleep problems are caused by a variety of different factors. For example, certain medications, night-shift work, and jet lag can throw off the sleep-wake cycle. A sleep medication may be an option when improving your sleep habits hasn’t worked, the cause of your sleep problem is known and is best treated with medication, or sleep troubles are making daily activities difficult to perform and the insomnia is expected to be temporary. Although sleep aids can help you fall asleep on occasional sleepless nights, it is best to talk to your HCP or pharmacist about taking any sleep aids or supplements like melatonin or valerian root extract. Supplements, because they are not recognized as drugs, are not regulated by the FDA, so it can be hard to pinpoint the exact melatonin or valerian root extract dosage that works best.

It is normal to have an occasional sleepless night, but if you find yourself having trouble falling sleep or staying asleep on a regular basis, speak to your HCP and don’t get discouraged. Together you can create a plan to help you get the rest you need.

						Smith M, Robinson L, Segal R. How to sleep better. Helpguide .org website. helpguide.org/articles/sleep/how-to-sleep-better. htm. Accessed July 28, 2016.

						Brain basics: understanding sleep. National Institute of Neurological Disorders and Stroke website. ninds.nih.gov/disorders/ brain_basics/understanding_sleep.htm#Tips. Updated July 25, 2014. Accessed July 28, 2016.

						Insomnia. National Sleep Foundation website. sleepfoundation .org/insomnia/content/what-is-insomnia. Accessed July 28, 2016.

						Sleep and chronic disease. CDC website. cdc.gov/sleep/about_ sleep/chronic_disease.html. Updated July 1, 2013. Accessed July 29, 2016.

						Insomnia fact sheet. Office on Women’s Health website. womenshealth. gov/publications/our-publications/fact-sheet/insomnia. html. Updated July 16, 2012. Accessed July 29, 2016.

Beth is a clinical pharmacist and medical editor residing in northern California.

Articles

How to Get a Better Night's Sleep

, meaning vertebra, ankylosing spondylitis (AS) is a complex, painful condition that can affect many parts of your body. However, AS most often causes pain and stiffness of the lower back because it attacks the sacroiliac joints between the spine and the pelvis. Over time, AS can damage the spine and lead to the growth of new bone. This causes the spine to stiffen and can result in a hunched-forward posture. Other parts of the body, such as the ankles, heels, ribs, hips, shoulders, and hands, can be affected. In rare instances, the eyes can be affected. Even the lungs and heart can become involved in AS.

Unlike other forms of arthritis, such as osteoarthritis, which is a wear-and-tear degenerative disease that is more common among women and older adults, AS generally develops earlier in life. AS usually develops in men younger than 40 years; however, but it can also affect women, children, and older adults. 

The symptoms of AS can vary from person to person, but usually develop gradually over several months or years. At first, patients may not notice the signs of AS. In fact, AS often goes undiagnosed because symptoms can come and go. But over time, they can get worse. The earliest symptoms of the disease may include pain and stiffness in the lower back and hips, especially in the morning and after long periods of not moving. The Table lists the parts of the body most commonly affected by AS.

For most individuals, AS comes in painful episodes, or flares, followed by temporary periods in which symptoms subside. Over the course of the disease, symptoms can get better, get worse, or stop at irregular intervals. The pain often improves when patients are active and exercising.

In some cases, inflammation due to AS can make joints fuse together. This happens when ligaments turn into bone, causing the spinal bones to join. This fusing can affect the flexibility of the spine, giving some patients the hunched-forward posture previously mentioned.

AS can also lead to iritis or uveitis, conditions in which the eye becomes inflamed. About one-third of patients with AS experience iritis or uveitis at least once. Eye inflammation causes painful, red, watery eyes; blurred vision; and sensitivity to light. See your health care provider (HCP) right away if you develop these symptoms. In rare cases, patients with AS may experience bowel inflammation, which is related to Crohn’s disease and ulcerative colitis.

The cause of AS is unknown, but it is likely that genes and environmental factors play a role. AS tends to run in families, and the main gene associated with susceptibility to AS is

. Individuals are at an increased risk of AS if they:

		Have frequent gastrointestinal infections

Your HCP may suspect you have AS, but the diagnosis is often made by a rheumatologist, an expert in arthritis and rheumatic diseases. Diagnosis generally involves a thorough physical exam, which includes x-rays, a medical history, a look at family history of AS, and blood tests. In the physical exam, the rheumatologist looks for key signs of AS, which include the following:

		Onset of disease usually before 35 years of age

		Chronic pain, or pain that lasts for more than 3 months

		Back pain and stiffness that worsens and leads to immobility, especially at night and in the early morning

		Back pain and stiffness that improves with physical activity and exercise

		Improved pain after taking nonsteroidal anti-inflammatory drugs (NSAIDs)

Your rheumatologist will be looking for pain and inflammation in areas of the body associated with AS, including the back, pelvic bones, sacroiliac joints, chest, and heels. Imaging tests may be used to look for changes in your joints and bones. These tests include x-rays, computed tomography (CT), and magnetic resonance imaging (MRI).

Blood tests may also be used in the diagnosis process. Although no blood test can spot AS, some blood tests can look for signs of inflammation. However, inflammation can be caused by a variety of health problems. Blood tests can also show if you have the

 gene, indicating whether you have a higher risk of developing the disease.

Although there is no cure for AS, treatment can be effective in reducing pain and stiffness, and may stop or delay complications and spinal deformity. Treatment generally involves a combination of exercise, drug treatment, and physical therapy. If you have severe pain or joint damage, your HCP may recommend surgery.

NSAIDs reduce inflammation, relieve pain and stiffness, and are the most commonly prescribed drugs for treating AS. NSAIDs used in the treatment of AS include the following:

When NSAIDs do not work, corticosteroids, such as prednisone, methylprednisolone, and cortisone, may be used. These drugs are injected directly into the affected joints to bring quick but temporary relief. Disease-modifying antirheumatic drugs (DMARDs), such as sulfasalazine and methotrexate, also work to reduce inflammation due to AS.

If none of the above medications work, tumor necrosis factor (TNF) inhibitors are sometimes prescribed. These drugs block a cell protein called TNF, which promotes inflammation in rheumatic diseases such as AS. Blocking this protein can help relieve pain and stiffness while reducing tender or swollen joints. TNF inhibitors are injected into the skin.

TNF inhibitors used to treat AS include the following:

As with most medications, the drugs come with some adverse effects. NSAIDs can cause gastrointestinal bleeding. TNF inhibitors can reactivate latent tuberculosis (a type of lung infection) and may lead to certain neurologic problems. Patients should be aware of these potential problems and notify their rheumatologist if they experience them.

Certain breathing exercises preserve and improve lung capacity. If AS has progressed and is causing the hunched-forward position, a physical therapist may recommend a variety of exercises to maintain good posture. Abdominal and back exercises, as well as sleeping and walking correctly, can help patients to remain stay upright.

Some patients require surgery to treat severe pain and joint damage. Knee surgery and hip replacement surgery are sometimes required when joints become severely damaged. Surgical correction may also be required for severe deformities of the spine.

AS is a chronic disease, meaning that it can last a lifetime. In the beginning, patients may have only mild symptoms they feel they can handle. This may be true, but it is still very important for them to see a rheumatologist at least once a year. An arthritis expert can help keep symptoms under control and spot underlying problems that may arise as a result of AS.

Beth is a clinical pharmacist and medical editor residing in Northern California.

		Ankylosing spondylitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases website. niams.nih.gov/health_info/ankylosing_spondylitis/ankylosing_ spondylitis_ff.asp. Published November 2014. Accessed June 13, 2016.

		Reveille JD. Spondyloarthritis. American College of Rheumatology website. rheumatology. org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spondyloarthritis. Updated November 2013. Accessed June 13, 2016.

		Mayo Clinic staff. Ankylosing spondylitis. Mayo Clinic website. mayoclinic.org/ diseases-conditions/ankylosing-spondylitis/basics/definition/con-20019766. Published February 11, 2014. Accessed June 13, 2016.

Ankylosing spondylitis is a complex, painful condition that can affect many parts of your body. 

Understanding Ankylosing Spondylitis

Microorganisms, or microbes, for short, are everywhere: in the soil, in the water, and even on and in our bodies. Modern hygiene standards have taught us that microbes do bad things. So we arm ourselves with soaps, sprays, and wipes to try to rid germs from our bodies and our homes. When you hear the word bacteria, you probably associate it with being sick. And since the discovery of penicillin in the 1920s, antibiotics designed to kill harmful bacteria, or pathogens, have saved countless lives. Although some bacteria are harmful, and killing those pathogens is a good thing when you’re sick, most bacteria are good. In fact, bacteria play a vital role in supporting nature and life.

A lot has been learned in recent years about the microbiome—the trillions of probiotic bacteria that live inside and on our bodies. However, microbiome research is still in the very early stages. These microbes help our bodies digest and absorb nutrients, manufacture certain vitamins, protect against foodborne pathogens, and rally against intruders, such as influenza and toxic cancer-forming carcinogens. As we are learning, this vast number of microbes, collectively referred to as the human microbiota, have far-reaching effects on our bodies, including genetic control&mdash;by stimulating or blocking the expression of certain genes. In fact, recent research has shown that there may even be a link between gut microbiota and obesity, as studies in mice have shown certain microbes can affect behavior and food absorption.

Age, health status, hygiene, and diet can influence your microbe balance. Certain drug therapies, such as antibiotics and colonics, or serious diarrhea, can kill these helpful microbes that inhabit our bodies. When this happens, you want to replenish those beneficial microbes as quickly as possible to protect your health.

Probiotics are foods or supplements that contain live microorganisms that you introduce into your gut in order to obtain some health benefit. Probiotics are said to improve digestive and immune health. They are also touted as potential treatments for conditions such as obesity, dental problems, and diabetes. But, although the evidence is mounting for some possible health benefits, there is still much we don’t know about whether and how the probiotic products now on the shelves can improve health. Most probiotics contain bacteria from the Lactobacillus and Bifidobacterium groups. Within these groups are many different species, and each species has many strains. Other bacteria may also be used as probiotics, and so may yeasts such as Saccharomyces boulardii.

There is a lot we still don’t know about probiotic use: what types of bacteria are best, what is the ideal dosage, what is the optimal length of therapy, and which groups of people will benefit most? Research has shown that taking probiotics may help prevent antibiotic-associated diarrhea and traveler’s diarrhea. They may also shorten the duration of stomach flu symptoms such as diarrhea and other digestive symptoms, but only by about 1 day. Probiotic supplements might also help treat irritable bowel syndrome, and may be useful when used in addition to standard therapy for treating Clostridium difficile (C diff)—associated diarrhea, ulcerative colitis, or bacterial vaginosis.

Most probiotics are sold as dietary supplements or foods, and the FDA doesn’t regulate supplements in the same way it does drugs. For this reason, consumers can’t be sure probiotic supplements contain what’s on the label in terms of the type and number of bacterial cells. Before you start taking or eating probiotics, it is a good idea to discuss them with your health care provider or pharmacist, as probiotics are likely safe for healthy people, but they may cause problems in people who are very ill or who have compromised immune systems. If you decide to take a probiotic supplement that contains bacteria, it is important that you wait at least 2 hours after taking an antibiotic. After taking an oral antifungal medication, wait 2 hours before taking a probiotic that contains yeast.

Prebiotics are foods high in soluble fiber—a nutrient we can’t digest that promotes the growth of helpful bacteria in the gut. Eating foods high in soluble fiber keeps our probiotic bacteria healthy. Think of prebiotics as a healthy meal for the helpful bacteria in your gut. Foods rich in prebiotics include asparagus, Jerusalem artichokes, chicory root, garlic, onions, leeks, bananas, oatmeal, and legumes. And smaller amounts of soluble fiber are found in a wide range of foods, including fruits, vegetables, whole grains, bran, honey, and soybeans. Generally speaking, as long as you’re eating a varied diet that includes fruits, vegetables, legumes, and whole grains, you are probably getting enough prebiotics or soluble fiber to keep your “good bacteria” healthy.

It may be possible to nourish the beneficial bacteria inside us by modifying our diets. We know that dietary fiber serves as food for many of the bacteria that live in our gut and that when bacteria are starved of food, they eat the mucus lining of our large intestines. On the other hand, when the bacteria are well fed, they give off nutrients that nourish the cells that line the intestines. Grains, legumes, fruits, vegetables, and other fiber-rich foods feed the hungry, beneficial bacteria and offer them a fighting chance to crowd out the harmful bacteria. Another way to build a better microbiome may be to eat foods that are naturally full of probiotics, rather than foods that aren’t naturally fermented or cultured. Although natural, probiotic foods may not be as convenient to eat as probiotic supplements, the extra nutrition that foods can offer are a plus. The most natural way to deliver beneficial bacteria to the digestive system is to eat fermented foods such as yogurt, sauerkraut, kombucha, kefir, and kimchi (Sidebar). Other probiotic foods include tempeh, miso soup, some aged cheeses, sourdoughs, and pickled fermentations of turnips, eggplant, cucumbers, onions, squash, and carrots.

Make sure to read product labels and do your research. Choose reputable commercial brands whether you are purchasing probiotic foods or supplements. Not all foods and supplements are created equal, and you don’t want to waste money on products that aren’t actually helping you.

		Foods to restore your intestinal flora. 

 website. scientificamerican.com/article/foods-to-restore-your-intestinal-flora/. Accessed May 19, 2016.

		Probiotics: in depth. National Institutes of Health website. nccih.nih.gov/health/probiotics/introduction.htm. Accessed May 19, 2016.

		Fiber supplementation influences phylogenetic structure and functional capacity of the human intestinal microbiome: follow-up of a randomized controlled trial. 

Nutrition website. /ajcn.nutrition.org/content/early/2014/11/12/ajcn.114.092064.abstract. Accessed May 20, 2016.

		Metabolites produced by commensal bacteria promote peripheral regulatory T-cell generation. Nature website. nature.com/nature/journal/v504/n7480/full/nature12726.html. Accessed May 20, 2016.

		4 habits for a healthy gut. CNN website. cnn.com/2014/06/18/health/good-gut-bacteria/. Accessed May 20, 2016.

		Johansson ME, Gustafsson J K, Holmen-Larsson J, et al. Bacteria penetrate the normally impenetrable inner colon mucus layer in both murine colitis models and patients with ulcerative colitis. 

. 2014;63(2) 281-291. doi: 10.1136/gutjnl-2012-303207.

		My microbiome and me. Science website. science.sciencemag.org/content/336/6086/1248.summary. Accessed May 21, 2016.

		Ursell LK, Metcalf JL, Parfrey LW, Knight R. Defining the human microbiome. 

. 2012;70(suppl 1):S38-S44. doi: 10.1111/j.1753-4887.2012.00493.x.

		Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. 

2012;307(18):1959-1969. doi: 10.1001/jama.2012.3507.

		Goldenberg JZ, Ma SSY, Saxton JD, et al. Probiotics for the prevention of 

-associated diarrhea in adults and children. 

2013;5(CD006095). doi: 10.1002/14651858.CD006095.pub3.

		Hungin AP, Mulligan C, Pot B, et al; European Society for Primary Care Gastroenterology. Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice—an evidence-based international guide. 

. 2013;38(8):864-886. doi: 10.1111/apt.12460.

		Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. 

 2010;59(3):325-332. doi: 10.1136/gut.2008.167270.

		Hoveyda N, Heneghan C, Mahtani KR, Perera R, Roberts N, Glasziou P. A systematic review and meta-analysis: probiotics in the treatment of irritable bowel syndrome. 

. 2009;9:15. doi: 10.1186/1471-230X-9-15.

		Kristensen NB, Bryrup T, Allin KH, Nielsen T, Hansen TH, Pedersen O. Alterations in fecal microbiota composition by probiotic supplementation in healthy adults: a systematic review of randomized controlled trials. 

 2016;8(1):52. doi: 10.1186/s13073-016-0300-5.

Although some bacteria are harmful, and killing those pathogens is a good thing when you're sick, most bacteria are good.

Probiotics: Much Remains to Be Learned

Gynecologic cancer is any cancer that starts in the female reproductive organs. The 5 main gynecologic cancers are cervical, ovarian, uterine, vaginal, and vulvar.

Symptoms of these cancers may be difficult to recognize and not register as something to see a health care provider (HCP) about (Table). The symptoms are common and often vague. Many women do not realize anything is wrong, or they mistake the symptoms for other, less serious conditions. That is why it is important to know what is normal for you.

. Abnormal bleeding is a symptom of almost all gynecologic cancers. See an HCP for any vaginal bleeding that is not normal for you, including:		

				Heavier or longer-than-normal menstrual flow

				Spotting anytime in the menstrual cycle

. Sometimes infections are to blame for vaginal discharge that is bloody, heavy, and foul smelling. Sometimes, however, this kind of discharge can also mean cervical, ovarian, uterine, or vaginal cancer.

Frequent urination and other urinary disturbances

. Because the female reproductive system is near the bladder and the urethra, tumors or swelling can cause symptoms similar to urinary tract infections—burning or pain with urination, urgency, frequent urination, difficulty urinating, and bladder spasms. Although these symptoms could mean other things, such as overactive bladder, you should promptly report these symptoms to your HCP.

. Rapid weight loss of more than 10 pounds that is not related to dieting or exercise could mean a number of things, including some form of cancer. Make an appointment with your HCP.

Constant feeling of fullness or appetite loss

. If you have difficulty eating or a constant feeling of fullness, please visit your gynecologist. These could be early signs of ovarian cancer. Ongoing pain or pressure in the abdomen. Do not ignore continual abdominal pain, pressure, or discomfort. These can be signs of ovarian or endometrial cancer.

. It is common for women to have some bloating during their period or after eating and drinking. But if bloating or swelling persists for more than 2 weeks after your cycle is over, see your HCP about it because these problems can be signs of ovarian cancer.

. Ordinarily, if you are feeling tired or fatigued, a little rest is all you need to recover. However, tiredness that prevents you from working or doing your normal activities could point to ovarian cancer. Do not dismiss constant fatigue.

. Ongoing digestive problems such as gas, nausea, indigestion, diarrhea, or constipation could be signs of a gynecologic cancer. Tumors or swelling can put pressure on the digestive system, which can cause these symptoms. Although there can be many reasons for these symptoms, it is best to report any change in bowel habits or the above symptoms if they last more than 2 to 3 weeks.

. Lumps, bumps, sores, thickening, and areas of color change should be reported to your HCP. In addition, if you have vulvar or vaginal itching, burning, or bleeding, or unusual discharge, get it checked out, as these can also be signs of cancer or precancerous changes.

. If you have leg swelling—particularly if one leg appears to be swollen, or feels larger than the other&mdash;and you feel pain and have vaginal discharge, this can be a sign of cervical cancer or ovarian cancer.

It is best to try to detect gynecologic cancers early, but, unfortunately, most of the symptoms are late symptoms. If something feels out of the ordinary or lingers, see your HCP. Remember that the above symptoms may not be caused by cancer, but the only way to be sure is to see your HCP.

Gynecologic cancers. CDC website. cdc.gov/cancer/gynecologic/index.htm. Accessed April 25, 2016.

Gynecologic cancer symptoms diary. CDC website. cdc.gov/cancer/knowledge/pdf/cdc_gyn_symptomsdiary.pdf. Accessed April 28, 2016.

Cervical cancer. Mayo Clinic website. mayoclinic.org/diseases-conditions/cervical-cancer/basics/symptoms/con-20030522. Accessed April 28, 2016.

Ovarian cancer: take symptoms seriously. WebMD website. webmd.com/ovarian-cancer/news/20040608/ovarian-cancer-take-symptoms-seriously. Accessed April 28, 2016.

Ovarian cancer fact sheet. Womenshealth.gov website. womenshealth.gov/publications/our-publications/fact-sheet/ovarian-cancer.html. Accessed April 25, 2016.

11 symptoms women shouldn’t ignore. RxWiki website. rxwiki.com/feature-article/gynecological-cancer-symptoms-can-be-easy-miss. Accessed April 25, 2016.

Gynecologic cancer is any cancer that starts in the female reproductive organs.

Gynecologic Cancers: What to Look for

Every time you blink, the front surface of your eye, known as the cornea, is lubricated with tears. To help keep your eyes comfortable and your vision optimal, a thin tear film—which consists of a mucus layer, a watery layer, and a lipid (or fat) layer&mdash;coats your eyes.

Dry eye is a common disorder that occurs when the eye does not produce enough tears, when tears evaporate too quickly, or if there is an abnormality in the production of mucus or lipids normally found in the tear layer. Dry eye is more common in older adults, but can occur at any age.

Without tears to lubricate the eye, you may experience pain, redness, stinging or burning, a feeling of sand or grit in the eye, discharge, blurred vision, excess watering, and discomfort with contact use. Dry eye can make it more difficult to perform some activities, such as using a computer or reading for an extended period of time, and it can decrease tolerance for dry environments, such as the air inside an airplane.

In most cases, dry eye can be managed successfully, usually resulting in noticeably greater eye comfort and fewer dry eye symptoms. For ways to prevent dry eye, see the Table.

Dry eyes can be caused by ordinary things that increase tear evaporation, such as looking at a computer screen too long; being outside in windy, dry conditions; or just being tired. Cigarette smoke may also cause dry eyes. Other common causes of dry eye include:

		Aging. Tear production tends to decline with age. Dry eyes are common in individuals older than 50 years.

		Gender. A deficiency of tears is more common in women, especially with hormonal changes caused by pregnancy, the use of birth control pills, or menopause.

		The use of cold or allergy medicines, antidepressants, and drugs for high blood pressure; acne; birth control; and Parkinson’s disease.

		An eye injury or other problem with your eyes or eyelids.

		Sjögren’s syndrome, which includes dry eyes, mouth, and mucus membranes, and often rheumatoid arthritis or another joint disorder.

		Inflammation that causes tear gland damage.

If you have dry eyes, you may experience a dry, gritty, scratchy, or filmy feeling; burning or itching; redness of the eyes; blurred vision; foreign body sensation; and light sensitivity. You may also have strained or tired eyes after reading, even for short periods of time. If you wear contacts, they will likely feel uncomfortable. Having dry eyes for a while can lead to tiny abrasions on the surface of your eyes.

You may also notice episodes of excessive tearing followed by very dry eye periods. This is because the eyes produce a large amount of tears at once to try to get moist and comfortable again. Unfortunately, because tear ducts can only handle so many tears at any one time, the excess tears pour down the cheeks. The whole process may repeat itself, too.

Elderly individuals frequently experience dryness of the eyes more often. However, dry eye can occur at any age. Nearly 5 million Americans 50 years and older are estimated to have dry eye. Of these, more than 3 million are women and more than 1.5 million are men. Tens of millions more have less severe symptoms. Dry eye is more common after menopause. In addition, women who experience menopause prematurely are more likely to have eye surface damage from dry eye.

During a comprehensive eye exam, the ophthalmologist will most likely be able to diagnose dry eye based on your symptoms, general health problems, medications, and environmental factors that may be contributing to the dry eye problem. As part of the eye examination, the following tests may be performed:

		Measuring the volume of your tears. Your health care provider (HCP) may measure your tear production using the Schirmer test. In this test, your HCP will place the end of a special paper strip inside the lower eyelid of each eye. After 5 minutes, your HCP measures the amount of strip soaked by your tears.

		Determining the quality of your tears. Other tests use special dyes in eyedrops to determine the surface condition of your eyes. Your HCP looks for staining patterns on the corneas and measures how long it takes before your tears evaporate.

Depending on the causes of dry eye, your HCP may use various approaches to relieve the symptoms.

For occasional or mild dry eye symptoms, OTC eyedrops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces. An indoor air cleaner to filter dust and other particles can help prevent dry eyes, as can a humidifier by adding moisture to the air, avoiding dry conditions, and allowing your eyes to rest when performing activities that require you to use your eyes for long periods of time. Instill lubricating eyedrops before performing such tasks.

In some cases, treating an underlying health issue can help clear up the signs and symptoms of dry eyes. Underlying causes of dry eye, such as Sjögren’s syndrome or lacrimal and meibomian gland dysfunction, can be treated and, in turn, relieve dry eyes. If a medication is causing your dry eyes, your HCP may recommend a different medication that does not cause that adverse effect.

Prescription medications used to treat dry eyes include:

		Cyclosporine. This anti-inflammatory medication is the only prescription drug available to treat dry eye. It decreases corneal damage, increases basic tear production, and reduces symptoms of dry eye. It may take 3 to 6 months of twice-daily dosages for the medication to work. In cases of severe dry eye, short-term use of corticosteroid eyedrops that decrease inflammation is required.

		An artificial tear insert such as Lacrisert may be an option for individuals with moderate to severe dry eye symptoms. Tear inserts are inserted between the lower eyelid and the eyeball, and the cellulose within the insert acts to stabilize and thicken the film of tears over the eyes.

Procedures that may be used to treat dry eyes include:

		Partially or completely closing the tear ducts

		Facts about dry eye. National Eye Institute website. nei.nih.gov/health/dryeye/dryeye. Accessed March 24, 2016.

		Dry eyes. Medline Plus website. nlm.nih .gov/medlineplus/ency/article/003087.htm. Accessed March 24, 2016.

		Dry eyes. Mayo Clinic website. mayoclinic .org/diseases-conditions/dry-eyes/basics/definition/ con-20024129. Accessed March 24, 2016.

		Dry eye. American Optometric Association website. aoa.org/patients-and-public/eye-andvision- problems/glossary-of-eye-and-visionconditions/ dry-eye?sso=y. Accessed March 24, 2016.

Dry eye is a common disorder that occurs when the eye does not produce enough tears, when tears evaporate too quickly, or if there is an abnormality in the production of mucus or lipids normally found in the tear layer. 

Dry Eye

Everyone coughs. There is no reason to worry about an occasional cough. Allergies and short-term illnesses, such as the common cold, can cause repeated coughing. Although coughing can be annoying, it is the body’s way of clearing the throat and airways and helps to prevent infection. Coughing due to a cold or the flu usually goes away on its own without treatment.

 However, if your cough is not getting better—and especially if it brings up blood, disrupts your sleep, or affects your work&mdash;it may be time to call your health care provider (HCP).

Cough symptoms are divided into 3 categories: acute, subacute, and chronic.

Acute coughs often begin suddenly and go away in 1 to 3 weeks. They are typically caused by the common cold or other upper respiratory infections, including the flu, pneumonia, and whooping cough. Coughs caused by the common cold often get better within a week without specific treatment, although symptoms may continue for up to 3 weeks.

Subacute coughs last 3 to 8 weeks, persisting after a cold or another respiratory infection is over. Airways may remain swollen and inflamed after an infection, causing you to keep coughing. This is called airway hyper-responsiveness.

When a cough persists longer than 8 weeks (4 weeks in children), it is considered to be chronic. Chronic cough can have many causes. Postnasal drip syndrome (also known as upper airway cough syndrome), asthma, and gastroesophageal reflux disease are the most likely causes of chronic cough in adults. These conditions, alone or in combination, are responsible for 90% of cases of chronic cough.

Other important causes of chronic cough include pertussis (whooping cough), chronic obstructive pulmonary disease caused by smoking, angiotensin- converting-enzyme inhibitors (blood pressure medications), pneumonia, heart failure, and chronic bronchitis from exposure to cigarette smoke or other irritants. Less common causes include tuberculosis, lung cancer, cystic fibrosis, pneumothorax, bronchiectasis, and pulmonary embolus (a blood clot in the lung).

If you feel well and have only had a cough for a short while, you may not need to do anything but wait for it to go away on its own. Steps you can take at home to ease an acute cough include the following:

		Inhale steam using a vaporizer or take a steamy shower to sooth a dry, sore throat

		Drink plenty of fluids, including warm liquids with honey or lemon, to help thin mucus and soothe your throat

		Avoid exposure to irritants that can trigger a cough; if you smoke, make an effort to stop

		Try hard candy or cough drops to soothe a dry, tickling cough (never give these to children younger than 3 years)

A cough that persists for longer than 3 weeks, or is getting worse, requires a trip to your HCP for prompt medical care and to rule out something more serious. Immediately call your HCP if you have any of the following

		Coughing up of thick, yellow, or green mucus

Determining the cause of a nagging, chronic cough is essential to effective treatment. Your HCP will request a thorough medical history and perform a physical exam. He or she may ask questions about the duration of your cough, your symptoms, your medications, whether you smoke, and how exercise and cold air affect your breathing and cough (Table

). Chest x-rays, computed tomography scans, lung function tests, and laboratory tests may be performed.

Coughing is important for clearing mucus and other irritants, and may help prevent infection. For this reason, cough medicines are generally used only when a cough causes a lot of discomfort and disrupts daily activities. Your HCP may recommend the following medicines:

 Some coughs are dry, whereas others, known as productive coughs, bring up mucus (phlegm). For a productive cough, an expectorant called guaifenesin (brand names include Mucinex and Robitussin) helps to thin or loosen mucus, making it easier to move the mucus. Drink lots of fluids if you take guaifenesin.

 Phenylephrine and pseudoephedrine are examples of decongestants used to help clear a stuffy or runny nose and relieve postnasal drip. Use of these drugs is not advised in individuals with high blood pressure.

 A steroid nasal spray may help postnasal drip. Flonase (fluticasone propionate) and Nasacort (triamcinolone acetonide) are examples of OTC steroid nasal sprays.

 If you have allergies or a cold or flu, antihistamines may work better than nonprescription cough medicines.4 In fact, antihistamines such as brompheniramine and chlorpheniramine decrease the production of mucus and widen airways. Unfortunately, these drugs can make you sleepy and may be better to take only at night.

 Pain relievers, such as Tylenol (acetaminophen) and Advil (ibuprofen) can be taken for fever and aches and pains. Be careful not to take more than the recommended acetaminophen dosage because too much can cause liver damage, and even death. Be aware that some combination cough and cold medicines contain acetaminophen.

 Albuterol and other bronchodilators help to relax the airways and make breathing easier.

 When nothing else works, prescription cough suppressants may be useful to suppress a dry cough. There is no evidence to show that OTC cough suppressants relieve a cough.

Talk to your child’s HCP before you give a child 6 years or younger an OTC cough medicine, even if it is labeled for children. These medicines may not be helpful, depending on the case, and can have serious adverse effects.

		Cough medicine: understanding your OTC options. FamilyDoctor.org website. familydoctor.org/familydoctor/en/drugs-procedures-devices/over-the-counter/cough-medicine-understanding-your-otc-options.printerview.all.html. Accessed March 10, 2016.

		Chronic cough. MayoClinic.org website. mayoclinic.org/diseases-conditions/chronic-cough/basics/definition/CON-20030883?p=1. Accessed March 10, 2016.

		That nagging cough. health.Harvard.edu website. health.harvard.edu/staying-healthy/that-nagging-cough. Accessed March 10, 2016.

		Cough: MedlinePlus website. nlm.nih.gov/medlineplus/cough.html. Accessed March 10, 2016.

		Chronic cough: preparing for your appointment. Mayo Clinic website. mayoclinic.org/diseases-conditions/chronic-cough/basics/preparing-for-your-appointment/con-20030883. Accessed March 10, 2016.

		Chronic cough: questions your doctor may ask. National Jewish Health website. nationaljewish.org/disease-info/symptoms/questions.aspx. Accessed March 10, 2016.

Although coughing can be annoying, it is the body's way of clearing the throat and airways and helps to prevent infection.

When to See Your Health Care Provider about Your Cough

Alzheimer’s disease is the most common form of dementia in individuals older than 65 years and affects more than 5 million Americans, according to the Alzheimer’s Association.

 Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.

Alzheimer’s progresses slowly in 3 stages: an early stage with few symptoms, a middle stage of mild mental impairment, and a final stage of Alzheimer’s dementia (Table). These stages are general descriptions, as each individual with Alzheimer’s experiences it in a unique way. Mental, physical, and functional phases often overlap, the time in each stage varies widely from patient to patient, and not every patient experiences all Alzheimer’s symptoms.

Memory problems and changes in behavior and thinking are common as people age, so tests are needed to rule out other causes of symptoms that appear to be related to Alzheimer’s. Some conditions (such as stroke, tumor, Parkinson’s disease, sleep disturbances, adverse effects of medication, infections, or non-Alzheimer’s dementia) can mimic the symptoms of Alzheimer’s disease, but many of these conditions are treatable and possibly reversible.

The amount of time an individual can live with Alzheimer’s can range from 3 or 4 years, if older than 80 years when given a diagnosis, to as long as 10 years or more if younger than 80 years.

 Alzheimer’s can only be definitively diagnosed after death, however, by linking symptoms with examination of brain tissue in an autopsy.

Alzheimer’s disease begins slowly and initially involves the parts of the brain that control thought, memory, and language. In the very early stages, minor memory lapses or losing things around the house may be the only symptoms. Toward the end of the first stage, friends and family may recognize there is a problem. They may begin to notice their loved one frequently repeating questions, having difficulty finding the right word in conversations, and losing understanding of language. Over time, the disease deprives individuals of more memory, particularly the ability to remember new information, such as recent conversations or events. Based on performance on memory and mental tests, a physician will be able to detect impaired mental function at this stage.

Stage 2: Moderate/Middle (Lasts 2 to 10 Years)

Moderate Alzheimer’s can last for many years. During the moderate/ middle stage, brain function gets worse, affecting areas of the brain that control language, reasoning, sensory processing, and thought. The symptoms of moderate Alzheimer’s disease are mostly an increase in the severity of stage 1 symptoms. Professional and social functioning continue to deteriorate because of increasing problems with memory, logic, and speech.

The signs of the disease become more pronounced, and behavioral problems often occur. Individuals have greater difficulty performing tasks and begin to forget some details about their life. Affected individuals may still know their family members and some details about their past, especially their childhood and youth. Symptoms may include mood and behavior changes, social withdrawal, confusion, changes in sleep patterns, and an increased risk of wandering and becoming lost.

Information, skills, and habits learned early in life, such as the ability to read, dance, sing, enjoy music, and hobbies, are among the last abilities to be lost as the disease progresses. The part of the brain that stores this information tends to be affected later in the course of the disease. Making the most of these abilities can help maintain quality of life, even in the moderate phase of the disease.

Stage 3: Severe/Late (Lasts 1 to 3+ Years)

In the last stage of Alzheimer’s, nerve cells in the brain are extensively damaged, causing a severe decline in vocabulary, emotions, and the connection of the brain to body parts. Full-time care is required as patients lose the ability to walk, sit up straight, hold up their head, and smile. It is not possible for patients to move the hand to the mouth, place one foot in front of the other, or urinate on their own. Speech becomes severely limited.

Death often occurs when the body can no longer fight off infection or because the organs begin to break down. Pneumonia is one of the most frequent causes of death in late-stage Alzheimer’s disease.

 In patients who do not succumb to infection or other conditions that are not directly related to Alzheimer’s disease, death usually occurs when the brain can no longer control the body and organs.

Although the onset of Alzheimer’s disease cannot yet be stopped or reversed, an early diagnosis can allow individuals the opportunity to live well for as long as possible and plan for the future. Current treatment approaches focus on helping patients maintain mental function, manage behavioral symptoms, and improve the symptoms of disease. In the future, therapies may be available that target specific genetic, molecular, and cellular mechanisms so that the underlying cause of the disease can be stopped or prevented.

Alzheimer's disease is the most common form of dementia in individuals older than 65 years and affects more than 5 million Americans.

Educated Patient