A: All children and teens have moments when they can be difficult, moody and argumentative. This is perfectly normal. However, when tantrums, arguing and angry or disruptive behaviors (especially toward the parent/guardian and other authority figures) become regular occurrences, ODD may be the reason.

Symptoms are hard to distinguish from normal behaviors of strong-willed or emotional people. In fact, the symptoms of ODD are the same as behaviors expected during certain stages of a child's development. When these behaviors become persistent, are disruptive to the family, home or school, and have lasted at least six months, ODD must be considered.

Negativity, defiance, hostility toward authority figures and disobedience are common with ODD and lead to temper tantrums, academic problems, anger, resentment, argumentative, spiteful or vindictive behavior with adults and aggressiveness toward peers. There may be deliberate annoyance of others, blaming others for mistakes, difficulty maintaining friendships, easy annoyance, acting irritably and refusal to comply with requests. ODD often accompanies other problems, such as depression, anxiety and attention deficit/hyperactivity disorder.

There is no clear cause, but it is thought that is it likely the result of a combination of inherited and environmental factors.

Diagnosis is not made through blood or other physical testing. A child must meet certain criteria set by the American Psychiatric Association.

Treatment of ODD typically involves several types of psychotherapy and training for the child and parents. Medication to treat any associated conditions, such as ADHD, may also be used. Individual and family therapy can help the child manage anger and express feelings, and help the family understand how the child is feeling and provide a safe, neutral environment to discuss concerns, and learn how to cope and work together. Parent-child interaction therapy teaches parents how to interact with their children to bring out their best behavior without stressing the parent and straining the already tenuous relationship. This may include social-skills training, which teaches the child how to interact with others in a positive manner; parent training; and cognitive problem-solving training.

The best approach is for your entire family to seek out some or all of the treatment options. In this way, everyone can come to understand what is happening and how best to handle problems.

PETER GOTT, M.D., is a retired general internist. Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: PCOS is a hormonal disorder that commonly begins when a female begins menstruation; however, it can develop later in life.

Obesity presents in nearly half of all patients with PCOS and is often the initial complaint. Abnormalities in the menstrual cycle, infertility, pre or type II diabetes and the presence of polycystic ovaries diagnosed through ultrasound are but a few of the other symptoms. It should be noted, however, that having polycystic ovaries is not a firm indication of PCOS.

There is no specific testing for diagnosis. Rather, it is one of exclusion, meaning that a physician will rule out a number of related possibilities prior to deciding on PCOS. The disorder makes other conditions, such as type II diabetes, hypertension and sleep apnea, more likely to occur.

Only you and your granddaughter can determine the sequence of events. When was she diagnosed? Could the PCOS be a result of her obesity? Is that issue under control? I cannot tie in high-cholesterol levels with her excess weight; however, thyroid disorders are often linked with obesity, elevated cholesterol and menstruation abnormalities.

There is help and hope that focuses primarily on her major symptoms. She should exercise and become involved with a regular weight-control program.

Diet modification appears essential. There is some initial evidence of success on a low-carbohydrate diet without discrimination between carbs on either end of the glycemic index.

No flour, no sugar

Q: I'm 100 pounds overweight and have tried every diet known. I know it's never too late to start a healthier lifestyle.

A: You have several options. The first is to order my "A Strategy for Losing Weight: Introduction to the No Flour, No Sugar Diet." Simply send a self-addressed, stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print an order form off my website at www.ask drgottmd.com. My books, "Dr. Gott's No Flour, No Sugar Diet" and "No Flour, No Sugar Cookbook," can be ordered by following the links on my website. You're on the right track, and it is never too late to take steps to improve your health.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: There are a number of reasons why you might have a few random high readings. Perhaps you ate out and consumed something the evening before your testing that had a higher-than-normal amount of sugar included. Or you've experienced trauma, had a minor illness, consumed alcohol, or have been placed on a medication that affects your readings.

I would certainly keep a close eye on it but would not jump the gun to consider medication at this stage. Watch your sugar intake. Eat healthful meals, avoid sugar, reduce your carbohydrate intake, and exercise appropriately.

What's 'quality time'?

Q:   In one of your replies to a reader who, at 39 years of age, was having severe hip pain, you said he had a lot of time left and that it should be quality time.

First, I don't believe you can determine how much time someone has left to live. Secondly, at what age does an individual's right to quality time expire?

As a senior with a family history of longevity, the issue of quality time greatly concerns me.

A: Well, you're certainly right that I can't determine how much time someone has left to live. My inference was that at 39, and under ideal circumstances, a person likely has 45 or more years of life left. In fact, average life expectancy in the United States is nearly 78 years. I've personally seen all too often that a young person with so much to look forward to has the rug pulled out from under him or her. And I've also seen people who don't contribute to society, defy what we perceive to be a good lifestyle, smoke, drink too much, drive too fast, are obese, eat all the wrong foods and live to a ripe old age.

In large part, quality time is what we make of every day of our lives, and hopefully, it involves good or relatively good health, not a life fraught with pain and the unhappiness of one serious medical condition after another.

Human beings should not have a predetermined age at which quality time expires. That would open a can of worms, and we would likely behave in inappropriate ways, knowing we had little time left.

An exemplary lifestyle can often be snuffed out like a lit candle at an early age. We simply have no control over that. I cannot play God, nor can anyone else and determine an age at which quality is no longer important and we become mere shadows of our former selves. That's why it is so important to make every day count. Take care of your health to fight off the unknown.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

I now suffer from a constant ringing in my ears. At 65, I'm in good health and take no medications other than Allegra D for nasal congestion. My blood pressure is good, and I just had a recent checkup.

Is there some medication that I can take that might reduce or eliminate the noise I hear all the time? I mentioned the problem to my doctor and just got a blank look.

A: There are a number of conditions that can cause tinnitus (ringing in the ears). For example, more than 200 medications, kidney malfunction, tumors, wax buildup, ear infection, dental issues including temporomandibular joint syndrome, migraine headaches, trauma, inner-ear injuries, hypertension and exposure to loud noises can be to blame. It's likely that work exposure is the culprit, but you should request referral to an otolaryngologist (ear-nose-and-throat specialist), who can perform testing to determine whether an underlying, treatable cause is to blame.

Your primary-care physician can certainly remove a wax impaction and can treat infection with antibiotics; however, because you have a positive history, I believe a specialist might get to the bottom of the issue. Until you determine the problem, it is difficult to determine whether drug therapy, hearing aids, counseling or another form of therapy will be most beneficial.

Sense of taste lost

Q: I am a senior citizen. My problem is that I've lost my taste buds. Nothing I drink or eat has any taste. What can I do to get my sense of taste back?

A: Some loss of taste (and smell) is common with aging. Other than that, there are several possibilities, including poor dental hygiene, Alzheimer's and Parkinson's diseases, a smoking habit, allergies, sinus problems and medications.

Make an appointment with your primary-care physician. If he or she determines the problem is age-related, there may not be a way to reverse it. If, however, your physician has you on a specific medication with even a minor side effect of loss of taste, a simple switch to another drug might be all that is necessary. If you smoke, quitting will make a big difference. If you need dental work, that option might provide the relief you are seeking. Work with your doctor to get to the root of the problem. Only then can you take steps to correct the problem.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

I have constant cramping in my legs, thighs, toes, hands, rib cage and arms. Lately, most of my cramping is happening at night when I go to bed. Both legs cramp up, and one of my feet twists to one side. These cramps are painful. I can turn over in the middle of the night and catch a cramp. I have had all types of blood work performed, and when my potassium was a little low, I was told to take a potassium pill. I cramped twice as much.

I have gone to internal-medicine doctors, rheumatologists, orthopedic specialists, family medical practitioners, OB-GYNs and cardiologists with no resolution.

I am taking Celebrex and magnesium oxide - specifically for cramping - which has helped, but not completely. I also take Singulair, Diovan, Prevacid, a garlic pill and Zocor at night only. In the past, I have taken some cramping medications, such as clonazepam, quinine tablets and others I can't even remember the names of. Can you shed some light on my medical problem that might assist me with these awful cramps?

A: You indicate you are in good health with the exception of your allergies. Let's review your other medications. Celebrex is a prescription medication used to control the pain, stiffness and swelling of osteo and rheumatoid arthritis. Magnesium oxide and Prevacid are commonly used to relieve symptoms of acid indigestion. Diovan helps control hypertension and is sometimes prescribed for patients with heart failure who cannot take ACE inhibitor medications. Zocor is a statin drug designed to reduce bad cholesterol while increasing the good. Garlic is believed to help symptoms of arthritis and lower high-cholesterol and blood-pressure readings. So it appears that you have arthritis, acid indigestion, hypertension and high cholesterol.

Statins have a bad reputation for causing muscle pain, cramping, fatigue, and muscle tenderness and weakness in some people. You appear to be one of them. I cannot clearly state that this is the cause of your problem, but it's a good place to start. Speak with your physician to determine whether you can take a different cholesterol-lowering medication that isn't a statin. Perhaps an over-the-counter such as niacin or an OTC with plant stanols and sterols might be effective. Because of your history, my inclination is to have you refrain from red-yeast-rice products only because they include lovastatin-like substances. Try eating dill pickles for relief from your cramps.

PETER GOTT, M.D., is a retired general internist. Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: Familial refers to a hereditary disease or disorder seen in some families and not in others - thus, your genetic tremor.

Essential, tremor affects millions of people across the United States. It is a disorder of the nervous system that causes involuntary tremor or shaking, primarily seen in the hands, head and eyelids but never the feet or legs. Other signs and symptoms are generally not observed when a person is asleep. It differs from other disorders such as Parkinson's or disorders that result from head trauma.

Essential tremor is commonly observed in the elderly. It is not dangerous; however, it can affect a person's ability to pick up a cup of coffee, eat with a fork, apply makeup, shave and a host of other day-to-day activities we so commonly take for granted. Symptoms can be worsened by such things as temperature extremes, caffeine, emotional stress and fatigue.

Mysoline (primidone) is an anticonvulsant prescribed to control specific types of seizures. It works by reducing abnormal electrical activity in the brain.

The medication may help control your tremor, but it will not cure it.

I don't know the reason your physician prescribed the Mysoline, but you might speak with him or her about a trial switch to propranolol, a beta blocker used to treat tremor, hypertension, rhythm disorders of the heart and migraine headaches.

As with all drugs, this medication carries the potential for side effects, including edema of the feet and ankles, nausea, constipation, diarrhea, shortness of breath and cardiac arrhythmias. It should not be taken by anyone who has been diagnosed with a second- or third-degree heart block.

I sound like a broken record when I often repeat that a drug manufactured for one reason can be successfully prescribed for another. Therefore, I don't at all question the reason your physician chose one medication over another.

The real concern here is that what was once working no longer is. Make an appointment, and express your concerns. It appears time for a change.

To provide related information, I am sending you a copy of my health report "Consumer Tips on Medicine." Other readers who would like a copy should send a self-addressed, stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print an order form off my website at www.askdrgottmd.com.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: I'm not all that sure your son suffers from alopecia, an autoimmune disorder in which the immune system attacks hair follicles. In most cases, with the various types of alopecia, hair falls out in small patches about the size of a quarter. It can regrow in the same areas but may fall out again. Severe cases result in complete loss of hair over the entire body. Treatment to promote hair growth may include minoxidil (Rogaine), topical creams and corticosteroids.

A person suffering from alopecia will not ordinarily have other autoimmune difficulties but could have an increased incidence of nasal allergies, atopic eczema, asthma and thyroid disorder.

Most people shed up to 100 hairs every day and don't bald. And thinning hair is often a part of the aging process. Balding occurs when the rate hair sheds surpasses the rate it grows. Causes can include having diabetes or lupus; scalp infection such as ringworm; a hair-pulling disorder, such as exhibited with mental illness; medical treatment, such as chemotherapy and radiation for cancer; arthritis medications, high blood pressure, some cardiac conditions or gout; several forms of alopecia; and more. A diagnosis can be made by scalp scrapings and other methods. Your son may have a hormonal or medical disorder. I would defer to his primary-care physician about seeing a dermatologist.

Rogaine is a medication to slow hair loss and promote new growth for androgenic alopecia and alopecia areata. It is rubbed onto the scalp twice daily, and it may take up to 12 weeks before any progress is seen. If your son is under a lot of stress, he may wish to address that issue as well.

Medicine to blame?

Q: My husband has been taking Simply Sleep by Tylenol nightly for more than a year. I feel it is harmful to the body. There's no warning on the label that states it causes liver damage, but other sleep aids have the warning.

A: Simply Sleep is an antihistamine that contains diphenhydramine, a common ingredient in several sleep aids. It was designed for occasional sleeplessness and difficulties falling asleep. I agree with your view and don't believe it is meant to be taken every night. Nonetheless, I don't know his complete medical history, whether he eats properly, exercises, is under stress or works a swing shift. Your husband should speak with his physician.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016.

This is a woman in her 80s, still tall and slender, never smoked or drank alcohol, doesn't consume caffeine and doesn't take drugs of any kind. Her diet is exemplary with no white sugar, bread, flour, starchy foods, red meats or luncheon meats. She has always eaten a lot of fruits and vegetables, buying organic whenever possible.

Lately, she has complained about being very tired, she fell a couple of times, and now she has a constant fear of falling. How could someone who took such good care of what she put into her body end up with an enlarged spleen? What purpose does it serve, anyway?

A: The spleen is an organ located in the upper portion of the abdomen. Because it is protected by the rib cage, it generally cannot be felt unless it enlarges. The spleen acts as a filter for blood, destroying old and damaged blood cells. It fights bacteria such as meningitis and pneumonia by producing white blood cells known as lymphocytes. It stores iron from old cells, returning the iron to our bone marrow, where hemoglobin is made. Oddly enough, with all the important things this organ does, we can live without it if necessary.

An enlarged spleen, known as splenomegaly, can occur because of infection, parasites, liver disease, lymphoma, leukemia and a number of other conditions. When the condition occurs, this relatively small organ can weigh up to 4 pounds and becomes palpable on examination. Symptoms can include frequent infections, fatigue, anemia and pain in the left upper abdomen that radiates to the left shoulder.

Diagnosis, other than through palpation, can be made by ultrasound, CT scan or MRI and will often provide a physician information such as how large it is and whether it is crowding other organs in its proximity.

Treatment is directed toward determining the underlying cause for the enlargement and may be as simple as antibiotics to cure infection or chemotherapy and radiation if Hodgkin's or another more complex disorder is discovered.

Sadly, an enlarged spleen can occur despite doing all the right things. A healthful diet, plenty of exercise and abstaining from smoking, drinking and drugs has likely kept her well all these years. Now, however, she should be under the care of a physician, who can get to the bottom of the issue and get her back on the road to recovery. She should also address her fear of falling. It might be that she has been so well for so many years that she now perceives the falls to be the beginning of a massive decline in her general health.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: This is a serious dilemma. Your daughter is an adult at 33. I don't know how serious her condition is and how much outside assistance, if any, she requires. Is she able to care for herself as long as she remains on her medication? Or is the situation much worse than that? If she is certified as mentally ill, I am surprised she doesn't have a family member, attorney, trusted friend or state designee as power of attorney who can make necessary decisions. If she is in a psychiatric ward, why is the staff allowing her to refuse her medication? Is her condition so mild that she does not need it? But if this is the case, why then is she hospitalized?

With your inability to speak with her doctors, I'm sure that you don't have answers to these questions. And it's likely that, if she has someone in charge, she has made it abundantly clear that you are not to be involved in any way. You might speak with your attorney or patient advocate to determine if you have any rights at all, but my guess is that you don't.

Vegetarian trouble?

Q: For health reasons, I have chosen to be a vegan. I eat no animal matter and watch closely not to take in many refined carbohydrates. I am in excellent health. My problem is that during annual physicals, my blood tests come back distorted, usually indicating I am slightly anemic.

I have no outward symptoms of any illness. I tell my doctors that I am a vegan, but each year they search for some other cause. In non-Western countries where animal protein is not a large part of the diet, do doctors have different standards for blood-test results? Would I then be normal in those countries?

A: Frankly, I am unsure if you were tested in another country whether your lab work would reveal anemia or not. Numerous studies have shown that poor meal planning is the cause of nutritional deficiency, not the absence of animal foods.

Do you feel tired, run-down and lacking in energy? From the sound of your letter, I would guess not. You are likely healthier than a great number of us. If you feel your diet may be lacking in any way, consider a good daily multivitamin. Beyond that, stay on course and you'll likely outlive us all.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: There are a number of causes for dizziness, including vertigo, benign paroxysmal positional vertigo, Meniere's disease, inflammation of the inner ear, migraine headaches and as a result of using specific medications. Dizziness can also result from specific medications, low-blood-pressure readings, Parkinson's and other neurological disorders, nerve damage to the legs, inner-ear abnormalities and anxiety.

Your first step is to work with your physician to determine the cause of your hypertension.

Both medications you have been prescribed treat hypertension. Diovan carries such side effects as headache, diarrhea, back/joint/stomach pain and dizziness. Tekturna does not carry a side effect of dizziness.

You didn't indicate what your blood-pressure readings were prior to being placed on medication. While I don't know the specific numbers your physician is hoping to achieve, you might consider asking if you can reduce the dosage of your Tekturna. While it doesn't come in doses smaller than 150 milligrams, perhaps you can take half-doses.

Blood-thinner effects

Q: Is it safe to have blood drawn while on a blood thinner?

A: Yes, it is. When you cut yourself, the body's defenses kick in to halt the bleeding by forming a clot. On the other hand, without that cut and with blood moving through your veins and arteries, clots should not occur. Unfortunately, they do. When they occur, a physician will likely prescribe a drug to bring the disorder in line.

Some of the causes are inherited, some are acquired, such as occurs with HIV/AIDS, inflammatory bowel syndrome, obesity, trauma and hormone-replacement therapy. These conditions and a host of others must be checked periodically with laboratory. The testing performed is commonly a PT/INR and may include a PTT.

As an example, people may take prescription Coumadin (warfarin) to reduce the formation of blood clots. There are specific ranges a physician wants a patient to remain in, and the only way to achieve that goal is by testing on a regular basis while the patient is on the drug. Once the fine-tuning occurs and a patient is stable on a specific dosage, testing might only be necessary on a monthly basis.

While we commonly refer to Coumadin or warfarin as a blood thinner, the drug is actually an anticoagulant, as there is no medication that actually "thins" the blood.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: Tricuspid regurgitation, also known as insufficiency, occurs when this particular valve in the heart fails to close properly. This causes blood to flow backward into the right atrium when the right ventricle contracts.

There are several reasons this may occur, including but not limited to injury to the right ventricle, radiation therapy, carcinoid tumors, rheumatoid arthritis, rheumatic fever, Marfan syndrome and, in the presence of Ebstein's anomaly, a congenital heart disorder.

Without pulmonary hypertension, there may be no symptoms at all. When pulmonary hypertension and moderate to severe tricuspid regurgitation occur together, patients may experience fatigue, pulsing of the neck veins, decreased urinary output, weakness, symptoms of right-sided heart failure and edema of the feet, ankles and stomach.

A physician can make a diagnosis if he or she feels a pulse over the liver or swelling of the liver and spleen, when a murmur or abnormal sounds are heard through a stethoscope. A physician may choose to order a chest X-ray, EKG or echocardiogram to correctly diagnose the disorder.

Mild cases may not require any treatment at all.

Patients should reduce their salt intake and may find relief by elevating the head of their beds to combat feelings of shortness of breath. If you haven't already, I recommend you engage the services of a cardiologist and rely on his or her judgment when it comes to how much exercise you should undertake.

Battling arthritis

Q: I'm 81 years young, actively involved with work, home and yard. As I have aged, I have "met Arthur" in various parts of my body. Of tremendous help to me with knee, shoulder and back problems is massaging centrifuge-extracted virgin coconut oil into the areas of pain. The underlying cause will not be cured but the pains can be lessened. .

A: This material is extracted from wet-milled coconut milk that retains its flavor and aroma. The cost appears a little off-putting for me at about $65 per gallon and is high in saturated fats, but if it works to keep your arthritis at bay, I am sure it is well worth it. And I'll bet you smell mighty good, too! Another alternative is rubbing castor oil onto the affected joints. This is just as safe, but has the added benefit of being less expensive.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

The pain gets so bad that no one understands it unless they have this ugly disease. I've become disenchanted with the medical community. I'm sent from doctor to doctor because of their lack of knowledge and/or treatments. I've been on so many medications in the past 17 months that I feel like a guinea pig.

I've had 18 ganglion blocks in a two-month span, being put under each time thinking that we could put this disease back into a remission of sorts. There is a lack of communication between doctors' offices, so I carry all of my medical records.

I recently went into a pain management/surgical center and was placed on Kadian. This made me feel so bad that I stopped taking it after five days. Another MD later suggested Ketamine infusions.

This is my last chance at getting some sort of hold on the RSD. Is there some sort of protocol that a doctor should perform before the infusions? I had a psych work-up and then a cardiac clearance. What I have been told so far is that I will be in a recliner for four hours a day for 10 days, similar to a chemo patient, but without all the chaos that chemo brings.

On a happier note, after my first accident, I was in a pool playing with my kids and supervising them. I was in the pool for four hours and found myself going off on my own a lot. I started doing kickless laps and stretching my aching limbs. I think this has helped me a lot, but my problem now is finding a pool where I can do these exercises.

I have one last shot with the Ketamine, and I have hope. If it doesn't work, I will have to find a pool, and I know that will help me feel better.

A: RSD is a complex pain disorder. Many of the things you are feeling commonly accompany any disorder that causes chronic pain. Depression, anxiety, feeling helpless or a burden, and others lead to more stress that can, in turn, worsen symptoms.

Despite your difficult situation, you have found a way to ease your pain in a medication-free way and are unwilling to give up when things get tough. If hydrotherapy provides relief, I highly endorse it. Check with your local community center, hospital physical therapy department and other locations for the nearest location to you. I applaud your outlook and offer your letter as inspiration to others.

PETER GOTT, M.D., is a retired general internist. Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: As you are aware, hormonal changes occur during menopause. Those changes can produce symptoms of insomnia that can range from transient and temporary to chronic and annoying. A woman actually goes through three phases: perimenopause, menopause and postmenopause. During the first stage, estrogen levels can decline, resulting in abnormal cycles, hot flashes and temporary insomnia. Menopause occurs when a woman has remained free of a cycle for 12 months. A woman may awaken during the night, leading to chronic insomnia. Postmenopause can lead to still more pronounced sleep disturbances such as sleep apnea and restless-legs syndrome. So yes, there is definitely a strong link.

Estrogen is produced in the ovaries and adrenal glands in females. In menopausal women, it is prescribed to reduce the unpleasant symptoms that can plague a woman. Some physicians might choose to prescribe hormone-replacement therapy. I don't know that I would be one of them. That decision is best left for you to determine with your gynecologist, based on your full medical history.

You might consider modifying your diet to include cucumbers, soy sprouts, garlic, green beans, yams, apples, corn, peas, olive oil, sunflower seeds and beets. During waking hours, consider yoga or another exercise program. Retire at about the same time each evening. Be sure your room is dark and quiet.

Itchy skin

Q: I have an itchy scalp and body. It's not ringworm. I get small bumps on the skin when it itches. My doctor gave me pills that help on my body and lotion for my scalp, but these last only about 15 minutes.

A: There are numerous causes of itchy skin, most of which are harmless. Then there's the itch from stress, anxiety, hyperthyroidism, polycythemia, an allergic reaction, sun exposure, dermatitis, psoriasis, eczema and liver or kidney disease.

There are steps you might consider, such as ruling out food allergies, reducing stress, using cold compresses, over-the-counter antihistamines and anti-itch creams. Beyond that, you might have appropriate blood or allergy testing. If your physician is unable to prescribe something for control that is effective, request a referral to a dermatologist to sort out the problem.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

I went to my physician for a regular checkup. Routine lab work indicated I had an elevated TSH (6). My doctor asked about fatigue, weight gain, hair loss, brittle nails, dry skin and more. I explained the circumstances of my former job and because of my age, I was at least perimenopausal. I was still having periods every three weeks instead of four. I felt the symptoms I had indicated hypothyroidism. I expressed my feelings and was prescribed levothyroxine, which was to continue forever. Well, I took it for six months and saw no improvement, except for a lowered TSH level. I gained back the 20 pounds and weaned myself off the medication. I still noticed no change in my health.

Could adrenal fatigue or exhaustion from the stress and being perimenopausal be factors in the elevated TSH? Could they normalize on their own when the stress is removed? I understand there are cardiac implications with levothyroxine. At what point does the risk outweigh the benefit?

A: I can understand why your physician put you on levothyroxine, because hypothyroidism can cause fatigue, changes in hair texture and thickness, split finger nails, dry skin and irregular menstrual cycles. One striking difference is that weight gain is relatively common. However, the reversal in your case is obviously job-related.

Let's cover a few basic differences between adrenal fatigue and hypothyroidism. Adrenal fatigue carries no specific symptoms of heart palpitations, no fluid retention, orthostatic hypotension, good flexibility of ligaments, thin and brittle nails, thin hair, insomnia, dry skin, cold intolerance and a craving for sweets. Hypothyroidism isn't generally associated with palpitations and presents with fluid retention, no orthostatic hypotension, poor flexibility of ligaments, normal to thick nails, coarse hair, sleepiness, normal skin, heat intolerance and a craving for fats.

Stress plays an enormous role in health, affecting us in a variety of ways and worsening many medical conditions. Therefore, I cannot rule it out as having a bearing on the symptoms you have. My recommendation is to have your TSH retested to determine what your readings are without the levothyroxine. Maintain a healthful diet, get adequate rest, reduce the stress in your life, and exercise.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: Motion sickness is rather common and can affect people of any age. It stems from a sensitivity of the inner ear. Unfortunately, it's more traumatic when it happens to a youngster. Symptoms can include stomach upset, loss of appetite, cold sweats and vomiting. I hear about queasy feelings more frequently from people who sit in the back seat of the car and from people who read or otherwise engage in visual and mental stimulation in an effort to pass the time. This certainly is not the case with a 2-year-old, however. A child of that age is prohibited by law from riding in the front seat for safety reasons. So let's consider options:

Have him look out the window at passing cars, signs and people. Play a game of spotting a green car, a red wagon or a person with black hair. He might eat an hour or two before getting into the car. Bring along a water bottle so he can remain hydrated. Sing songs or listen to the radio. If he can doze off, by all means let him do so.

In other words, focus his attention elsewhere and attempt to trick his inner ears. You may also wish to try ginger capsules, Dramamine or Benadryl.

Fighting gas pains

Q: I have had gas pains under my rib cage for the past year. The pain leads to sediment-type diarrhea within 15 minutes of eating anything, occurring at least three times before it stops.

I've been unemployed and without health insurance for three years, so I am unable to see a doctor about this. I have determined I am allergic to wheat. I take no medicines other than over-the-counter naproxen for knee arthritis. Can you figure this out?

A: Gas pains can occur for a number of reasons. Perhaps you have acid reflux, indigestion, hiatal hernia, gallbladder disease, peptic ulcer, are lactose intolerant or have an undiagnosed abnormality of the digestive tract. You also don't appear to be digesting your food properly, as evidenced by the diarrhea. Naproxen and other OTC NSAIDs can also lead to nausea, gas and diarrhea.

If you are unemployed and without insurance, apply for state aid. This will remove an enormous burden from your shoulders. Then make an appointment with a physician for an examination and possible lab work and X-rays so you can determine the exact cause of your pain. If necessary, request a referral to a gastroenterologist.

Once appropriate testing is accomplished and a diagnosis can be made, proper treatment can begin. Until then, it's anyone's guess.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

In June, the surgeon decided the wound was not healing. He suggested that he reopen it, remove additional tissue and sew it up, turning it into a primary wound. The initial wound was 5.5 centimeters deep by 5 centimeters long and 4 centimeters wide. Now it is going to be even larger.

We met with another surgeon who suggested he would make the wound even bigger and "dishpan" it so it would be easier to pack. I'm at my wits' end. I have had two open-heart surgeries that healed in weeks. Six months later, I'm starting all over. I still have no infection, but no one can seem to get the wound to heal. Do you have any advice?

A: There are a number of reasons why wounds do not heal, but it often gets down to a lack of blood supply. Blood transports oxygen, platelets and plasma to heal wounds. That's why people with diabetes (diabetic ulcers), infections (from bacteria or foreign bodies), smokers (vascular disease) and a host of other conditions have difficulty healing wounds. I'm not sure why yours has persisted, but it's time for a change.

Get a referral to a top-notch surgeon at a local, well-respected hospital. Explain the length of time you have had the open wound and the circumstances leading up to it. If there is an underlying cause hampering your recovery, be sure to address and correct it. Then ask about treatment with IV antibiotics; vacuum-assisted closure; stem-cell therapy, which can provide the injured tissue with cells that can develop into healthy tissue; and skin grafting.

You need the help of a wound-care specialist who can determine the reason your wound isn't healing and take the necessary steps to ensure it does.

Sanitary enough?

Q: My husband uses self-catheters four times a day, voiding into a urinal he holds between his legs. He uses a baby wipe before and after on his hands and rinses the urinal. He believes this is enough. I wish he would wash his hands under running water after putting his urinal away. Is there any way to convince him to do this?

A: Try a compromise. Ask him to wash his hands under running water before coming to the dinner table, using the telephone, touching doorknobs, and after petting the dog.

Make it sound as if it's his idea to deter bacteria, not yours.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

A: Multiple sclerosis is an autoimmune disease that occurs when the body's immune system destroys the protective sheath covering the nerves. This, in turn, interferes with signals between the brain and the remainder of the body, resulting in nerve deterioration.

Symptoms vary from person to person but can include an inability to speak or walk, dizziness, tremor, unsteady gait, double or blurred vision, weakness on one side of the body at a time or on the bottom half of the body. Increases in body temperature can worsen symptoms.

The disorder can affect anyone at any age but commonly begins between the ages of 20 and 40. Women are more likely to develop MS than are men. Heredity plays an important role except in the case of identical twins. Should one twin be diagnosed with MS, the second has only a 25 to 30 percent chance of developing it. People also appear more susceptible if they have other autoimmune disorders, such as Type 1 diabetes, a thyroid disorder or inflammatory bowel disease.

Diagnosis can be difficult because other disorders with similar symptoms must be ruled out first. A spinal tap, MRI or electrical testing might be considered. A spinal tap can show abnormal levels of white blood cells or proteins. The MRI can detect lesions of myelin loss caused by MS. Electrical testing can trigger the brain to respond to outside stimuli. An MRI may not provide proof-positive results, however, because the lesions detected could be caused by other conditions, including lupus and Lyme disease.

While there is no cure, there are medications, such as corticosteroids to reduce inflammation, and glatiramer, which protects the myelin (the fatty substance that covers nerve fibers) and prevents it from being attacked. Another procedure patients might consider is interferons (proteins that protect against vital infection), which appear to slow the progression of MS. The downside is that interferons can cause liver damage. Then there's physical therapy, obtaining sufficient rest, avoiding extreme heat and eating properly.

Herbal remedies are a long shot but could include omega-3 fatty acids, such as is found in freshwater salmon, and bromelain, a substance extracted from pineapple that is thought to control pain and inflammation. Before trying either of these, I recommend your relative speak with her physician to get his or her opinion. Your daughter-in-law should be under the care of a specialist who can guide her through this ordeal.

PETER GOTT, M.D., is a retired general internist. Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

Such tubes are made of soft, metal-like zinc but with an internal layer of polymer plastic coating the interior surface to prevent metal contamination or any reactive ingredients from chemically reacting with the metal walls. The defect comes when the user squeezes and deforms the tube walls to such an extent that the internal plastic layer fractures into small chips and delaminates from its attachment to the wall. What results are many small and almost microscopic flakes of the plastic lining, with sharp points and razor-sharp edges like broken glass, mixing into the cream product as it is delivered. Such a production of tissue-cutting particles will cause visible to microscopic lacerations in the delicate barrier tissues it comes into contact with and thus allow infections to occur or reoccur.

This should be the first thing a woman needing such a product should look at and demand an alternative to. Plastic-walled cream-delivery tubes or pre-filled syringe packaging would eliminate this kind of injury.

As an aside, the case was ultimately settled quietly after I demonstrated to both sides that this was the defect in the product leading to her injuries. I am not sure whether the makers of such products have changed from that design of packaging and delivery.

A: I, like you, am unaware of what type of packaging Premarin and similar estrogen creams come in; therefore, I am hoping that this letter is either late (in the case of newer, safer packaging) or will bring greater attention to this issue.

Vaginal infections are often minor and disappear with treatment, but if left untreated can result in considerable symptoms and problems. I urge any woman who has symptoms of a vaginal infection to speak with her gynecologist so she may receive appropriate treatment early before the infection can take hold.

As I have said many times, there is no reason to be embarrassed by symptoms for any condition. Doctors have been there and done that.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

My neurologist prescribed 10 milligrams of baclofen for the few leg cramps I was getting at night. I declined after hearing the side effects from my pharmacist. Because the weather was hot, I decided to try a high-carb sports drink, which took away the cramps until the weather changed.

I have always been a user of Vicks VapoRub, so I began massaging it onto both feet. My chiropractor also suggested 1/8th teaspoon of cream of tartar mixed with water at night.

Seven years later, I have a little numbness in spots but no pain and only cramps at night when my feet get cold. I also take 100 milligrams of vitamin B6 along with the alpha-lipoic acid per day. My neurologist agrees that the Vicks will keep the nerves alive, and the exercise by massaging keeps the muscles strong. Please tell people. I do. Thank you.

A: Peripheral neuropathy is caused by damage to the peripheral nerves in the feet, legs, hands or arms. Causes can be untreated or poorly controlled diabetes, chemotherapy or radiation side effects, improper diet or injury. When the cause cannot be found, the condition is labeled idiopathic.

Common treatment includes prescription nerve blockers such as gabapentin. Another treatment that has received a lot of positive review is Anodyne therapy. Home remedies range from topical mentholated chest rubs to dietary vitamin and mineral supplements and topical ointments containing capsaicin. Massage may also be beneficial since it aids circulation.

The cream-of-tartar remedy offered by your chiropractor is new to me, but if it works for you, stick with it. I cannot think of any harm it could do, especially given the minimal amount used.

Alpha-lipoic acid is an antioxidant made by the body and is present in every cell. It is both fat- and water-soluble. It has been shown to lower blood-sugar levels, kill free radicals and improve symptoms of autonomic neuropathy (damage to the nerves of the heart associated with diabetes). It is being studied as a part of a treatment program for glaucoma, stroke, brain disorders and liver disease.

Because of your success, I am printing your letter in the hope that it may help others. I also ask for feedback from my readers.

PETER GOTT, M.D., is a retired general internist. Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016. His website is www.askdrgottmd.com.

Seriously, I am a 56-year-old female teacher, and I wanted to get in shape before I retired a year ago. I also wanted to be healthier and have a long retirement life. At my previous weight, I was unhappy, unhealthy and unfit to do anything physical, so I tried your diet plan. It worked, and it has just kept on working.

It took me two years to get the weight off, and I still have around 27 pounds to go, but my doctor says I have probably added 10 years to my life. I used to be on three different high-blood-pressure medications and had to use a c-pap machine every night because of sleep apnea. Now I am medication-free, and my sleep apnea has disappeared.

I have taken up walking each day now, and last week, even at my age of 56, was able to walk 34 miles. I truly believe you have saved my life.

A: Congratulations! You have made a remarkable change in your life, and I commend your efforts. Making the decision to turn your life around and work toward better health is often the most difficult part of losing weight.

Healthful weight loss will not happen overnight. It takes time to gain weight and it takes time to lose it. You averaged a weight loss of about 1½ pounds per week, which is appropriate.

I am pleased to hear that you are now able to be more active. If you continue to walk four to five miles a day, you will increase your muscle tone and further improve your health.

Readers interested in my no-flour, no-sugar diet should order my health report "A Strategy for Losing Weight: An Introduction to the No Flour, No Sugar Diet" by sending a self-addressed, stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167.

Combat constipation

Q: Some time ago, you published a formula of four natural ingredients to combat constipation. I gave this to a friend who suffers from this but she has lost it. Could you please reprint this?

A: I believe the recipe you are looking for is that of my colon cocktail. It consists of equal portions of applesauce, prune juice and bran. One to 2 tablespoons taken daily in the morning should relieve symptoms of constipation. I often advise that it be made in small batches in order to keep it fresh because it does not have a long shelf life. It must also be stored in the refrigerator.

Other home remedies include a mug of warm water a half-hour before breakfast each morning, warm apple juice, prune juice (warm or cold), whole prunes, powdered fiber drink mixes and even consuming more raw fruits and vegetables.

PETER GOTT, M.D., is a retired general internist and the author of "Dr. Gott's No Flour, No Sugar Cookbook." Send questions to Dr. Gott, c/o United Media, 200 Madison Ave., 4th Floor, New York, NY 10016.