Foreign Body Retrieval Site Index A-Z Foreign Body Retrieval Foreign body retrieval is the removal of objects or substances that have been introduced into the body. Objects may be inhaled into the airway, swallowed or lodged in the throat or stomach, or embedded in the soft tissues. About 80 percent of foreign body ingestions occur among children. Most foreign bodies pass through the gastrointestinal tract without complication, and endoscopic or surgical intervention is required only 10 to 20 percent of the time. Evaluation and treatment will depend on the type of foreign body and how it was introduced. If it was swallowed, you may undergo a direct examination of your throat and esophagus or an x-ray examination. If it is lodged in a soft tissue, such as a splinter embedded under the skin, you may undergo an ultrasound, x-ray or CT scan to locate and remove the object. Tell your doctor if there’s a possibility you are pregnant and discuss any recent illnesses, medical conditions, medications you’re taking and allergies, especially to iodinated contrast materials. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown. What are the limitations of foreign body detection and removal? What is Foreign Body Retrieval?

Foreign body retrieval involves the removal of potentially dangerous objects or substances in the body that have been introduced from the outside. They can be inhaled into the airway or swallowed and enter the esophagus and stomach either accidentally or intentionally, or introduced into the soft tissues. Commonly swallowed objects include coins, buttons, pins, nails, glass pieces, toothpicks, batteries, small toys or pieces of toys and fish bones. Swallowing of magnets can cause significant problems including bowel blockages that may require surgical removal of magnets. Children account for about 80 percent of foreign body ingestions. Sometimes problems occur when button batteries are swallowed as mercury within the batteries can leak into the bowel and cause mercury poisoning. Magnetic toys can obstruct the bowel when they stick together. Foreign bodies in the throat or stomach: Some ingested foreign bodies cause no symptoms. Alternatively, the patient may experience a sensation of something being stuck in their throat or esophagus. Drooling and difficulty swallowing are common symptoms. A small sharp object may become lodged in the esophagus and cause pain, even though they are able to swallow.

Larger foreign bodies can partially or completely obstruct the stomach, the small intestine or, in rare cases, the large intestine, causing cramps, bloating, loss of appetite, vomiting, and sometimes fever. A sharp object that pierces the stomach or intestines can cause severe abdominal pain, fever, fainting and shock. Foreign bodies in the airway: Most foreign bodies in the airway are usually expelled through coughing. However, some foreign bodies may move from the throat into the bronchial branches. This can cause the patient to cough, but the foreign body remains trapped in the lung. This typically occurs in children and requires removal by bronchoscopy. Foreign bodies in the soft tissues: A soft tissue foreign body is an outside object like a splinter, rock or piece of metal or glass that gets embedded in the tissue under the skin. Soft tissue foreign bodies can cause infection and damage to surrounding tissues. top of page What are some common uses of the procedure? Foreign body retrieval is used to remove one or more foreign objects that have been ingested through the mouth or airway or introduced into the soft tissues. In some cases, objects can be dislodged rather than removed so that they pass safely through the digestive system.

top of page How should I prepare? If you ingest a foreign body or witness a child ingest one or suspect the presence of a soft tissue foreign body, contact your physician immediately. Treatment will depend on the type of foreign body and nature of the symptoms. You should inform your physician of any medications being taken and if there are any allergies, especially to iodinated contrast materials . Also inform your doctor about recent illnesses or other medical conditions. You may need to fast for about four hours before direct examination of the esophagus , so that your stomach is empty as you may receive sedation. If sedation is required, you will need to have a relative or friend accompany you and drive you home afterward. Foreign bodies are typically dealt with in the emergency room and the x-ray department. Some patients require sedation before their imaging exam. You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images. If you are to undergo a direct examination of your throat and esophagus, you may be given lozenges containing a local anesthetic to numb your throat.

This eliminates the gag reflex and enables the physician to perform the examination without discomfort. Alternatively, the back of your throat may be sprayed with a local anesthetic. You also may be given a sedative to relax you. Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays. If the foreign body is lodged in a soft tissue, an x-ray or ultrasound exam may be performed to locate the object. In some cases, a CT scan may be needed to see the foreign body. What does the equipment look like? A variety of x-ray or ultrasound equipment may be used to detect foreign bodies. The equipment typically used for this examination consists of a radiographic table, one or two x-ray tubes and a television-like monitor that is located in the examining room. Fluoroscopy, which converts x-rays into video images, is used to watch and guide progress of the procedure.

The video is produced by the x-ray machine and a detector that is suspended over a table on which the patient lies. A portable x-ray machine is a compact apparatus that can be taken to the patient in a hospital bed or the emergency room. The x-ray tube is connected to a flexible arm that is extended over the patient while an x-ray film holder or image recording plate is placed beneath the patient. Additionally, ultrasound imaging may be used to detect foreign bodies, evaluate the surrounding area and potentially guide removal of the object. Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to do the scanning. The transducer is a small hand-held device that resembles a microphone, attached to the scanner by a cord. Some exams may use different transducers (with different capabilities) during a single exam. The transducer sends out inaudible, high—frequency sound waves into the body and then listens for the returning echoes from the tissues in the body. The principles are similar to sonar used by boats and submarines. The ultrasound image is immediately visible on a video display screen that looks like a computer or television monitor.

The image is created based on the amplitude (loudness), frequency (pitch) and time it takes for the ultrasound signal to return from the area within the patient that is being examined to the transducer (the device used to examine the patient), as well as the type of body structure and composition of body tissue through which the sound travels. A small amount of gel is put on the skin to allow the sound waves to best travel from the transducer to the examined area within the body and then back again. Ultrasound is an excellent modality for some areas of the body while other areas, especially the lungs, are poorly suited for ultrasound. Common equipment for identifying and removing foreign bodies from the esophagus includes an endoscope, which is a long, thin, flexible or rigid tube with a light and a video camera attached. A bronchoscope is used to remove foreign bodies from the airway. The physician may also use forceps and other instruments to grasp and remove the foreign bodies. top of page How does the procedure work? Your physician may use an x-ray or ultrasound of the neck, chest and abdomen to locate objects and to identify possible complications of foreign body ingestion, including swelling and perforation of the esophagus.

X-rays are a form of radiation like light or radio waves. X-rays pass through most objects, including the body. Once it is carefully aimed at the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an image on photographic film or a special detector. Many foreign bodies, like coins and batteries, are radio-opaque, meaning that x-rays will not pass through them, and they will appear white on an x-ray. Some soft-tissue foreign objects, such as metal, gravel and glass, are radio-opaque or white on x-ray. Fluoroscopy is a special x-ray technique that makes it possible to see internal organs in motion. When used with an oral contrast material, which clearly defines the area being examined by making it appear bright white, this special x-ray technique makes it possible for the physician to locate foreign bodies not visible on ordinary x-rays. Ultrasound imaging is based on the same principles involved in the sonar used by bats, ships and fishermen. When a sound wave strikes an object, it bounces back, or echoes.

By measuring these echo waves, it is possible to determine how far away the object is as well as the object's size, shape and consistency (whether the object is solid or filled with fluid). In medicine, ultrasound is used to detect changes in appearance, size or contour of organs, tissues, and vessels or to detect abnormal masses, such as tumors. In an ultrasound examination, a transducer both sends the sound waves and receives the echoing waves. When the transducer is pressed against the skin, it directs small pulses of inaudible, high-frequency sound waves into the body. As the sound waves bounce off internal organs, fluids and tissues, the sensitive microphone in the transducer records tiny changes in the sound's pitch and direction. These signature waves are instantly measured and displayed by a computer, which in turn creates a real-time picture on the monitor. One or more frames of the moving pictures are typically captured as still images. Short video loops of the images may also be saved. Using an ultrasound transducer to visualize the location of the object, the physician may make an incision in the skin and remove the soft tissue foreign body.

With continuous ultrasound imaging, the physician is able to view the surgical instrument as it advances to the location of the foreign object in real-time. Your physician also may locate soft-tissue objects by probing the wound. Additional tests may include magnetic resonance imaging (MRI) or computed tomography (CT). top of page How is the procedure performed? There are a number of ways to remove foreign bodies or facilitate their exit from the body. When your physician suspects that a blunt foreign body is stuck in the esophagus, you may receive an intravenous drug to relax the esophagus and allow the object to pass through the digestive tract. Other drugs taken by mouth can help blunt foreign objects pass through the digestive tract by causing muscles to contract and push the object farther down. In some cases, prompt removal of the foreign body is necessary. Common procedures include: Flexible esophagoscopy Flexible esophagoscopy is a common diagnostic examination that enables a safe and detailed visual study of the esophagus while the patient is under local anesthesia and sedation. See the Safety page for more information about anesthesia. A flexible esophagoscope is introduced with gentle pressure as the patient swallows.

Air is blown into the esophagus for improved visualization, and images of the inside of the digestive tract can be seen on a screen. Rigid esophagoscopy This highly effective procedure involves the introduction of a rigid tube down the esophagus, while the patient is under general anesthesia. Once the foreign body has been identified, instruments can be passed through the tube to grasp or manipulate it. Among the instruments that may be used are forceps, snares, magnets and oval loops, as well as Roth baskets, which are mesh nets that can be closed to trap small objects. Foley catheter technique A Foley catheter is a thin tube that can be used to help trap smooth objects like a marble, or to orient foreign bodies with the use of two snares. The catheter is guided into place just beyond the foreign object using x-ray fluoroscopy. A balloon at the end of the catheter is inflated with contrast material, and then the catheter is slowly withdrawn, pulling the foreign body out ahead of it. Esophageal bougienage For this procedure, you will sit upright while the physician passes a device from the mouth to the stomach that helps dilate, or widen, the esophagus.

This helps advance the foreign body into the stomach, from where it is most likely to pass spontaneously onwards. It is useful for freeing smooth, round objects from the esophagus. Open surgery You may need surgical intervention in cases of perforation or abscess formation. Your physician may make an incision in your skin to remove soft tissue foreign bodies. You might require stitches or other treatments to close the wound, and your caregiver may give you antibiotics if the wound has a high risk of infection. You also may need a tetanus shot to prevent a potentially deadly infection of the nervous system. In some cases, your physician may choose to perform surgery using ultrasound guidance. Ultrasound provides real-time imaging, making it a good tool for guiding removal procedures. In some cases, it is potentially more harmful to remove the foreign body, such as when it is located near vital structures like nerves and blood vessels, so your physician may choose to leave it in place. The majority of foreign bodies pass through the gastrointestinal tract without complication, and intervention in the form of endoscopy or surgery is required in only 10 percent to 20 percent of cases. top of page What will I experience during and after the procedure?

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected. Most of the sensation is at the skin incision site which is numbed using local anesthetic. You may feel pressure when the catheter is inserted into the vein or artery. If you receive a general anesthetic, you will be unconscious for the entire procedure, and you will be monitored by an anesthesiologist . If the procedure is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated. For endoscopic procedures, you may receive a mouthpiece to help you keep your mouth open. You may be asked to lie on your left side, your knees drawn up slightly, or you may be seated or asked to lie on your back. As the tip of the esophagoscope is placed in your mouth and directed down your throat, you will be asked to swallow. Even with anesthesia and sedation, you may gag or experience pain. Your physician may need to adjust the levels of sedative and anesthetic.

Ultrasound may be used to guide the foreign body removal procedure. After you are positioned on the examination table, the radiologist or sonographer will apply some warm water-based gel on your skin and then place the transducer firmly against your body, moving it back and forth over the area of interest until the desired images are captured. There is usually no discomfort from pressure as the transducer is pressed against the area being examined. If scanning is performed over an area of tenderness, you may feel pressure or minor pain from the transducer. For surgical removal, you may feel pressure or discomfort as your physician makes an incision and removes the foreign body. You will remain in the recovery room until you are completely awake and ready to return home. At first you may feel lightheaded, but this should pass. It takes a few hours for the effects of any local anesthetic to wear off, and you must not eat or drink anything until sensation has returned fully. top of page Who interprets the results and how do I get them? The radiologist will interpret any imaging results. Follow-up imaging may be necessary to ensure that no foreign bodies remain in the body and to check for the presence of any side effects such as infection. What are the benefits vs.

risks? Benefits Removal of a foreign body will reduce your chances of suffering an infection or an allergic reaction. Prompt removal of the foreign body will ensure that it does not migrate to other areas of the body, or enter your blood vessels. Removal of larger foreign bodies will ensure that they do not partially or completely obstruct your stomach, small intestine, or large intestine, or pierce the stomach or intestines. Removal of button batteries will ensure that mercury is not ingested from the intestines. Removal of magnets will ensure that there is not a bowel obstruction from the magnets pulling together parts of bowel. Removal of soft-tissue foreign bodies will reduce chances of an infection that could damage tissue, nerves and blood vessels, block blood flow or cause a blood clot. Ultrasound provides real-time imaging, making it a good tool for guiding foreign body removal procedures. Risks While foreign body removal procedures are safe and effective, there is a slight risk of damage to your esophagus from the instruments and devices used to remove them. A foreign body dislodged during the Foley catheter technique may temporarily block your airway. By observing the procedures under fluoroscopy, this can be avoided.

In rare cases, the general anesthesia used during rigid esophagoscopy can cause allergic reactions, changes in blood pressure, and other complications. There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. top of page What are the limitations of foreign body detection and removal? The primary limitation of an x-ray examination is the potential failure to detect radiolucent (does not appear on x-rays or CT) foreign bodies like toothpicks. Small esophageal foreign bodies like fish bones also may be difficult to visualize. Additional evaluation is required when the suspected foreign body is radiolucent or when the presence of a retained object is highly suspected. X-ray evaluations can underestimate the extent or degree of involvement, such as the amount of swelling with foreign bodies that are retained for long periods. The limitations of endoscopic procedures include the need for anesthesia and an operating suite, post-procedural hospitalization and greater complication rates than those experienced with other techniques. In spite of these limitations, endoscopy is still widely regarded as the most successful and reliable technique for foreign body removal. Limitations of the Foley catheter technique occasionally include the need for anesthesia, intravenous access and fluoroscopic guidance.

However, it is typically an outpatient procedure requiring no sedation(anesthesia) and no IV. Liver Transplant | Johns Hopkins Medicine Health Library << Back to Gastroenterology Tests and Procedures What is a liver transplant? A liver transplant is surgery to replace a diseased liver with a healthy liver from another person. A whole liver may be transplanted, or just part of one. In most cases the healthy liver will come from an organ donor who has just died. Sometimes a healthy living person will donate part of their liver. A living donor may be a family member. Or it may be someone who is not related to you but whose blood type is a good match. People who donate part of their liver can have healthy lives with the liver that is left. The liver is the only organ in the body that can replace lost or injured tissue (regenerate). The donor’s liver will soon grow back to normal size after surgery. The part that you receive as a new liver will also grow to normal size in a few weeks. Why might I need a liver transplant? You can’t live without a working liver. If your liver stops working properly, you may need a transplant.

A liver transplant may be recommended if you have end-stage liver disease (chronic liver failure). This is a serious, life-threatening liver disease. It can be caused by several liver conditions. Cirrhosis is a common cause of end-stage liver disease. It is a chronic liver disease. It happens when healthy liver tissue is replaced with scar tissue. This stops the liver from working properly. Other diseases that may lead to end-stage liver disease include: Acute hepatic necrosis. This is when tissue in the liver dies. Possible reasons include acute infections and reactions to medicine, drugs, or toxins. Biliary atresia . A rare disease of the liver and bile ducts that occurs in newborns. Viral hepatitis . Hepatitis B or C are common causes. Metabolic diseases. Disorders that change the chemical activity in cells affected by the liver. Primary liver cancers. These are cancerous tumors that start in the liver. Autoimmune hepatitis . A redness or swelling (inflammation) of the liver. It happens when your body’s disease-fighting system (immune system) attacks your liver.

The transplant evaluation process If your provider thinks you may be a good candidate for a liver transplant, he or she will refer you to a transplant center for evaluation. Transplant centers are located in certain hospitals throughout the U.S. You will have a variety of tests done by the transplant center team. They will decide whether to place your name on a national transplant waiting list. The transplant center team will include: A transplant surgeon Other team members such as a dietitian, a chaplain, or an anesthesiologist The transplant evaluation process includes: Psychological and social evaluation. Many different issues are assessed. They include stress, financial concerns, and whether you will have support from family or friends after your surgery. Blood tests. These tests are done to help find a good donor match and assess your priority on the waiting list. They can also help improve the chances that your body won’t reject the donor liver. Diagnostic tests. Tests may be done to check your liver and your general health. These tests may include X-rays, ultrasounds, a liver biopsy, heart and lung tests, colonoscopy, and dental exams. Women may also have a Pap test, gynecology exam, and a mammogram. The transplant center team will review all of your information.

Each transplant center has rules about who can have a liver transplant. You may not be able to have a transplant if you: Have a current or chronic infection that can’t be treated Have metastatic cancer. This is cancer that has spread from its main location to 1 or more other parts of the body. Have severe heart problems or other health problems Have a serious condition besides liver disease that would not get better after a transplant Are not able to follow a treatment plan Drink too much alcohol Getting on the waiting list If you are accepted as a transplant candidate, your name will be placed on a national transplant waiting list. People who most urgently need a new liver are put at the top of the list. Many people have to wait a long time for a new liver. You will be notified when an organ is available because a donor has died. You will have to go to the hospital right away to get ready for surgery. If a living person is donating a part of their liver to you, the surgery will be planned in advance. You and your donor will have surgery at the same time. The donor must be in good health and have a blood type that is a good match with yours. The donor will also take a psychological test.

This is to be sure he or she is comfortable with this decision. What are the risks of a liver transplant? Some complications from liver surgery may include: Bleeding Blocked blood vessels to the new liver Leakage of bile or blocked bile ducts The new liver not working for a short time right after surgery Your new liver may also be rejected by your body’s disease-fighting system (immune system). Rejection is the body’s normal reaction to a foreign object or tissue. When a new liver is transplanted into your body, your immune system thinks it is a threat and attacks it. To help the new liver survive in your body, you must take anti-rejection medicines (immunosuppressive medicines). These medicines weaken your immune system’s response. You must take these medicines for the rest of your life. Some liver diseases can come back after transplant. To help the transplant be more successful, you may be started on hepatitis B or C medicines ahead of time, if you have these diseases. How do I get ready for a liver transplant? Your healthcare provider will explain the procedure to you. Ask him or her any questions you have about the surgery. You may be asked to sign a consent form that gives permission to do the surgery.

Read the form carefully and ask questions if anything is not clear. For a planned living transplant, you should not eat for 8 hours before the surgery. This often means not having any food or drink after midnight. If your liver is from a donor who has just died, you should not eat or drink once you are told a liver is available. You may be given medicine to help you relax (a sedative) before the surgery. Your healthcare provider may have other instructions for you based on your medical condition. What happens during a liver transplant? Liver transplant surgery requires a hospital stay. Procedures may vary depending on your condition and your provider’s practices. Generally, a liver transplant follows this process: You will be asked to remove your clothing and given a gown to wear. An IV (intravenous) line will be started in your arm or hand. Other tubes (catheters) will be put in your neck and wrist. Or they may be put under your collarbone or in the area between your belly and your thigh (the groin).These are used to check your heart and blood pressure, and to get blood samples. You will be placed on your back on the operating table.

If there is too much hair at the surgical site, it may be clipped off. A catheter will be put into your bladder to drain urine. After you are sedated, the anesthesiologist will insert a tube into your lungs. This is so that your breathing can be helped with a machine (a ventilator). The anesthesiologist will keep checking your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. The skin over the surgical site will be cleaned with a sterile (antiseptic) solution. The doctor will make a cut (incision) just under the ribs on both sides of your belly. The incision will extend straight up for a short distance over the breast bone. The doctor will carefully separate the diseased liver from the nearby organs and structures. The attached arteries and veins will be clamped to stop blood flow into the diseased liver. Different surgery methods may be used to remove the diseased liver and implant the donor liver. The method used will depend on your specific case. The diseased liver will be removed after it has been cut off from the blood vessels. Your surgeon will check the donor liver before implanting it in your body. The donor liver will be attached to your blood vessels.

Blood flow to your new liver will be started. The surgeon will check for any bleeding where you have stitches. The new liver will be attached to your bile ducts. The incision will be closed with stitches or surgical staples. A drain may be placed in the incision site to reduce swelling. A sterile bandage or dressing will be applied. What happens after a liver transplant? In the hospital After the surgery you may be taken to the recovery room for a few hours before being taken to the intensive care unit (ICU). You will be closely watched in the ICU for several days. You will be hooked up to monitors. They will show your heartbeat, blood pressure, other pressure readings, breathing rate, and your oxygen level. You will need to stay in the hospital for 1 to 2 weeks or longer. You will most likely have a tube in your throat. This is so you can breathe with the help of a machine (a ventilator) until you can breathe on your own. You may need the breathing tube for a few hours or a few days, depending on your situation. You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow.

The tube will be taken out when your bowels start working normally again. You won’t be able to eat or drink until the tube is removed. Blood samples will be taken often to check your new liver. They will also check that your kidneys, lungs, and circulatory system are all working. You may have IV drips to help your blood pressure and your heart, and to control any problems with bleeding. As your condition gets better, these drips will be slowly decreased and turned off. You may receive antibiotics. Once the breathing and stomach tubes have been removed and you are stable, you may start to drink liquids. You may slowly begin to eat solid foods as directed. Your anti-rejection medicines will be closely watched to be sure you are getting the right dose and the right mix of medicines. When your provider feels you are ready, you will be moved from the ICU to a private room. You will slowly be able to move about more as you get out of bed and walk around for longer periods of time. You will slowly be able to eat more solid foods. Your transplant team will teach you how to take care of yourself when you go home. At home Once you are home, you must keep the surgical area clean and dry.

Your provider will give you specific bathing instructions. Any stitches or surgical staples will be removed at a follow-up office visit, if they were not removed before leaving the hospital. You should not drive until your provider tells you to. You may have other limits on your activity. Call your healthcare provider if you have any of the following: Fever. This may be a sign of rejection or infection. Redness, swelling, or bleeding or other drainage from the incision site More pain around the incision site. This may be a sign of infection or rejection. Vomiting or diarrhea Jaundice (yellowing of the skin and eyes) Your healthcare provider may give you other instructions, depending on your situation. What is done to prevent rejection? You must take medicines for the rest of your life to help the transplanted liver survive in your body. These medicines are called anti-rejection medicines (immunosuppressive medicines). They weaken your immune system’s response. Each person may react differently to medicines, and each transplant team has preferences for different medicines. New anti-rejection medicines are always being made and approved. Your provider will create a medicine treatment plan that is right for you. In most cases you will take a few anti-rejection medicines at first.

The doses may change often, depending on how you respond to them. Because anti-rejection medicines affect the immune system, people who have a transplant are at a higher risk for infections. Some of the infections you will be at greater risk for include: Herpes Respiratory viruses For the first few months after your surgery, you should avoid contact with crowds or anyone who has an infection. Each person may have different symptoms of rejection. Some common symptoms of rejection include: Fever A yellowing of the skin and eyes (jaundice) Dark-colored urine Estrogen Vaginal: MedlinePlus Drug Information Other names IMPORTANT WARNING: Estrogen increases the risk that you will develop endometrial cancer (cancer of the lining of the uterus [womb]). The longer you use estrogen, the greater the risk that you will develop endometrial cancer. If you have not had a hysterectomy (surgery to remove the uterus), you may be given another medication called a progestin to take with vaginal estrogen. This may decrease your risk of developing endometrial cancer, but may increase your risk of developing certain other health problems, including breast cancer.

Before you begin using vaginal estrogen, tell your doctor if you have or have ever had cancer and if you have unusual vaginal bleeding. Call your doctor immediately if you have abnormal or unusual vaginal bleeding during your treatment with vaginal estrogen. Your doctor will watch you closely to help ensure you do not develop endometrial cancer during or after your treatment. In a large study, women who took estrogen with progestins by mouth had a higher risk of heart attacks, strokes, blood clots in the lungs or legs, breast cancer, and dementia (loss of ability to think, learn, and understand). Women who use vaginal estrogen alone or with progestins may also have a higher risk of developing these conditions. Tell your doctor if you smoke or use tobacco, if you have had a heart attack or a stroke in the past year, and if you or anyone in your family has or has ever had blood clots or breast cancer. Also tell your doctor if you have or have ever had high blood pressure, high blood levels of cholesterol or fats, diabetes, heart disease, lupus (a condition in which the body attacks its own tissues causing damage and swelling), breast lumps, or an abnormal mammogram (x-ray of the breasts used to find breast cancer).

The following symptoms can be signs of the serious health conditions listed above. Call your doctor immediately if you experience any of the following symptoms while you are using vaginal estrogen: sudden, severe headache; sudden, severe vomiting; speech problems; dizziness or faintness; sudden complete or partial loss of vision; double vision; weakness or numbness of an arm or a leg; crushing chest pain or chest heaviness; coughing up blood; sudden shortness of breath; difficulty thinking clearly, remembering, or learning new things; breast lumps or other breast changes; discharge from nipples; or pain, tenderness, or redness in one leg. You can take steps to decrease the risk that you will develop a serious health problem while you are using vaginal estrogen. Do not use vaginal estrogen alone or with a progestin to prevent heart disease, heart attacks, strokes, or dementia. Use the lowest dose of estrogen that controls your symptoms and only use vaginal estrogen as long as needed. Talk to your doctor every 3 to 6 months to decide if you should use a lower dose of estrogen or should stop using the medication.

You should examine your breasts every month and have a mammogram and a breast exam performed by a doctor every year to help detect breast cancer as early as possible. Your doctor will tell you how to properly examine your breasts and whether you should have these exams more often than once a year because of your personal or family medical history. Tell your doctor if you are having surgery or will be on bed rest. Your doctor may tell you to stop using vaginal estrogen 4 to 6 weeks before the surgery or bed rest to decrease the risk that you will develop blood clots. Talk to your doctor regularly about the risks and benefits of using vaginal estrogen. Why is this medication prescribed? Vaginal estrogen is used to treat vaginal dryness, itching, and burning; painful or difficult urination; and sudden need to urinate immediately in women who are experiencing or have experienced menopause (change of life; the end of monthly menstrual periods). Femring® brand estradiol vaginal ring is also used to treat hot flushes ('hot flashes'; sudden strong feelings of heat and sweating) in women who are experiencing menopause.

Premarin® brand vaginal cream is also used to treat kraurosis vulvae (a condition that may cause vaginal dryness and discomfort in women or girls of any age). Vaginal estrogen is in a class of medications called hormones. It works by replacing estrogen that is normally produced by the body. How should this medicine be used? Vaginal estrogen comes as a flexible ring and a tablet to insert in the vagina, and as a cream to apply to the inside of the vagina. Estrogen vaginal rings are usually inserted in the vagina and left in place for 3 months. After 3 months, the ring is removed, and a new ring may be inserted if treatment is still needed. Estrogen vaginal tablets are usually inserted once a day for the first 2 weeks of treatment and then are inserted twice a week as long as treatment is needed. Estrace® brand vaginal cream is usually applied once daily for 2 to 4 weeks, and then applied one to three times a week. Premarin® brand vaginal cream product is usually applied according to a rotating schedule that alternates several weeks when the cream is applied every day with one week when the cream is not applied. Use vaginal estrogen at around the same time of day every time you use it.

Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use vaginal estrogen exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor. To use the vaginal ring, follow these steps: Wash and dry your hands. Remove the vaginal ring from its pouch. Stand with one leg up on a chair, step or other object, squat, or lie down. Choose the position that is most comfortable for you. Hold the vaginal ring between your thumb and index finger and press the sides of the ring together. You may want to twist the ring into a figure-of-eight shape. Hold open the folds of skin around your vagina with your other hand. Place the tip of the ring into your vagina and then use your index finger to gently push the ring inside your vagina as far as you can. The vaginal ring does not have to be positioned a certain way inside your vagina, but it will be more comfortable and less likely to fall out when it is placed as far back in your vagina as possible. The ring cannot go past your cervix, so it will not go too far in your vagina or get lost when you push it in.

If you feel discomfort, use your index finger to push the ring further into your vagina. Wash your hands again. Leave the ring in place for 3 months. The ring may fall out if you have not inserted it deeply in your vagina, if your vaginal muscles are weak, or if you are straining to have a bowel movement. If the ring falls out, wash it with warm water and replace it in your vagina following the directions above. If the ring falls out and is lost, insert a new ring and leave the new ring in place for up to 3 months. Call your doctor if your ring falls out often. You can leave the ring in place when you have sex. If you choose to remove it or if it falls out, wash it with warm water and replace it in your vagina as soon as possible. When you are ready to remove the ring, wash your hands and stand or lie in a comfortable position. Put a finger into your vagina and hook it through the ring. Gently pull downward and forward to remove the ring. Wrap the ring in a tissue or a piece of toilet paper and dispose of it safely, so that it is out of reach of children or pets. Do not flush the ring in a toilet.

Wash your hands again. To use the vaginal tablet, follow these steps: Tear off one applicator from the strip of applicators in your carton. Open the plastic wrap and remove the applicator. Stand with one leg up on a chair, step, or other object, or lie down. Choose the position that is most comfortable for you. Hold the applicator in one hand with a finger on the end of the plunger. Use the other hand to gently guide the applicator into the vaginal opening. If the tablet falls out of the applicator, do not try to replace it. Dispose of that applicator and tablet and use a fresh applicator. Insert the applicator into your vagina as far as is comfortable. Do not force the applicator into your vagina or insert more than half of the applicator into your vagina. Gently press the plunger until you hear a click. Remove the empty applicator from your vagina and dispose of it as you would a plastic tampon applicator. Do not save or reuse the applicator. To use the vaginal cream, follow these steps: Remove the cap from the tube of cream. Screw the nozzle end of the applicator onto the open end of the tube.

Gently squeeze the tube from the bottom to fill the applicator with the amount of cream that your doctor has told you to use. Look at the markings on the side of the applicator to help measure your dose. Unscrew the applicator from the tube. Lie on your back and pull your knees up toward your chest. Gently insert the applicator into your vagina and press the plunger downward to release the cream. Remove the applicator from your vagina. To clean the applicator, pull the plunger to remove it from the barrel. Wash the applicator and plunger with mild soap and warm water. Do not use hot water or boil the applicator. Ask your pharmacist or doctor for a copy of the manufacturer's information for the patient. Other uses for this medicine This medication may be prescribed for other uses; ask your doctor or pharmacist for more information. What special precautions should I follow? Before using vaginal estrogen, tell your doctor and pharmacist if you are allergic to vaginal estrogen, any other estrogen products, any other medications, or any of the ingredients in the type of vaginal estrogen you plan to use. Ask your pharmacist or check the manufacturer's patient information for a list of the ingredients.

tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, and nutritional supplements, you are taking or plan to take.

Be sure to mention any of the following: amiodarone (Cordarone, Pacerone); certain antifungals such as itraconazole (Sporanox) and ketoconazole (Nizoral); aprepitant (Emend); carbamazepine (Carbatrol, Epitol, Tegretol); cimetidine (Tagamet); clarithromycin (Biaxin); cyclosporine (Neoral, Sandimmune); dexamethasone (Decadron, Dexpak); diltiazem (Cardizem, Dilacor, Tiazac, others); erythromycin (E.E.S, Erythrocin); fluoxetine (Prozac, Sarafem); fluvoxamine (Luvox); griseofulvin (Fulvicin, Grifulvin, Gris-PEG); lovastatin (Altocor, Mevacor); medications for human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) such as atazanavir (Reyataz), delavirdine (Rescriptor), efavirenz (Sustiva), indinavir (C

rixivan), lopinavir (in Kaletra), nelfinavir (Viracept), nevirapine (Viramune), ritonavir (Norvir, in Kaletra), and saquinavir (Fortovase, Invirase); medications for thyroid disease; other medications that are used vaginally; nefazodone; phenobarbital; phenytoin (Dilantin, Phenytek); rifabutin (Mycobutin); rifampin (Rifadin, Rimactane, in Rifamate);sertraline (Zoloft); troleandomycin (TAO); verapamil (Calan, Covera, Isoptin, Verelan); and zafirlukast (Accolate).

Your doctor may need to change the doses of your medications or monitor you carefully for side effects. tell your doctor what herbal products you are taking, especially St. John's wort. tell your doctor if you have or have ever had yellowing of the skin or eyes during pregnancy or during your treatment with an estrogen product, endometriosis (a condition in which the type of tissue that lines the uterus [womb] grows in other areas of the body), uterine fibroids (growths in the uterus that are not cancer), asthma, migraine headaches, seizures, porphyria (condition in which abnormal substances build up in the blood and cause problems with the skin or nervous system), very high or very low levels of calcium in your blood, or thyroid, liver, kidney, gallbladder, or pancreatic disease. If you will be using the vaginal ring, also tell your doctor if you have a vaginal infection; any condition that makes your vagina more likely to become irritated; a narrow vagina; or a condition where the rectum, bladder, or uterus has bulged or dropped into the vagina. tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding.

If you become pregnant while using vaginal estrogen, call your doctor immediately. you should know that the manufacturer of one brand of estrogen vaginal cream states that use of the cream may weaken latex or rubber birth control devices such as condoms or diaphragms. These devices may not be effective if you use them during your treatment with estrogen vaginal cream. Talk to your doctor about methods of birth control that will work for you. What special dietary instructions should I follow? Talk to your doctor about eating grapefruit and drinking grapefruit juice while using this medicine. What should I do if I forget a dose? Apply or insert the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not use a double dose or apply extra cream to make up for a missed dose. What side effects can this medication cause? Vaginal estrogen may cause side effects.

Tell your doctor if any of these symptoms are severe or do not go away: breast pain or tenderness difficulty falling asleep or staying asleep changes in sexual desire spotty darkening of the skin on the face sudden feelings of heat or sweating difficulty wearing contact lenses swelling, redness, burning, itching, or irritation of the vagina vaginal discharge swelling of the eyes, face, tongue, throat, hands, arms, feet, ankles, or lower legs hoarseness difficulty breathing or swallowing Estrogen may increase your risk of developing cancer of the ovaries or gallbladder disease that may need to be treated with surgery. Talk to your doctor about the risks of using vaginal estrogen. Estrogen may cause growth to slow or stop early in children who receive large doses for a long time. Vaginal estrogen may also affect the timing and speed of sexual development in children. Your child's doctor will monitor her carefully during her treatment with estrogen. Talk to your child's doctor about the risks of giving this medication to your child. Vaginal estrogen may cause other side effects. Call your doctor if you have any unusual problems while taking this medication.

If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online ( ) or by phone (1-800-332-1088). What should I know about storage and disposal of this medication? Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA's Safe Disposal of Medicines website ( ) for more information if you do not have access to a take-back program.

In case of emergency/overdose If someone swallows vaginal estrogen, uses extra tablets or rings, or applies extra cream, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911. Symptoms of overdose may include: nausea What other information should I know? Keep all appointments with your doctor. Before having any laboratory test, tell your doctor and the laboratory personnel that you are using vaginal estrogen. Do not let anyone else use your medication. Ask your pharmacist any questions you have about refilling your prescription. It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies. Brand names

Question: A probang is used to remove an object from, or apply medication to, which part of the body?
Answer: Throat