Dear Doctor: I am 56 and in menopause. A couple of months ago, I started having severe restless leg syndrome, which even included my arms. I am now taking ropinirole before bed every night -- I also take Pristiq for depression. Although the medication has eliminated my restless leg syndrome, I worry about potential long-term effects. Any idea what could cause restless leg syndrome?

Dear Reader: Restless leg syndrome (RLS) is appropriately named. The syndrome is defined by an uncomfortable urge to move one's legs or arms during periods of inactivity. Because most people are less active in the evening, these symptoms often are first noted at that time. People describe the feeling as a pulling, creeping, cramping, crawling or tingling sensation that makes them feel an urge to move in order to relieve it. The periodic leg movements can also awaken people with the condition -- or those who sleep with them.

Restless leg syndrome occurs more often in people of Northern European ancestry; it's rare in those from East Asia and from Africa. Overall, it affects 2 to 3 percent of the population.

There is no specific cause of RLS, although genetic factors can play a part. Forty to 60 percent of people with RLS report a family history of the condition. Low iron storage can also be a factor, as can alterations in the brain function of the neurotransmitter dopamine.

Certain medications can worsen RLS symptoms, such as the antihistamine diphenhydramine and antidepressants. Thus, the antidepressant Pristiq (desvenlafaxine) could make your symptoms worse, but there are no specific studies of its connection with RLS.

Because poor sleep can aggravate RLS, be sure you are getting good rest. Exercise also appears to decrease symptoms, as can reductions in caffeine. Doing mental activities during a person's evening "down time," such as crossword puzzles, can reduce the focus on symptoms.

Medication that binds dopamine receptors, such as the ropinirole that you're taking, can decrease the symptoms of restless legs. Such medications are started at night and, although they can initially cause drowsiness, this subsides after 10 to 14 days. One problem with such drugs is that they can lead to rebound symptoms -- that is, the restless leg sensations -- in the morning. An even bigger problem is that long-term use can lead to decreased effectiveness, a shorter duration of action, symptoms noted earlier in the day and a spread of symptoms into the arms; these problems can worsen with increased dosages. To reduce the likelihood of this, I'd recommend staying on low doses of the drug and not taking it on a nightly basis, if possible.

You might also want to consider the anti-seizure medications gabapentin or pregabalin. They may not be as effective as ropinirole, but there is less likelihood of rebound or worsening of symptoms. Benzodiazepines, such as clonazepam, can be used for RLS, but can lead to tolerance or even dependency.

In summary, have your doctor check your blood ferritin level, a marker for iron stores. If it's low, consider iron supplementation. Also, be sure to increase your levels of exercise, decrease your caffeine intake and try mental activities at night.

If you feel that your symptoms are worsening on the ropinirole, talk to your doctor further. You have other options.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: What is in the flu vaccine that makes people feel so bad? A co-worker of mine got a flu shot last year and wound up feeling quite ill. Can a flu shot give you the flu?

Dear Reader: No, you can't get the flu from a flu shot. The flu vaccine is made two ways. One type of vaccine is made from a virus that has been inactivated, also known as a "killed" virus. Another type of vaccine contains no virus at all.

That said, it's entirely possible to have a physical reaction to the flu vaccine. For some people, that's redness, pain and swelling at the injection site. For others, it's a few days of aches and pains, perhaps with a bit of fever. This second reaction, which can feel similar to a slight case of the flu, is quite likely how the misconception that the vaccine can give you the flu first arose. But those symptoms are actually your body's response to the immune system as it rallies to produce antibodies to the flu virus.

It's also possible to catch the flu in the two weeks after you get your flu shot. That's because it takes up to two weeks for the vaccine to offer full protection. During that time, if you're exposed to the flu virus, you can go on to become ill. And don't forget -- flu vaccines target the specific viruses that epidemiologists believe will be active during a given flu year. If you run afoul of a different virus than the ones your flu shot targets, it can make you sick. Another thing to remember -- flu symptoms like chills, high fever, coughing, sneezing and bodily discomfort are shared by a range of different illnesses, including the common cold.

Speaking of which, the flu -- we're really talking about influenza here -- is more than a particularly nasty cold. Thanks to advances in modern medicine, it's easy to forget that the influenza pandemic of 1918 killed between 50 and 100 million people worldwide. According to the Centers for Disease Control and Prevention, when adjusted for today's increase in population, that would equal 175 to 350 million deaths.

Today, flu deaths in the United States have dropped significantly to about 4,600 per year. However, the very young, the elderly, people with chronic diseases like asthma, diabetes and congestive heart failure, and those with compromised immune systems are at increased risk for developing serious complications. The flu virus can cause lung inflammation serious enough to lead to respiratory failure. It can also lead to pneumonia, bronchitis and infections of the ear or sinus. For those living with chronic health conditions, the flu can make them worse.

All of which, in our opinion, are strong arguments in favor of an annual flu shot. The CDC recommends everyone older than 6 months old get one. Here in the U.S., flu season is fall and winter, with the peak months typically running from November through March. That means we're in the thick of it right now.

If you haven't gotten your shot yet, it's fast, it's easy, and there are plenty of low-cost and even free flu shot clinics. And there's still plenty of time.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I am a 70-year-old woman who has been taking 20 milligrams of Paxil for 17 years. It has worked wonders for me, changing my life after a lifetime of depression. Last year my doctor told me she wants me to go off Paxil, saying that patients taking the drug were dying earlier. I have severe withdrawal symptoms when missing more than one dose, but she has left it up to me to wean myself from the drug. Do you suggest I continue the medication? Also, is there a connection between Paxil and Alzheimer's/dementia? It is very prevalent in my family.

Dear Reader: For some people, Paxil and similar drugs can indeed work wonders. But they're not without long-term and short-term risks, not to mention withdrawal difficulties.

Paxil (paroxetine) is a selective serotonin reuptake inhibitor (SSRI) used for depression, generalized anxiety and panic disorder. The long-term problem with Paxil and the drug Luvox is that, unlike other SSRIs, they have anticholinergic properties, meaning that they block the neurotransmitter acetylcholine within the brain, spinal cord and the peripheral nerves.

In the short-term, anticholinergic medications can cause dry mouth, urine retention, constipation and increased heart rate. But they also can cause poor coordination, an increased risk of falls, confusion, disorientation and poor concentration. These latter side effects are more common in older patients, raising concerns that they'll lead to hip fractures and severe memory problems. Further, anticholinergic drugs in general have been linked to an increased risk of dementia. Because Paxil has anticholinergic properties, some health experts fear it may pose a problem for older patients.

So far, the data aren't supportive. A 2015 study compared 1,898 elderly nursing home who used Paxil with 18,054 who used another SSRI. The study found no difference in the rate of dementia between the two groups. A 2017 study also compared Paxil to other SSRIs among elderly nursing home patients. It, too, failed to find any difference in the death rate between people taking Paxil and those taking other SSRIs. Even so, however, I agree with your doctor's worries about Paxil. The potential side effects at your age may warrant stopping its use.

You're correct that Paxil is not easy to stop cold turkey and, in fact, poses more difficulties than most other SSRIs, causing headaches, nausea, dizziness, fatigue and, in some cases, sweating, chills, agitation and tremors.

To reduce or prevent these symptoms, you can start by lowering your dose to 10 milligrams for four weeks, then stopping the drug. But for many, even this transition is difficult. Some people stopping Paxil switch to another SSRI, Prozac (fluoxetine), at a dose of 10 to 20 milligrams for four weeks before stopping that drug as well. Because Prozac has a very long half-life, discontinuation produces fewer symptoms.

But let's focus on a crucial issue: your history of lifelong depression. Depression and anxiety can be debilitating at any age, but especially among older people. Because Paxil has changed your life so dramatically and has worked well for the last 17 years, discontinuing all antidepressants would seem unwise. Ask your doctor about switching to another SSRI, such as Prozac, Lexapro, Zoloft or Celexa; your mental health cannot be taken lightly.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)