The down & dirty on women's wellness
Please Shine Down on Me: The Skinny on Sun Exposure
Please Shine Down on Me: The Skinny on Sun Exposure
July 2, 2020
We all know that sun exposure can cause skin cancer. We have heard the public service announcements and we have seen the advertisements for sunscreen that emphasize regular use to prevent cancer. We have had the inquiries when we see our primary care providers and have wondered about the size and shape of moles on our bodies. We are not confused about the potential deleterious effects of the sun on our skin. However, many of us are confused about the details that underlie these effects, our protection & the best mode of prevention. SPF numbers have increased to now represent seemingly impossible integers, UV light has been split into different nebulously risky categories, and we have been told that sunscreen is destroying oceanic habitats. It would be hard, with so many mixed messages and so much conflicting information coming at us, to not be confused about our best approach to staying safe while enjoying the PNW's limited summer sun. Here are the answers to six frequently asked questions/concerns about UV exposure that may help clarify the murkiness of managing the risks associated with sun exposure:
1. What harm can come of UV exposure? It's just the sun.
The sun itself is not a problem. It is beautiful, warming, glorious. Exposure to the sun improves our moods & can actually improve our overall health. The rays of UV radiation emitted by the sun are the cause for concern & the concerning thing about the UV radiation is the kind of energy it produces. These rays have more energy contained in them than visible light but less energy than X-ray radiation, which is known to cause various kinds of cancer with repeated exposure. UV radiation itself does not itself produce a specific amount of radiation. There are variations in the radiation exposure based on the different wavelengths of UV rays. Higher-energy UV rays are a form of ionizing radiation. This means they have enough energy to remove an electron from (ionize) an atom or molecule. Ionizing radiation can damage the DNA (genes) in cells, which in turn may lead to cancer. But even the highest-energy UV rays don’t have enough energy to penetrate deeply into the body, so their main effect is on the skin that they do penetrate. This is why we worry about skin cancer developing in response to sun exposure. Most skin cancers are a result of exposure to the UV rays in sunlight. Both basal cell and squamous cell cancers (the most common types of skin cancer) tend to be found on sun-exposed parts of the body, and their occurrence is typically related to lifetime sun exposure. The risk of melanoma, a more serious but less common type of skin cancer, is also related to sun exposure, although perhaps not as strongly. Exposure to UV rays can also cause premature aging and sun damage to the skin, including wrinkles, texture changes, brown spots & raised lesions. UV rays can also cause eye problems, including inflammation or the cornea, formation of cataracts or growth of tissue on the surface of the eye that impairs vision. Excessive UV exposure can also weaken the immune system, making it harder for the body to fight off infections, which can cause such things as reactivation of dormant viruses.
2. Don't we need sun exposure to make Vitamin D?
Yes. Your skin makes vitamin D naturally when it is exposed to UV rays from the sun. How much vitamin D you make depends on many things, including how old you are, how dark your skin is, and how strong the sunlight is where you live. Vitamin D has many health benefits. It might even help lower the risk of some cancers. It is very difficult to get sufficient vitamin D from dietary sources or to absorb it well from oral supplements. It is important, therefore, to ensure that you do have some UV exposure during the day in order to successfully synthesize adequate amounts of Vitamin D. The amount of time required to synthesize sufficient vitamin D will depend on the amount of melanin in your skin; if your complexion is fair, you do not need more than 25 minutes of direct exposure to the sun, but if your complexion is darker, you may require 40-60 minutes of exposure. This amount of exposure to the sun should not significantly increase your risk of cancer. Beyond those recommended times of exposure, you continue to synthesize more vitamin D, but your risk of harmful UV radiation effects increases.
3. Is higher SPF better?
Not necessarily. SPF stands for sun protection factor. The SPF number represents the level of protection the sunscreen provides against UVB rays, which are the main cause of sunburn and are the primary source of damaging UV radiation. A higher SPF number means more UVB protection (although it says nothing about UVA protection). What the SPF number means is that you get 1 minute of UVB protection for that number of minutes spent in the sun (it decreases the amount of overall exposure by that number of minutes). For instance, when applying an SPF 30 sunscreen correctly, you get the equivalent of 1 minute of UVB ray protection for each 30 minutes you spend in the sun. So, 1 hour in the sun wearing SPF 30 sunscreen is the same as spending 2 minutes totally unprotected. People often do not apply enough sunscreen, so they get less actual protection. Sunscreens labeled with SPFs as high as 100+ are available. Higher numbers do mean more protection, but many people don’t understand the SPF scale. SPF 15 sunscreens filter out about 93% of UVB rays, while SPF 30 sunscreens filter out about 97%, SPF 50 sunscreens about 98%, and SPF 100 about 99%. The higher you go, the smaller the difference. There is no sunscreen available, despite the high SPF number, that confers complete protection from the possible harmful effects of the radiation emitted by the sun.
4. Is sunscreen more damaging than the sun?
There are two basic kinds of sunscreen: mineral & chemical. Mineral sunscreens are largely composed of one of two compounds: zinc oxide (think diaper rash cream) & titanium oxide. These minerals create a physical barrier or shield that sits on top of the skin & prevents deep penetration of UVA & UVB rays into the skin. Chemical sunscreens use a variety of different chemicals, which may include oxybenzone, avobenzone, octisalate, octocrylene, homosalate, octinoxate, or any combination of these compounds. The most common chemical sunscreen ingredient, oxybenzone, is an endocrine (hormonal) disruptor & its use is legally limited in many countries (not the US). Oxybenzone is also directly linked to damage, destruction & death to many oceanic creatures, including coral reefs & has been banned in such places as Hawaii to prevent further harm to underwater habitats. Many sunscreens also contain a compound called methylisothaizolinone, which is both an endrocrine disruptor & a potent skin allergen for many. The mineral sunscreens do not penetrate the skin itself & are minimally absorbed, as their purpose & function is to create a physical barrier between the sun & your skin. The chemical sunscreens, on the other hand, do deeply penetrate the skin in order to alter the skin's response to the sun & convert & denature UV radiation as it is penetrating the skin. It is well-established that chemical sunscreens have systemic absorption & effect, & many of these chemicals have been found in studies to be circulating in users' bloodstreams at more than 400% the recommended level. Things get even dicier when sunscreen becomes aerosolized & the compounds are now inhaled in small particles into a user's lungs & coat the membranes lining the lungs. We recommend being highly aware of what you are putting on your skin & how you are putting it there. We recommend using a mineral barrier sunscreen & applying it as a lotion or cream that allows you to control the site of application. We also recommend that you take the time to fully understand the chemical composition of anything you are putting onto or into your body & to grasp the risks of use. The environmental working group is a non-profit organization dedicated to evaluating potential environmental exposures that may have toxic potential for humans & is a great source of information regarding ingredients in many over-the-counter, off-the-shelf products available in the US.
5. What's the difference between various types of UV radiation?
There are three fundamental groups of UV radiation: UVA, UVB & UVC. Of these, UVA has the least amount of energy & therefore poses the lowest threat in terms of cellular damage. UVA radiation can cause skin cells to age & can cause some indirect damage to cells’ DNA. UVA rays are mainly linked to long-term skin damage such as wrinkles, but they are also thought to play a role in the development of some skin cancers. From an aesthetic perspective & in terms of preventing premature aging of the skin, these rays are the most important to avoid. UVB radiation is the middle-of-the-road in terms of energetic potential for UV radiation. These rays can damage the DNA in skin cells directly, & they are the main cause of sunburn. They are also thought to cause most skin cancers. Unfortunately, it is these same radiation that is responsible for provoking our skin's synthesis of Vitamin D. Therefore, it requires a very delicate balance of limited unprotected exposure to optimize our health benefits & risks. Broad-spectrum sunscreens protect against both UVB & UVA radiation. UVC radiation has the highest amount of energy of any UV radiation. These rays are so energetic that they react with ozone high in our atmosphere & generally don’t even reach the ground, so they are not normally a risk factor for skin cancer. However, UVC rays can also come from some man-made sources, such as arc welding torches, mercury lamps, & the UV sanitizing bulbs that are used to kill bacteria & other germs (such as in water, air, food, or on surfaces). There is no sunscreen in existence that protects skin or any other body part from exposure to UVC rays, which are invariably more damaging than UVB radiation.
6. If I tan easily or have darker skin at baseline, does sun protection still matter for me?
The short answer is yes. Regardless of the amount of melanin in your skin, it is still important for you to protect yourself against excessive exposure to UV radiation because of the invisible damage that can be done to the cells within your skin. Such damage is not rooted in the amount of available melanin. It is easier for individuals with fairer skin to experience burning more readily from sun exposure, & their sun-related risks are therefore greater. Women whose skin naturally has more melanin do have more innate cellular protection against UV radiation. However, having darker skin does not confer instant protection & is not a form of prevention for UV-associated harm. Women with large amounts of melanin can still burn their skin & there is some risk that they may not realize it when they have, as their skin is less likely to appear reddened & more likely to feel hot, sensitive & itchy. And, skin cancer, while less likely to occur in women with darker skin, is deadlier for browner ladies--they are more likely to have their skin cancers overlooked, diagnosed at later stages, & result in their death. Therefore, it may actually be MORE important for the darker skinned women among us to ensure that they are protecting themselves from UV damage. We recommend that women with all colors of skin have exposure to the sun each day. For fair individuals, we recommend limiting unprotected exposure or calculating exposure based on protection to an equivalent of less than 1 hour each day. As melanin production in the skin increases, based on genetics or reactivity to the sun (e.g., the tanning effect), that duration can gradually lengthen without increasing health risks related to exposure. However, even for the woman with the darkest skin on the planet, we do not recommend direct exposure to the sun for more than 2 hours.
There are many things other than sunscreen that matter for UV protection, including sun-protective clothing ( wide-brimmed hats, UPF-designed tops/leggings, umbrellas, other sources of shade), sunglasses & consideration of the UV index, which is a metric designed to convey the amount of risk associated with sun exposure at any given time of day in any given location of the world (check your weather statistics for your location's UV index). Skin isn't the only thing that can be harmed by UV exposure, so it is equally important to ensure that you are protecting your eyes with proper sunglasses that are specifically designed to block harmful rays. We want you to have fun in the sun, & we want you to enjoy the briefly glorious summer of the Pacific Northwest, but we also want to ensure you have proper protection & are not increasing your risk with your use of products intended to protect you. As always, we are available to answer any questions you might have, look at any moles that concern you, or treat any skin condition that has arisen.
What a Headache!
What a Headache!
June 1, 2020
Of the more than 39 million American sufferers, 28 million are women. Migraine is one of the leading serious health problems that disproportionately affects women. Women suffer from migraine three times as often as men. In the U.S., 18% of women suffer compared to 6% of men. But during the reproductive years, as many as 43% of women suffer. Of those who suffer, 50% have more than 1 attack each month, & 25% have 4 or more severe attacks per month. 85% of chronic migraine sufferers are women. 92% of women with severe migraine are disabled.
The difference in migraine headache prevalence & presentation in women as compared to men is often attributed to differences in hormones &, in particular, the fluctuant nature of hormones in women’s bodies. Unlike men, who are biologically programmed in ways that do not require them to dramatically cycle throughout the month, women are affected by sudden increases or decreases in luteinizing hormone, follicle stimulating hormone, estrogen & progesterone in rapid succession throughout each month. Not only are migraine headaches more common in women, but they are also harder to treat, & we can blame this on estrogen. Estrogen regulates the female reproductive system, & it also happens to control chemicals in the brain that impact the sensation of pain. A drop in estrogen levels can cause a headache, typically in the form of a migraine, that lasts anywhere from four to 72 hours.
In addition to having more migraine headaches more often than men, women experience migraine differently than do men. Women report episodic pain (often for a longer duration) & chronic pain more frequently than men. Women who experience more severe & more frequent migraine attacks often have dramatic changes in estrogen levels. Research has consistently connected hormones to migraine, but not all migraines are hormonal.
It is important for women who suffer from recurrent headaches to keep careful track of the nature of the headaches, including when the occur (especially relative to her menstrual period), how long they last, what activities preceded them, how much sleep they got, which medications they took, which treatments failed & which offered relief, & what they had been recently eating & drinking. Each of these things can shed light on the potential source of the headaches & offer options for prevention &/or treatment.
Sometimes, things that provoke migraine headaches can be surprising, & sometimes they can be difficult to identify because the inciting factors may not be readily apparent. This is part of why it is so essential for female headache sufferers to track their symptoms (& their cycles) diligently. The exact cause of migraine headaches is not fully understood. Most researchers think that migraine attacks result from abnormal changes in levels of substances that are naturally produced in the brain. When the levels of these substances increase, they cause inflammation. This inflammation then causes blood vessels in the brain to swell & press on nearby nerves, causing pain.
Genes also have been linked to migraine. People who get migraines may have abnormal genes that control the functions of certain brain cells & migraine headaches tend to run in families.
Experts do know that people with migraines react to a variety of factors & events, called triggers. These triggers can vary from person to person & don't always lead to migraine. This inconsistency can sometimes cause frustration in tracking potential triggers. A combination of triggers — not a single thing or event — is more likely to result in a headache. A person's response to triggers also can vary from migraine to migraine. Many women with migraine tend to have attacks triggered by:
• Lack of or too much sleep
• Skipped meals
• Bright lights, loud noises, or strong odors
• Hormone changes, including those related to menstruation, ovulation, conception, pregnancy, childbirth, lactation, perimenopause & menopause
• Underlying inflammatory conditions, such as autoimmune conditions
• Fluctuations in blood pressure, heart rate, or temperature
• Stress & anxiety, or relaxation after a prolonged period of stress (in direct response to the release of stress hormones)
• Weather changes
• Medications (of all kinds—even pain medications can cause headaches as a side effect)
• Alcohol (often certain kinds of red wine)
• Physical activity (overexertion that causes blood vessel swelling OR not being active enough)
• Caffeine (too much or withdrawal)
• Foods that contain nitrates, such as hot dogs and lunch meats
• Foods that contain MSG (monosodium glutamate), a flavor enhancer found in fast foods, other food preservatives or coloring agents, artificial flavors, broths, seasonings, & spices
• Foods that contain tyramine, such as aged cheeses, soy products, fava beans, hard sausages, smoked fish, & Chianti wine
• Aspartame (NutraSweet® and Equal®) or other non-sugar sweeteners
Not all headaches are migraine headaches. Migraine pain is an intense pulsing from deep within your head. This pain can last for days. The headache significantly limits one’s ability to carry out her daily routine. Migraine is throbbing & usually one-sided. People with migraine headaches are often extremely sensitive to light & sound. Nausea & vomiting also usually occur.
Some migraine is preceded by visual disturbances. About one out of five women will experience these symptoms before the headache starts. Known as an aura, it may cause one to see:
• flashing lights
• shimmering lights
• zigzag lines
• blind spots
Auras can also include tingling on one side of the face or in one arm & trouble speaking, which are symptoms that are also consistent with having a stroke. If a woman is unsure whether she is having a migraine-related aura or is experiencing symptoms that are not her usual experience of migraine headaches, she should be evaluated to ensure she is not suffering a stroke. Migraine sufferers have an increased risk of stroke as a result of the spasms in the blood vessels that can result in clot formation & release, & it is extremely important to differentiate the causes of symptoms & identify a stroke as soon as possible.
Headaches that occur that do not follow the typical characteristics of migraine headaches may still be migraine headaches, but it is important to identify the type of headache in order to develop an effective plan for prevention & treatment. Other kinds of headaches include:
• Tension headaches
• Cluster headaches
• Allergy or sinus-related headaches
• Post-traumatic headaches
• Rebound headaches
• Hypertension headaches
There is significant overlap between migraine headaches & other kinds of headaches, both in triggers & in treatment & prevention options. If you are experiencing recurrent headaches, begin your diary & request assistance from a skilled set of eyes to review the diary & initiate a plan of care that can help you reclaim a life previously hindered by headaches.
These Unprecedented Times: Protecting Your Mental Health In the Midst of Collective Uncertainty & Fear
These Unprecedented Times: Protecting Your Mental Health In the Midst of Collective Uncertainty & Fear
May 5, 2020
The COVID-19 crisis hit us like a bomb & devastated all of our routines, many of our mundane tasks, & the processes & circumstances within which we have lived our daily lives. Rapidly changing recommendations & directives altered our lives moment-by-moment & made impossible many of the activities we used to take for granted & enjoy, from sitting in a coffee shop to getting our hair cut. Many of us found our children suddenly without a place to go during the day. Many of us found ourselves furloughed & without the paychecks that support our families. In the midst of it all, we are surrounded by a constant barrage of faulty information that we have struggled to rely on to tell us how to safely conduct our lives to protect ourselves & our loved ones. Repeatedly, the directives & recommendations have been conflicting, & they have changed at a dizzying pace as the crisis has unfolded. On a daily basis, we interact with women who have told us how sick they are of living their lives in COVID-mode & how they just need things to get back to normal so they can go on with their lives.
Women are going stir crazy at home, are increasingly anxious as a result of the inundation with information from social media & the news, & are developing COVID-fatigue, all in the midst of feeling unmotivated & fairly hopeless about the state of the world at large. It is Mental Health Awareness month, which is incredibly appropriate for these times when we are all in a state, regardless of our privilege, that threatens our mental health. If we had mental health concerns (e.g., stressors, illnesses, anxieties, sadness) prior to the turmoil this pandemic has inflected on our lives, we are worse for wear. It is difficult now to know where to turn for help or how to help ourselves, especially in the throes of what feels like overwhelming catastrophe. The following are five surefire ways to get yourself back on track:
1. Breathe. No, seriously. Take a deep breath, focus on the air that fills your lungs & then on the way it leaves your body as you exhale. Slow your breathing. Intentionally focus on the way that you are breathing & on the otherwise involuntary task of filling your body with oxygen. Deep, mindful breathing is not just instantaneously relaxing, it also has the power to positively impact your physical health. Breathing exercises can alter the pH of the blood, the oxygen content that is delivered to our brains & even our blood pressure. Mindfully controlling our breathing has demonstrated consistently positive effects for our hearts, our lungs, our brains, our digestive systems (see previous article about the connection between our guts & our brains) & our immune responses. If you’re feeling stressed & overwhelmed, panicky or depressed, take a moment out of your day to just sit & breathe. Observe your breath & try to regulate its rate, its rhythm, & its depth. This is a practice that can be undertaken in any setting, at any time, without prior planning. The ingredients, after all, are right under your nose.
2. Limit your social media consumption. We know: it’s connection. We know: it’s information. We know: it’s distraction. We also know it’s fodder for anxiety. Social media is a terrible source for accurate information & can provide you with an overload of seemingly valid news that can actually be quite destructive. From the circulation of unverified conspiracy theories that can keep you awake at night & cause you to question your own sense of reality to the unintentional boarding of the emotional rollercoasters all Facebook users are currently riding, social media can provide you with a black hole of information that is potentially triggering & incredibly difficult to parse. It’s hard to know what to heed. It’s difficult to determine which conflicting pieces of information you can believe. It’s a whole host of new uncertainties you had not previously considered. And that’s a recipe for panic. If you are finding yourself increasingly anxious after scrolling through your social media feed or going down rabbit holes you didn’t know existed before you found them on Facebook, set strict boundaries for yourself around your social media use, including time limits, clicking limits, & attention limits. Choose what you consume wisely in order to limit the barrage of “data” in your head.
3. Get back to basics. There are many things we can worry about right now. The sky absolutely feels like it is falling. It is hard to not be caught up in concern about the economy, our public health, politics, the future at large. Each of these topics, while important, is enormous & is not likely to be something we can control. Feeling out of control is detrimental to our mental health. In our current settings, life feels terribly out of control such that even our most routine activities (going to the grocery store, getting gas) are now unpredictable & scary. Having an enduring sense of control has been consistently associated with lower levels of psychological distress. The reality is that we cannot control what is happening in the world right now. The reality is that we cannot control Governor Inslee’s decisions. For many, the reality is that we do not know when we will be able to return to work. Instead of compiling mental lists of things that you cannot control & worrying about outcomes you can’t personally manage, realign your focus to those things you can control. Focus on what is immediately before you & the things that you can directly influence, like what you will make for dinner, when you will go to bed, whether you will do your laundry. Simple tasks that afford you a sense of immediate accomplishment & control are tremendously important right now. Feeling overwhelmed? Clean the toilet. Crawling with unmanageable anxiety? Start (& finish) an art project. Despondent about the state of the stock market? Weed the garden. Ground down into those things you can control &, as much as possible, release pre-occupations with the things that make you feel out of control.
4. Connect with others. Yes, social distance. Absolutely keep following the directives to prevent the asymptomatic or presymptomatic spread of the virus. But, don’t socially isolate. You may be spending all day with your children (whom you love, yes, but who are still children) in ways you weren’t before. You may be unable to enjoy activities that afforded you a sense of connection before: yoga class, book club, church. You may find yourself isolated from friends with whom you used to regularly visit or text (they may not be texting as much now because they are also home with their children & trying to balance their work with concurrent parenting demands). Reach out to your community of humans. Create intentional encounters that honor social distancing parameters: Zoom with your girlfriends, join an online themed support group, share highlights of your daily experiences with others who can relate, call your sister, Skype your mom. As humans, we are social animals. Even if we are introverted, we crave connection, validation & support. And, getting these things is medicinal for our bodies & our minds. Research consistently demonstrates higher rates of happiness among people who report having good relationships & sources of external emotional support. This might mean that you have a heart-to-heart to vent & release all your anxieties & fears, or it might mean that you share an absurd meme that has all your friends laughing aloud on your Zoom encounter. Reach out. It matters for you, & it matters for them.
5. Lighten up! We know it’s hard to feel light-hearted when we are mired in the stark realities of current affairs. Still, we also strongly believe that laughter is the best medicine & that distraction can be a treatment. If you’re feeling bogged down in negativity, seek ways to purposefully infuse your life with sources of humor & heart-warming content. Think of those things that bring your spirit the most joy: watching baby pandas tumble down slides, sitting on your porch with the hummingbirds flitting around you, reading trashy romance novels, watching Comedy Central, tickling your kids, busting out old board games, or playing Frisbee with your puppy. Whatever makes you happy & is accessible to you in these restricted moments: do that. A lot. Disconnect & disengage deliberately with an intent both to escape the incessant direness & to spark genuine happiness. If you can’t muster the spirit to engage in frivolity, fake it till you make it. Plan your fun & force yourself to do it, starting with enjoying the laughter or hilarity offered by others & progressing to intentional activities, from doing something you loved to do as a kid (drawing with chalk, challenging yourself with your Skip-It, finger painting, catching frogs) to embarking on a new leisure activity you’ve always wanted to explore. Finding the fun & the funny moments in between reruns of serious, disconcerting updates will make bad news that much easier to bear.
Sometimes, however, despite intentional activities designed to heighten your mood & diminish your anxiety & pessimism, it persists. Sometimes, we can’t get ourselves off the couch to engage in these activities. Sometimes, we are so overwhelmed that we get stuck & feel frozen, as if there is nothing that we can actually do to effect change in our moods or our mindsets. Sometimes, the emotional roller coaster is too far gone for us to climb off whenever we desire. If you are finding yourself there, let us know. We have a host of resources to assist you, & we truly understand the depth of the impact that this crisis is having on your entire life, your being, & your mental & physical health.
No Laughing Matter
No Laughing Matter
April 2, 2020
We are a jovial bunch in this office. We like to see the lighter side of things. We like to laugh & have fun. Each of the women in our office really enjoys a good time & truly sees laughter as the absolute best medicine. If you’ve ever met us, you know that we are not uptight, that we are whimsical, that we adapt easily & readily, & that we can find the humor & good even in some of the worst scenarios. Let us be clear: not one of us is laughing right now. We did not engage in any April Fool’s Day trickery, nor have we been finding ways to giggle outside of that jocular holiday. What is before us, both from an economic perspective & from a public health perspective, is no laughing matter.
We have been appalled, but not surprised, by the incredible lack of guidance, awareness, & preparedness surrounding the COVID-19 crisis. These shortcomings are in part because we, as a collective, DID NOT PAY ATTENTION. It is also, though, because our health care system is inexcusably inefficient & tethered to profiteering spearheaded by non-clinical MBAs & other nebulous administrative personnel, mythical images of “quality care” & “centers of excellence” designed by non-clinical public relations & marketing professionals, & our national cultural proclivity to shameless self-promotion & lack of insight or retrospection that would allow us to honestly assess the reality of our assertions. America’s health care systems—pluralized because we are not, in fact, one unified system, but instead many privatized entities that have been called upon to do the public work of providing healthcare—are tremendously profitable.
American healthcare is a big-ticket item. Insurance premiums are outrageously expensive, deductibles remain astonishingly high, & the cost of care is an elusive, phantom-like figure that no one seems capable of dragging into the light. This healthcare provision is a total cash cow. It is extremely high cost & has been consistently extremely low value. The more care gets fragmented into different systems competing for consumers, the more distant the actual care providers get from making decisions that impact the care they can provide & the actual, human outcomes of that care. As a result, the value of the care provided treacherously erodes. As healthcare entities vie for customer preference, marketing professionals develop enticing slogans that then get bandied about to attract a larger volume of paying patients & the true meaning of those words (“Excellence in Women’s Care,” “Caring for the Community”) vaporizes, because the fixation has been on ensuring high volumes of patients, not on measuring the actual outcomes of the care provided. In the midst of this, patients are also losing their choices even among the increasingly similar options that are rapidly decreasing in number as larger systems continue to threaten & then absorb smaller clinics or practices, as non-clinical negotiations that have little to do with care provision & everything to do with financial exchanges between health systems administrators & insurance company administrators determine which facilities & providers will receive contractual preference.
A list of in-network options for provider and facility “choices” is then provided to the consumer, who is given little to no information about how or why she would elect to receive care in a particular location or from a particular provider, except as dictated by a monetary agreement that had nothing to do with her. In the midst of all of this, the healthcare providers, who are the people who are personally responsible for the provision of the care that is the supposed commodity being sold, lose autonomy to practice, partly because health systems dictate how many patients must be seen in a day, how rapidly those patients must be seen, what can be provided in a single visit, & how the patient might get shuffled about within the system, all of which are decisions aimed to ensure each encounter is as lucrative as absolutely possible for the healthcare system, & none of which are decisions aimed at enhancing clinical outcomes. The clinical outcomes cannot even be understood by the people making the decisions, because they have absolutely NO medical training.
The other major player in the erosion of healthcare provider autonomy is the particular insurance company providing benefits for the patient, which, based on a separate financial negotiation made with pharmaceutical companies & other distinct negotiations made with health systems offering diagnostic testing, will determine which medications & which tests a provider is allowed to order for any particular patient. It is both the health system’s intent to maximize their profit & the insurance company’s intent to maximize their profit. The people who are caught in the middle of all this financial juggling are the patient, who is directly paying for the service of healthcare & the provider who is providing but not being paid for the provision of any specific service.
This is a recipe for disaster. Patients are left feeling lost & confused. Providers are left feeling overwhelmed, morally injured, frustrated & burnt out. Patients disengage from their care because it has lost purpose & value & providers try their damnedest to get as far away from the provision of direct patient care as possible: the administrator roles offer better salaries, a greater degree of respect, & much more manageable lifestyles. As clinicians scramble to try to keep up with the pace & patients scramble to try to be seen as more than a number, health systems & insurance companies profit off of what has now become a largely hollow service that is profoundly removed from any semblance of actual care and any concern for outcomes, well-being, effective treatment, accurate diagnoses, & individual improvements.
This has long been the greater picture of healthcare in America, but the extent to which it has been corporatized has accelerated astronomically over the course of the past 2 decades. Fewer & fewer clinicians are opting to practice in an independent manner & more & more smaller practices are being absorbed into one dysfunctional monolithic system that removes any personal accountability for care. The people who are getting wealthy off of this model are not the medical providers. They are the executives, the administrators, the ostensible leaders of the hospital systems: the same people who didn’t think it mattered that they have a stockpile of masks.
As long as there is not a national crisis, the healthcare systems have been allowed to putter along without having to be accountable for the many ways in which they are failing the American public. Occasionally, someone will call out the insane expense & inquire as to the value of the expensive care being provided. Occasionally, someone will point out that we have outcomes that are the worst among developed nations. But, generally, we just accept it for what it is & go about our business. Individuals may be adversely affected. Some groups may find themselves systematically disenfranchised. Someone’s loved one might be unnecessarily harmed. For the most part, though, we have turned a blind eye & put our trust in the systems that we believe are truly there to serve the public good. Enter COVID-19. Suddenly, the strawman falls apart.
Suddenly, we see that the administrators did not have the public’s interest at heart. If they had, they would have planned for the worst-case health scenarios that could occur in their communities. Even if COVID-19 hadn’t emerged, it’s clear now that they weren’t prepared for ANY degree of outbreak of droplet-transmitted or airborne pathogen, including tuberculosis, which continues to be endemic in many countries worldwide. Suddenly, we see that the systems that employ our healthcare providers are not interested in ensuring they have the most basic equipment required to safely perform their jobs & provide the most fundamental acute care services. We see doctors falling ill because they were not properly protected. We see nurses having to choose between infecting their own vulnerable loved ones or continuing to respond to the public need for their care. We see swaths of staff threatened, fired, retaliated against all in the name of protecting the public appearance & reputation of the systems, which are faltering to provide much-needed care to the very public whose relations may be in jeopardy. We see, suddenly, the importance of clinical acumen, & why it matters that someone who is making major public health decisions have an understanding of global public health happenings as well as the clinical implications for our own public health & an ability to predict & respond appropriately to moving targets. Now, in crisis, we see that the research findings were not being routinely perused, that evidence was not truly driving the care that was being provided, that appearances have mattered infinitely more than any measurable clinical metric.
The news stories that are currently scattered throughout the media about various practitioners, respiratory therapists, housekeepers, nurses & the like receiving retaliatory actions for exposing a failure in the health system that employs them are not new. The gaslighting & threatening of employees that is coming to light in the midst of this colossal crisis are routine occurrences. Individual providers have been punished for years for pointing out flaws & have been treated as though they are disposable, as though their relationship with & understanding of the consumer/patient & their clinical needs is the least important aspect of the healthcare transaction. Now that we see that this grand emperor is naked, now that the failure of these systems to provide care for our communities is abundantly apparent, now that we can publicly observe the lack of dignity & basic care offered health system staff & consumers alike, none of us should feel like laughing. These failures have cost the US in lives: both of patients & of their providers. These failures should make us all profoundly uncomfortable. The question is: will this discomfort be enough for us to demand a change?
Listen to Your Gut(s): What Your Digestive Processes Are Telling You & Why They Matter
Listen to Your Gut(s): What Your Digestive Processes Are Telling You & Why They Matter
March 2, 2020
I have had cause recently to think about intuition and the importance of heeding it, which has led me several times in the past week to ponder the idiomatic expression, “listen to your gut.” For clinical reasons, I have been thinking a lot during this same time about women’s digestive processes, and, as it turns out, the idiom is not just a random expression; rather, it is an old adage that possesses wisdom exceeding anything we understood in the medical world until very recently.
Our intuition, our sense of well-being, our uneasiness are all intrinsically tied to our guts. The mind-gut connection, the link between our emotional states and our digestion, is so deeply entwined that it is fair to say we have a sort of primitive brain in our bowels. In fact, running the length of our entire digestive tract, from the openings of our mouths to the exits of our anuses is a different kind of brain called the enteric nervous system (ENS). The ENS is composed of two thin layers of more than 100 million nerve cells lining your entire gastrointestinal tract. While the ENS differs from the central nervous system (CNS) that controls our conscious thoughts and actions, it communicates directly and readily with our conscious brains.
The ENS may trigger big emotional shifts, such as those experienced by people who are coping with irritable bowel syndrome and functional bowel problems such as constipation, diarrhea, bloating, pain and stomach upset. Up to 40 percent of the population experiences functional bowel problems at some point in their lives, and these affected individuals are likely to be told that their anxiety and depression cause their problems. Recent studies, however, have demonstrated that the causality is the other way around: irritation in the gastrointestinal system sends signals to the CNS that trigger mood changes, resulting in anxiety and depression.
In fact, the gut produces neurotransmitters that are active in the brain and were long thought to arise from activity in the brain. In particular, 95% of the body’s serotonin is actually produced in the gastrointestinal tract. Serotonin is a chemical that controls and stabilizes your mood and functions in your brain. It is also crucial to the functions of your digestive system. Changes in your serotonin level affect your gut as well as your brain, impacting your pooping patterns as much as your mood. Serotonin affects many aspects of your gut function, including: how fast food moves through your system, how much fluid is secreted in your intestines and how sensitive your intestines are to sensations like pain and fullness from eating. Serotonin in the brain is thought to regulate anxiety, happiness, and mood. Low levels of the chemical have been associated with depression, and increased serotonin levels brought on by medication are thought to decrease arousal and increase fatigue.
Serotonin is made from the essential amino acid tryptophan, which we associate with the sleepiness that sets in after eating turkey at Thanksgiving. This amino acid must enter your body through your digestive and is commonly found in foods such as nuts, cheese, and meat. Problems with absorbing or limitations on consumption of any of these foods can cause tryptophan deficiency, which can lead to lower serotonin levels. This can result in mood disorders, such as anxiety or depression, or mood instability that looks like mood swings or erratic responses.
When compared to men, women are six times more likely to experience irritable bowel syndrome, and the fluctuations in progesterone that women experience throughout their reproductive lives affects their digestive processes, which also affects their serotonin production & the availability of serotonin in the CNS to regulate mood. Not only are women more likely than men to experience digestive woes, including chronic nausea, abdominal pain and heartburn, but female anatomy differs importantly from male anatomy in ways that impact digestive function: in a biologically female body, the colon navigates a pelvic structure and the presence of organs that differ from a biologically male body, causing a more convoluted bowel pathway.
The female gastrointestinal tract also produces enzymes that break down ingested substances differently than a male gastrointestinal tract and the transit time for most ingested substances tends to be slower, meaning that what a woman ingests stays in her system longer than what a man ingests, including medications, which may affect women very differently than they affect men, a concept that continues to elude most medical practitioners, who still often treat women as if they are small versions of men. Most studies of medication are not conducted independently among populations of biologic females, which means we don’t always know what the response of a body affected by female digestion and enzymatic processes will be to any given medication, just as women are differently affected by consumption of preservatives, additives, and chemical components of our modern diet. Everything we ingest, therefore, is also potentially affecting our brains’ functions, the other bodily processes mitigated by serotonin (sleep, wound healing, blood clotting, sexual functioning, bone growth), and our moods.
Listen to your guts, ladies. Ingest mindfully. Pay attention to how your body digests what you’re feeding it. Constipation is meaningful. Diarrhea is meaningful. Abdominal pain is meaningful. Chronic nausea is meaningful. AND: your anxiety and depression are at once equally meaningful and inextricably connected.
Let's Get It On: What Love Actually Has to do with Your heart
Let's Get It On: What Love Actually Has to do with Your heart
February 1, 2020
Plastered all over the month of February (and tourist t-shirts in New York City) is the universal symbol of love: the curvaceously recognizable if not anatomically correct, scarlet heart. By February’s mid-point, we are all keenly aware of the symbolic implications of that heart for our love lives. A cartoony cupid, diaper sagging, inflicts the swooning drama of falling in love on his victims with an arrow shot directly into their hearts. We have been inculcated since kindergarten, cutting & pasting construction paper hearts for our friends: this <3 is love. The sorrow of lost love in our culture is a “broken heart.” When we (finally!) disclose our secret crushes & desires, we are “speaking from the heart.” The American Heart Association has jumped on the Hallmark bandwagon & claimed February, in all its lovey-dovey lacey, sparkly heartiness, as American Heart Month, leaving us all to wonder what, if anything, does Love have to do with the heart.
From that first grade-school crush to the rapture of discovering that most recent One, scientific researchers & poets alike have described the experience of seeing or being near the beloved: tachycardia, a heart that skips a beat, is all aflutter or, as comically depicted in Looney Tunes, throbs to the point of pounding right out of our chests. This experience of cardiac excitement at proximity of the object of one’s desire is the result of the thrill of the adrenaline rush one’s body supplies as a result of the hormonal cascade that is triggered by love. Awash in norepinephrine, serotonin, cortisol, dopamine & adrenaline, the cardiac fibers respond to electrical stimulation by kicking it up a notch. The result: titillation, scintillation, bow chicka wow wow.
In someone with a cardiac disorder or someone with compromised cardiac function, this potent potion of neurochemicals could actually induce a heart attack as a result of increased oxygen requirements to support that pounding heart. Academic cardiologists cite situations in which they have prescribed medications to cardiac patients to reduce the impact of the physiologic effect that falling in love has on the heart. So, then, is Love dangerous for the heart?
The answer, as derived from recent studies involving another romantic chemical, the hormone oxytocin, is that love may be precisely what the doctor ordered: the very key to a healthy, happy heart. Oxytocin is a neurohypophyseal hormone found in all mammals that has received mass media play as the “trust hormone.” While oxytocin is directly involved in the establishment and maintenance of social relationships (and its lack has recently been implicated in the presentation of autistic spectrum disorders), the physiologic and psychologic impact that oxytocin has on us goes far beyond trust. To get to the heart of it, we must first examine the roles thus far discovered for this crucial molecule.
Oxytocin in the medical world was previously limited to study & evaluation of childbearing women, whose uteri respond to stimulation by oxytocin by contracting. Oxytocin levels are increased in women during spontaneous labor as well as immediately following delivery, and these naturally increased levels have long been demonstrated to increase maternal bonding behavior as well as to promote milk production & successful breastfeeding. Oxytocin is so effective at facilitating labor that a synthetic formulation is now routinely utilized for labor induction and augmentation and administered postpartum for prevention and treatment of maternal hemorrhages.
But oxytocin comes into play long before the emerging baby was ever conceived. Oxytocin plays a critical role in the sexual attraction and sexual encounter that led to the conception of the baby that is later born with the help of its mother’s or Big Pharma’s oxytotic juices. The release of oxytocin occurs during human contact and increases measurably when gazing into another human’s (or, actually, animal’s--herein lies the role of the therapy dog, or cat, or hamster) eyes. This increase in oxytocin under the right circumstances can lead to sexual arousal in both women & men, and the continuous stream of oxytocin-induced arousal helps men to maintain and sustain their erections. The ongoing rush of oxytocin during sexual arousal plays a primary role in both male and female orgasmic experiences, the contractions of which are postulated to facilitate fertilization.
Not surprisingly, the delightful hormone that floods our brains and pervades our tissues during sexual stimulation also has the yummy effect of relieving stress, decreasing anxiety levels inducing a sense of calm contentment and obliterating fear. This hormone has been implicated in pair-bonding, social connectedness, and inhibition of the amygdala (the brain region associated with risk aversion and the flight-or-fight response). Recent studies demonstrate that a gene mutation that blocks oxytocin receptors is associated with autistic spectrum disorders as well as aggressive and anti-social behavior. In people without such a genetic mutation, normal oxytocin reception results in increased empathy and generosity--that is, big-heartedness.
While all of these lovely effects of the love-inducing, monogamy-encouraging hormone may have a secondary effect on the heart (from decreased stress and anxiety, lower blood pressure and reduced systemic cortisol levels), studies reveal a direct, demonstrable effect of oxytocin on the heart, such that higher levels of circulating oxytocin result in direct repair of cardiac tissue when damaged. When added to experimental equations, oxytocin directly enhances the success of tissue grafting within the heart, suggesting regenerative chemical properties when applied to cardiac tissue (just as a rebound relationship might mend a broken heart). Moreover, oxytocin, in addition to being released from the pituitary gland, is actually secreted directly from the heart, where it has a positive impact on blood pressure, inflammation and the destructive effects of free radicals, reducing the overall risk of heart disease. That oxytocin release prompted by your sweetie’s embrace is as good as your morning bowl of Wheaties in terms of cardioprotection.
So, go ahead, get it on. Skip your morning jog, bask in the oxytocin-colored glow of your dear one’s love, and rest easy knowing you’ve still done something good for your heart.
At Your Cervix
At Your Cervix
January 1, 2020
The dawn of 2020 brings with it the year’s first mention of the elusive and poorly understood cervix, which is not quite an organ, but which has nevertheless come to represent women’s health almost as much as its sister not-really-an-organ breast. Not to be outdone by the pink ribbon awareness campaign, cervical celebrants have crafted a ribbon in a fashionable teal and white motif and have adopted the slogans “fight like a girl” and “choose hope.” Despite these efforts and the fact that nearly half of Alaska’s population had (or once had) a cervix, local awareness of the existence of this anatomical tunnel and its role in women’s health as well as understanding of screening tests and results remains poor. This is partly the result of the breast cancer campaign’s old friend, Taboo: the cervix is, after all, the endpoint of the vagina (gasp!), and it is responsible for such gruesome things as, shudder, menstruation, and is associated with such grotesque words as, ew, mucus. In an effort to shed some light on this otherwise enshrouded topic, let us begin with the original spelunking endeavor: the all-famous, much-feared, oddly titled pap smear.
“Pap smear” is a gross term for a very important test, partly because it involves smearing and partly because, well, what is a “pap,” anyway? The original pap smear was conducted by Georgios Papanicolau, the father of cytopathology. Dr. Papanicolau had a really long, hard to pronounce, Greek last name. So, we Americans, impatient & ethnocentric as we are, shortened the name and labeled the test accordingly. Georgios P. determined that collecting a specimen of cells from the outermost surface of the cervix and smearing them onto a slide, then evaluating them beneath a microscope would allow for detection of cellular changes that were indicative of the development of eventual cancer and developed a system for tracking changes to allow for detection of different degrees of precursors to cancer. Read that again. The pap smear screens for changes suggestive of cells that could eventually become cancerous. It is not a diagnostic test for cancer. Which means that having an abnormal pap smear is not the same thing as having cervical cancer. An abnormal pap result also does not mean that you are somehow dirty, or that you have gonorrhea. The same is true of your sister, your cousin, your bff, and your neighbor’s bff’s cousin. Abnormal pap results are not cancer diagnoses, nor are they indications of your promiscuous lifestyle. Phew.
Where are these cells coming from? From deep inside the vagina, which, it turns out, is not a black hole, but more of a cul de sac that terminates in a dead end in the center of which is a 2-4 centimeter firm, protruding nubbin with a rich blood supply, varying sensation, and such an extremely important job that, when this nubbin fails to uphold its duties, it is declared “incompetent.” The cervix is composed of a mixture of cells, and those of utmost importance are surrounding and just inside the endocervical canal, or the gateway to the sterile cavity of the uterus. The cervix is, in other words, a sort of bouncer for entrance to (and exit from) the uterus. Throughout a woman’s reproductive life, the cervix has an inside job introducing that cyclic friend, aunt flo, determining which sperm are suitable suitors for any eligible eggs that happen to be briefly released, and protectively holding in what might result from the courtship of these two tiny cells while protectively keeping out any potential threats, which all involves, you guessed it: mucus.
So, what’s the big deal with paps, anyway? Why do you need a pap? And why is your provider trying to kill you by refusing your pap and telling you that it’s ok for you to go ahead and wait a few more years? Isn’t a pap scary, long & painful? A pap smear is the process of collecting the above-mentioned external cervical cells and those just inside the tiny tunnel towards the uterine cavity. It involves the placement of the fearsome speculum (ask your provider to warm it, please!), and a very quick sampling (no scraping, roto-rooting or cutting involved!) of the cells, which are then sent for evaluation by a pathologist. It may be uncomfortable, but it should not be painful. If something is painful, say something--not to your friends at the mall or over a glass of wine at book club--but to the person wielding that duck-billed speculum.
The pap smear is not, in and of itself, a screening for sexually transmitted infections, just as a screening for sexually transmitted infections is not synonymous with “getting a pap.” A pap smear is not done any time a speculum is placed, but rather is performed at regularly scheduled preventive visits and as indicated by prior pap test results. We used to think this had to happen every single year for every single woman from the moment she first had sex. And then we discovered that this was not actually true and that our screening every single year of every single woman who had ever had any kind of sex was actually causing more harm than it was benefitting these lovely ladies who came reluctantly and religiously to subject themselves to our specula every single year. The screening guidelines have thus evolved to now recommend that an initial pap smear be performed at age 21 (and not before), regardless of sexual activity, and then be performed as recommended by the results of the preceding pap smear(s). This means that, for women with normal pap smears under the age of 30, the screening interval could be extended to 3 years and, for women with normal pap smears who are over the age of 30, even 5 years, with no decrease in cervical cancer prevention rates.
What?! So that means I only have to see my provider every 5 years?! No. Why not?! Women are not cervixes any more than they are breasts. Women are human beings with a whole host of hidden body parts (like a heart!), that also require annual evaluation, sort of like a tune-up for your car. Problem visits to your provider generally get you in the door once something has already happened, but preventive visits are as important, if not more, because they can potentially (like a pap smear) stop the disease (like cervical cancer) from progressing as it’s just begun. But this is possible only if the changes that tell your provider that something is wrong are detected. And for that to happen, you have to see your provider annually, regardless of your relationship with the speculum. Although there are loopholes and insurance carriers invariably find them, federal law does require that all insurers pay for your preventive care visit. This is precisely because those visits are designed to detect problems before they progress, saving us all time, money, heartache, and, with appropriate employment of the pap smear, sometimes a cervix.
Lighten up: Brighten UP!
Lighten up: Brighten UP!
December 1, 2019
Ah, winter in the Pacific Northwest! There is nothing quite so jolly as a day filled with utter grey. Unless, of course, you consider a cold day filled with utter grey and a dozen scattered showers of frigid rain. When I think of Washington winters, I think of hibernation. I just want to stay inside. My beloved outdoor activities are disrupted, and I rush from car to house and car to clinic without pausing long outside. This winter, I am rekindling my love of heated seats and I am reveling in the glory of our FAR infrared sauna that heats me to my very marrow & penetrates my tissue with its warmth as quickly as the cold winter wind seems to whip into my bones when I go outside. At the clinic, we are all in line for our turn in the sauna, and we are also all fighting for time and space in front of our medical and medicinal full-body red and near infrared light unit. If you pass the clinic at night, you will notice the warm, rosy glow emitted from the window of the redlight room. The room pulses with the lifeblood of What Will Get Us Through These Bleak Winter Days. Seasonal Affective Disorder is so common in our region, particularly in women, that it is often referenced cavalierly, almost as though it is a given that any one of us might have it. And Seasonal Affective Disorder, or, very aptly, SAD, is indeed something that affects a large percentage of women in Washington State, but it is often also misunderstood. SAD is not the desire to, for God’s sake, just have a single sunny day. It is not being sick of the grey sky and the rain. It is not longing for the warmth of summer.
Rather, SAD is a form of major depression that sets in most commonly in the fall as the seasons begin to change and the days grow shorter. When it is colder out and when the suns shines for fewer hours in the day, there is significantly less exposure to natural light, in part because we are all thinking of hibernation and spending significantly less time outside. For 10% of us, this will result in a shift in our brain chemistry that causes depression.
Current treatments for SAD are similar to treatments for other forms of clinical depression, including psychotherapy and antidepressant medications. Some people with SAD try lamps that shine bright artificial light, which is intended to mimic the sun and decrease darkness in the home and workplace. Emerging clinical research is also showing potential for treating SAD and depression with natural light treatments, like red and near infrared (NIR) light therapy.
“Red light therapy”, otherwise known as photobiomodulation, is used to describe natural light treatments that most often include red and near infrared wavelengths. For mental health treatment, NIR wavelengths may be most effective in treating depression, because they can reach deeper into body tissues than red light. When NIR light from a clinical light therapy device shines on a person’s head, those wavelengths are actually able to go beyond the surface of the skin, reaching the brain and affecting brain cells directly. Natural light is absorbed by cell mitochondria, which boosts cerebral metabolism, improves function, and decreases inflammation, according to cutting-edge depression research. More natural light for your brain cells has also been found to improve the metabolic capacity of your neurons, increase oxygen consumption, and boost cells’ ATP energy production, all of which simply means that it makes your brain work more efficiently and effectively.
Research has shown that, as an adjunct treatment or a stand-alone treatment, photobiomodulation is highly effective for treating (and preventing) all forms of major depression, including SAD. The leading psychiatric researchers at Harvard University and UCLA who are studying the impact of photobiomodulation on depression have concluded that the intervention is a safe and extremely effective treatment modality. A 2018 study demonstrated that two 20-minute sessions of direct exposure to a natural red and NIR light unit weekly over a period of eight weeks was more effective than medication for managing depression, and further demonstrated that the light therapy, unlike the medication, had no adverse effects. The trial showed that patients who were treated more often, with more total natural light treatments, registered better results than people who did fewer treatments, indicating that, at least in this case, there is no such thing as too much of a good thing. Remarkably, even among the most depressed patients considering suicide, all participants had marked improvement in mood and suicidal thoughts resolved entirely. Additional studies of photobiomodulation have found it effective for treating pain and inflammatory conditions, improving anxious symptoms, decreasing negative thoughts and behaviors associated with obsessive compulsive disorder, improving sleep quality, and enhancing athletic and sexual performance.
You might think, then, that the way to get through the gloom of these winter months is to pop a red light bulb into your nearest socket and go about your day. The benefits, however, are unique to specific wavelengths of red light, with cosmetic improvements (yes, it does that, too!) notable at wavelengths of visible red at 660nm and systemic effects, including overall mood improvement, more consistently observed at a wavelength of 850nm, or a NIR wavelength that is not visible to the human eye. The unit we use in the clinic combines those exact wavelengths to optimize the therapeutic effect. It’s not magic, although it feels and look a lot like magic; it’s science. All this to say: I know it’s cold. I know it’s grey. I don’t want to be outside searching for a glimmer of sunlight anymore than you do. I am inside with my redlight unit dreaming of Hawaii and basking in the glow of the unit’s rejuvenating bliss. Now that we are in the full throng of winter, we are seeing more and more women’s moods begin to deteriorate. Stop by. We’ll warm you up with a cup of tea and welcome you to enjoy a book near our fire. And, we’ll leave the light on for you.
The Glorious Art & Medical Value of Giving Thanks
The Glorious Art & Medical Value of Giving Thanks
November 1, 2019
Thank you, thank you, thank you, thank you, thank you! Thank you for reading my words! Thank you for giving me feedback! Thank you for visiting my website! Thank you for following me on Facebook! Thank you for engaging with my posts! Thank you for watching my Live Events and InstaStories! Thank you for referring your friends! Thank you for loving your care and telling me when it doesn’t fulfill your expectations! Thank you for the privilege of partnering with you in your care! Thank you for acknowledging how deeply I care about the quality of your care! Thank you for thinking outside the box and appreciating the value of our independent clinic! Thank you for being you!
It is Thanksgiving month, which means I am thinking a lot about gratitude. I think about gratitude extremely frequently as it is, because I am so deeply grateful for all the things, people, and opportunities I have now and have had in my life. I wake each day in a state of gratitude, reflecting on the things I GET TO DO each day. Before I fall asleep each day, I spend time thinking about the moments of the day that fill me with gratitude. As I take inventory of my goals and my desired achievements for the coming day, week, month, year, I always include in that inventory the good that surrounds me, what I am most grateful for and what I would like to cultivate. When I am consistent and dedicated to my practice of gratitude, I am a happier person. When I am consistent and dedicated to my practice of gratitude, I like my life a lot more. When I am consistent and dedicated to my practice of gratitude, I physically feel better. When it wavers, my physical and emotional health is invariably affected.
Thanksgiving is a holiday that I particularly love because it is not rife with expectation or potential for disappointment. Instead, an entire day of the month, the year, our lives is dedicated to giving thanks for what we have or what is to come. We eat good food. We surround ourselves with the people we love. We feel full from our bellies to our hearts. And then we eat turkey sandwiches for days and we slowly forget about the act of giving thanks until the following year when we again pull out our fall decorations: colored leaves, pumpkin spice and gratitude.
While I am cognizant of the role and benefit of gratitude in my own personal and professional life, I am also aware of the benefits of grateful expressions in all facets of all of our lives. Research consistently supports it. In research studies, gratitude is strongly and consistently associated with greater happiness. Gratitude helps people feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships. Emotional well-being has a direct and linear effect on our physical well-being. Engaging in activities that enhance our emotional state will result in improved healthcare outcomes, including improved responses to treatments (even surgical treatments). Expressions of gratitude are not wholly dependent on the state of our current life, and I am not suggesting that there is any way that anyone, confronted with adversity, can be grateful all the time. We can be grateful for what is happening in the present moment, or, if that’s bad, we can be grateful for things that have happened in the past, or—if that’s also bad—we can have gratitude for things that are possible or likely to happen in the future. Cultivating gratitude will improve your health. Here are a few ways to tap into feelings of gratitude in your own life:
1. Document the good stuff! We all have daily hassles. We all have gripes, aggravations, irritations. We get flat tires. We open the mail to find an unexpected bill. We lose more hair than we wanted to. We encounter a rude cashier at the grocery store. We get stuck in traffic. Bad things are going to happen. When we fastidiously document them, we integrate them more into our general emotional state. When we share the transgressions we experience and the hardships we encounter on social media, we saturate ourselves in negativity, and we saturate our friend networks with the same. Research has demonstrated that the simple act of WRITING DOWN the good stuff that happens to us improves our general outlook on life and our optimism about what is to come. Make a regular practice of documenting the good things that happen rather than the bad. If you are updating your status or your feed, dedicate yourself to making note of something positive that has happened in your life, from having a hot cup of coffee in the morning to winning a million dollars in the lottery. The relative size of the good thing isn’t what matters. It’s the active acknowledgment that counts.
2. Reflect on the past! Think of someone in your life who has been kind to you (again, it doesn’t matter HOW kind—they can have assisted you with your groceries or paid for your college—the effect is the same) who you feel has never been properly thanked. Write a letter of gratitude to that person and deliver it by hand. The improvements that researchers have seen in measurements of general happiness for participants in this activity are tremendous and boost general outlook in a way that is objectively measurable for a full month following participation. Make a habit of sending just one gratitude letter a month. Occasionally, send that letter to yourself!
3. Think about a relationship that challenges you. And then think about the things you like and appreciate about the person with whom you share that relationship. And THEN tell that person what you appreciate about them. Expressing your gratitude for and about another person improves your perspective of that person and enhances the relationship in ways that make it easier to address problems as they arise.
4. Set aside time to intentionally meditate on gratitude. We are all too busy. We are all too rushed. We flit from one activity or demand to another activity or demand with little time to pause between. We juggle jobs, children, pets, households, errands, friendships, relationships, other commitments. We wake up and get going. We fall asleep with our phones in our hands, catching up on email or updating our monthly Subscribe and Save. Set aside 5 minutes each day to spend time intentionally meditating on gratitude. Repeat the word “gratitude” or “grateful” or “thanks” or “blessing” to yourself and allow yourself to feel the feeling of something great happening.
5. Remember that you are going to die! This seems both morbid and like it would be unlikely to cultivate gratitude. This seems like it’s more depressing than anything. BUT! Regularly remembering that we do not have an infinite number of days left to live can help us look to the future in ways that maximize our positive experiences. If we stay acutely aware of our mortality, research demonstrates that we are more likely to engage actively in the days of life that we have and find ways to both appreciate and enhance our experiences.
If you have another method of consistently cultivating and promoting gratitude in your own life, I would love to hear about it. I would love to read about it on your social media feeds. I would love for you to come share it with my staff in clinic. I would love to share it with everyone else who may benefit from implementing your personal practice. I am grateful for you and all the ways you add to my life!
What Do I Do with These Boobs?
Sifting through the confusion around breast screening, from touching your tatas to mashing your melons
What Do I Do with These Boobs?
Sifting through the confusion around breast screening, from touching your tatas to mashing your melons
October 1, 2019
Any woman who has been to the doctor lately for her wellness exam has probably left with some degree of confusion about what it is that she is supposed to do with her breasts. Screening guidelines have changed dramatically over the course of the last 20 years, so much so that even healthcare providers are struggling to keep the recommendations straight. From one visit to the next, you might be told to perform a religious monthly self-breast exam or to not examine your breasts at all. You might be told you need yearly mammograms or you might be told that a clinical breast exam is not even warranted, despite your age or your expressed concerns. There was a time during which we all hung placards in our showers to remind us how to examine our breasts. Now, we have six different organizations making recommendations about our breast health and screening, and not one of them can agree on the best approach. In the end, the recommendations all seem to come together with only one unanimous, mostly unhelpful message: know thy breasts and decide for yourself. When even the experts seem confused, it’s no wonder myths and misconceptions around breast cancer and breast health abound. Here are 10 simple, straightforward tips to manage and understand your own breast health.
1. Lies about your lingerie: Underwire bras do not cause breast cancer. Period. Scientific studies have examined risks associated with bras. None have found any increased risk associated with wearing any kind of bra. Go ahead and support those puppies however you prefer! Push them up or let them hang. Your decision to wear or not wear a bra, however it is constructed, will not impact your likelihood of developing breast cancer of any kind.
2. Buddy up with your boobs: Breast self-awareness is absolutely key to early detection of both pre-cancerous and cancerous changes. While experts now recommend against rigorous, prescriptive self-breast exams (mostly because they seemed to be increasing anxiety without a corresponding or proportionate increase in the detection of disease), it is extremely important that you know what is normal for you. No two boobs and no two sets of boobs are the same. Your right breast might have more lumps than your left. Your left breast may have a nipple that sticks out further than the right. The most important thing is that your breasts feel and look fairly consistent FOR YOU over time. There will be fluctuations in the nature of your breast tissue throughout the month, as your hormonal levels naturally ebb and flow, causing the tissue to expand and contract, but there should not be new lumps, painful spots, or changes in your skin texture or appearance over the course of that month. If you become extremely familiar with what your own breasts feel and look like, over time and throughout each month, and you know which changes are normal for you as a result of differing hormonal levels, you will be able to tell when a change is not normal for you. The more you feel and look at your own boobs, the more you will understand them, and the more likely you are to notice when something concerning occurs. When you notice a change or have a concern, you should always tell your provider, who should ALWAYS do an exam in response to your concern.
3. Your lovely (lumpy) lady lumps: The problem with breast self-examination that arose was that women were examining their breasts and finding all kinds of lumps and bumps and nodules and “stuff”. Breasts are actually extremely lumpy things. If you perform a breast self-exam, chances are you’ll find a lump. And, if you find a lump, chances are you’ll worry it’s cancer. And, if you worry it’s cancer, chances are you’ll google your findings. And, if you google your findings, chances are the interweb will tell you that you definitely have cancer. And, if you do all this before you schedule your appointment with your provider, chances are you’ll be pretty worked up and nervous by the time you are actually seen by your provider. The reality is, though, that any concerning lump (that is, any lump that concerns you) a woman finds is not to be dismissed as “hysteria” or “anxiety.” If you find something that concerns you, you should be evaluated. Period. The end. The other reality, however, is that most of the things that you find (and you will find things) will NOT be cancer. Most breast lumps are benign (non-cancerous), but there are many changes that, while benign, DO increase your risk for developing breast cancer and do require increased monitoring to ensure stability. SO: if you follow #2 well & you know your boobs as well as you possibly can, you will know when something changes and you will be able to tell the difference between a lump that has always been there and a lump that is new or different.
4. Armpits are as important as tits: Your armpits and ribcages and shoulders and chest wall are actually parts of your boobs. They don’t sell cars very well, but they are part of the same organ, which means that getting to know your boobs also means getting to know these parts and pieces of your body as well. Lumps in armpits, down the sides of your ribcage, in your shoulders, or around your collar bones are NOT normal things and should always prompt you to call your provider for evaluation. As a side note, anti-perspirant itself does not cause breast cancer. Some myths exist that suggest that limiting your armpit sweat causes toxic build-up in the adjacent breast which can cause cancer. Your armpit sweat does not drain toxins from your breasts, and preventing your armpits from sweating will not increase the amount of toxins in your breast tissue. It will prevent you from smelling bad. There are, however, some concerns about some chemicals that are in some anti-perspirant (and many other personal care products) that may increase your risk for developing not just breast cancer but all kinds of cancer.
5. Toxins for the twins: We live in a world in which we now have all sorts of lovely and readily available products to help us live our lives beautifully, cleanly, and conveniently. From the plastic lining in the tin can that makes it easier for you to get the food out of it to the sunscreen you apply to PREVENT cancer, many products that women are exposed to on a regular, daily basis contain chemicals that are considered “endocrine-disruptors.” Endocrine disruptors are substances that mimic or block the activity of naturally occurring hormones in the body, which can jack up your own hormonal balance. Because hormonal disruption can make hormone-receptor-positive breast cancer grow and develop, it is prudent to try to limit exposure as much as possible to these problematic compounds, which are found in cosmetics, personal care products, pesticides, drinking water, lawn and garden chemicals, plastics of all variety, and some foods. This is enough to make anyone panicky or create complacency, since exposure seems practically unavoidable. Some of our exposure truly is out of our control, but much of our exposure can be modified by the choices that we regularly make. The Environmental Working Group is an American collective that creates databases of safe and concerning chemicals and products. They have a great website (ewg.org) that ranks brands from most concerning to least concerning to help you make decisions about limiting exposures. Alcohol is also a toxin. Sorry, ladies, but your evening nightcap also increases your risk of getting breast cancer. Compared to women who don’t drink at all, women who drink 3 alcoholic beverages a week have a 15% increase in their chance of getting breast cancer. For each additional drink per day, the risk increases another 10%. That said, you needn’t always forego wine or shun the occasional glass of champagne. Just know that moderation is crucial to limiting your overall risk. Other toxic exposures that are especially bad for the boobs include radiation and chemicals you may have been exposed to when you were a fetus. These are things that we can’t always modify, BUT, if you do have a known history of exposure, it is important to communicate it to your provider, who should individually tailor your screening plan.
6. Cigarettes actually are the devil: Just don’t smoke. If you do smoke, talk to your provider about getting help quitting. Vaping is NOT safer than smoking. Cigarettes are actually poison sticks. And e-cig/vaping juice is actually liquid poison. We know a lot about what cigarettes do to the bellows in our chests. We know cigarettes cause a whole host of lung-related diseases, including cancer. And we are learning more and more about the harms associated with vaping, including lung conditions that are potentially MORE problematic. We think very little about the impact of these activities on the crown jewels of our chests. We know, though, that smoking cigarettes is linked to a higher risk of breast cancer in younger, premenopausal women. Research also has shown that there may be link between second-hand smoke exposure and breast cancer risk in postmenopausal women. Moreover, if you do get breast cancer, smoking makes it harder to treat and harder for a woman’s body to heal. Just say no.
7. Jump Rope for Jugs: I am going to preach it until you can’t stand to hear it anymore. Exercise decreases a woman’s chance of dying from ALL CAUSES, including breast cancer. BUT, regular exercise also decreases the likelihood that a woman will develop breast cancer in the first place. Not only does exercise help prevent other conditions that would make treating and beating breast cancer harder, but exercise consumes and controls blood sugar and limits blood levels of insulin growth factor, which is a hormone that can affect how breast cells grow and behave. Additionally, women who regularly exercise tend to have lower body weights and less excess fat than women who don’t exercise. Fat cells create estrogen in the body and extra fat makes extra estrogen, which increases the risk of various female-specific cancers, including uterine, ovarian and breast cancers. Weight loss itself is a complicated creature, and many women need assistance with weight loss because their weight gain is the result of a medical condition, but, regardless of one’s ability to actually LOSE measurable pounds, time on the treadmill, laps in the pool, or a regular biceps curl will not only benefit your heart and potentially your waistline but will also protect your breasts.
8. The horror of hormones: Just being a woman increases your risk for breast cancer. Read that again. Women are 99% more likely than men to get breast cancer. Being biologically female causes breast cancer. The reason this is true is entirely because of hormonal differences in women and men, and they are the hormonal differences that make women need bras while (most) men don’t. Women’s breast cells are highly active and immature until they have their first full-term pregnancy. While they are immature, breast cells are extremely responsive to estrogen and other hormones as well as to all potential endocrine disruptors to which they are exposed. The earlier a girl begins to experience breast development, the longer her breast cells are susceptible to the effects of these hormones and hormonal disruptors. The later a woman stops having periods, the longer her breast cells are susceptible to the effects of her own hormones as well as hormonal disruptors. Taking combined hormone replacement therapy after or during menopause increases breast cancer risk significantly, but it seems not to be the estrogen (surprisingly) that is responsible for this increase. Rather, the progesterone component of the hormonal preparations seems to be the factor that increases risk significantly. For many women, combined hormonal replacement therapy is still safer than estrogen-therapy alone, but the exposure does increase overall risk of developing breast cancer, simply because of the effect those hormones have on the breast cells. Hormonal preparations of all kinds should be discussed from a risk/benefit perspective with your provider.
9. Mama’s milk factory: When a woman becomes pregnant, her breasts start to change dramatically. When breast cells are made during puberty, those cells remain immature and incredibly active until a woman’s first full-term pregnancy. The immature cells are extremely susceptible to the effects of the hormones in her body as well as to exposure to hormone-disrupting chemicals in products or the environment. Full-term pregnancy makes breast cells fully mature & renders them less vulnerable to the effects of hormones. Pregnancy, therefore, protects women against developing breast cancer. Being pregnant also reduces the exposure to overall menstrual hormonal fluctuations, which is also protective against breast cancer. Once a baby is born, breastfeeding dramatically decreases a woman’s breast cancer risk. This is because the hormonal environment required to produce breast milk is very different from the hormonal environment that exists when a woman isn’t making breast milk. Producing breast milk has a protective effect on the breast cells, causing them to be less susceptible to hormonal disruption, and breastfeeding a baby also causes women to avoid many of the toxins mentioned above, which provides additional protection against the development of cancer.
10. Lighten up: As a society, we spend more time inside, out of direct sunlight and we wear more sunscreen to prevent skin cancer. As a result, we have lower population levels of Vitamin D. Vitamin D we think of as a vitamin, but it is actually a hormone in our bodies. Research suggests that women with lower levels of vitamin D have a higher risk of breast cancer. Vitamin D may play a role in controlling normal breast cell growth and may be able to stop breast cancer cells from growing. The two most reliable ways to boost your levels of vitamin D are to get more exposure to direct sunlight and to take Vitamin D3 supplements. I am not suggesting you go tanning or expose yourself to sunlight for prolonged periods of time. Even short periods of direct peak sun exposure -- 15 minutes 3 times a week, for example -- can give you more than the recommended daily amount of vitamin D. It's also impossible to overdose on vitamin D from the sun. The flip side of light exposure for breast cancer risk is that women who are exposed to light during the night (for instance, women who work night shift, or women who sleep with the television on or have another source of artificial light invading their sleeping space at night) are more likely to develop breast cancer than women who sleep during the night and do so in a dark space. Researchers think that this increase in risk is linked to melatonin levels. Melatonin is a hormone that plays a role in regulating the body's sleep cycle. Melatonin production peaks at night and is lower during the day when your eyes register light exposure. When women work at night or if they're exposed to external light at night, their melatonin levels tend to stay low. There is not enough research that has been conducted yet on the use of melatonin supplements to suggest that this would mitigate the risk. Stay tuned, but in the meantime try to get a little natural sunshine exposure during the day and try to limit your exposure to light at night.
The issue of screening is complicated. As with any condition I treat, I like to have the existing evidence and use it as a guide, but I do not like to be beholden to recommendations that may or may not be applicable to any individual woman or any individual circumstance. I do strongly believe that well-trained clinicians who have had specific training in breast health and care (not the training that is offered in standard, general medical school and not the cursory training on breast health that is applicable to most practitioners providing women’s primary care) perform useful and indispensable examinations of the breasts, and I do strongly believe that these examinations are not a waste of time, as is suggested by some organizations’ screening guidelines. Because I am confident in my ability to detect abnormalities and discern a concerning lump from something that might be a normal physiologic variant, and because I have found breast cancer in women’s breasts, I will never stop performing clinical breast exams at least annually on my patients. Nor will I ever dismiss a concern that a woman brings to me about changes she has noticed in her own breasts. The issue of imaging is more complex and requires a discussion about individual risk profiles and modes of detection. Just as no two breasts are the same, no two women’s screening approach should look the same. Women with dense breast tissue need different screening approaches. How would you know if you have dense breast tissue? You wouldn’t. This is a relative term. A provider who is an expert in examining breasts would be able to determine the density of your breasts as compared to the average breast and direct you from there. The long and the short of screening is this: knowing your own breasts and regularly assessing them is crucial, seeing a skilled provider and having a regular assessment with her is key to detection and determining the best direction for further assessment and management, and crafting an imaging protocol that is specific to you and your personal risks is paramount.
The Skin She's In
The Skin She's In
September 1, 2019
The school buses are back on the road, prolonging our daily commutes in ways we hadn’t had to worry about for the past three months. The berries are picked and the apples are ripening. The leaves are beginning to turn. The air in the evening is crisp now; it is not yet fall, but the prelude is here. Summer is definitely turning in for the year, and the sun’s brightest rays occupy fewer hours of our days. We are at that turning point, still, that allows me to trace tan lines that, despite my meticulous sunscreen use, highlight more exposure than I thought was happening. Like the last few days that are still warm enough for shorts, my extra pigment lingers. It will mostly fade with time, and my hope is that what doesn’t fade remains as a benign (if bothersome) change to my most exposed organ.
When most women think about women’s healthcare, they think about their pap smears. They think about their “yearly” visit, or their annual exams, which they equate only with breast and pelvic exams. We women are aware of and attuned to our risks for breast and cervical cancer. We know we should be screened because we know bad things can happen. When we schedule our exams, we are thinking about these gender-specific parts of our bodies, not about our other organs or how their chromosomal makeup might affect them. An annual exam should involve the gamut of organ systems, including a full skin (yes, it’s an organ, and a very big and important one!) exam for all women.
Rates of skin cancer diagnoses have skyrocketed for women under the age of 50, and women are being diagnosed with melanoma, the most concerning form of skin cancer, in unprecedented numbers. Until age 50, American women have a higher likelihood of developing skin cancer than any other form of cancer, and a higher likelihood of developing melanoma specifically than any cancers other than breast and thyroid cancer. Experts attribute this increase in melanoma incidence among young women to suntanning and artificial tanning, UVA and UVB ray exposure. I am not a sun worshipper. I am keenly aware of the damage these rays can do. As I continue adding years over the age of 30 to my life, I am acutely aware of my diminishing collagen production and the toll the sun takes on my overall appearance, including the dewy, youthful skin I’d like to retain. Despite all this, even with my meticulous application of sunscreen and my general avoidance of prolonged time in the sun, I am at risk. My tan lines prove it. The hardest part of protecting my lovely skin is that I am completely covered in it. From my head to my toes, I am wearing skin. It is virtually impossible, then, for me to completely protect my skin without wearing a second, identical (and likely stifling) suit atop it.
Protecting and caring for my birthday suit is crucial, because it is actually a secret superhero suit. My skin serves as my armor: it keeps the outside out and my insides in. We think of the skin as a lesser organ, and certainly more superficial and less crucial, than, say, our hearts or our brains, which we consider essential to continue living. Without our skin, however, we would have no environmental protection and would be susceptible to a host of microbes that would thrive by feeding on our exposed musculature and blood supply, but we would also dehydrate and die. My skin, therefore, is integral to my life. It is as important as my heart and my brain. Not only that, but my skin houses my thermostat. It contains the nerves and sweat glands that regulate my heat and allow me to cool my body to prevent heatstroke, which can also result in dehydration and death. My skin is a rich network of nerves, blood vessels, muscles and fat that can even feed me if I’m in a state that requires I tap into that reserve. My skin is not just the frosting on the cake of my body, but it is, in fact, a truly vital organ.
As a woman, my DNA makes my armor more penetrable than that of a man. I am not thinner skinned in the sense that I am more sensitive or less capable, but I am thinner skinned in the sense that my skin is literally less thick than my brother’s. Male hormones increase the thickness of one’s skin, making a man’s skin about 25% thicker than a woman’s, and male skin thins much more gradually with age as a result of their hormone production, whereas my skin thickness will remain constant only up until I enter menopause, after which time my skin’s fragility (and, therefore, my overall susceptibility to damage) will sky rocket. This thickness isn’t the only difference. Men actually have a considerably higher innate collagen density than women do. They have more collagen available to combat their aging processes. And, while they lose collagen at the same rate from age 30 onward (about 1% loss of collagen per year), they lose it at a consistent and unfluctuating rate, whereas women’s collagen loss accelerates markedly in the perimenopausal and immediate postmenopausal period, meaning we end up with more lines and wrinkles and more skin laxity much more rapidly than our same-aged male peers, despite women generally being more attentive to and taking better care of the skin they’ve been given. We are drawn to harsh chemicals and Botox because of this: it promises to halt and reverse our accelerating aging process.
It’s not all a bed of roses for male skin, however; because a man’s skin is thicker, it is rougher than a woman’s skin. The stratum corneum, which is the topmost protective barrier of the skin, has a rougher texture and is more prominent in men. The hormones produced by testicles, while serving to plump and hydrate men’s skin, also promote the development of acne and cause men to sweat more and smell worse. And, it is not a lost cause for women. Our skin is not only our most malleable, pliable, complex and diverse organ, but it is also incredibly forgiving. Having the most rapid cellular turnover of any part of our bodies allows it to regenerate and renew, compensating on a regular basis for any inflicted damage. With regular, thorough evaluation and a proper care regimen to prevent damage and restore integrity when it’s been compromised, we can actively protect our protective suits, preventing ongoing and progressive damage that leads to both a more aged appearance and the development of female skin cancer. And, we can actively repair and remodel the skin we’re in, enhancing its function and appearance, which optimizes not only the confidence with which we approach life but also the quality of the lives we live.
So, You've Decided to Breastfeed...
So, You've Decided to Breastfeed...
August 2, 2019
From the moment you pee on that stick for confirmation (or often even well before), your breasts loudly announce your pregnancy. First, they’re tender. Then, they’re bigger AND tender. Then, they’re changing color and getting strange bumps they didn’t have before. Then, as you near the finish line, they start to ooze or leak. There is no escaping the fact that the pregnancy hormones are preparing your body not just to create and birth another person but also to biologically feed that little person. If all of this is a normal, natural process, why is it so DIFFICULT for some of us to breastfeed? Our bodies make milk without our consent, just as our babies grow without our consciously consenting to the development of tiny kidneys. If we are programmed to do this, shouldn’t it be as easy to grow and nourish our babies OUTSIDE our bodies as it is when they are IN?
Even aside from the woes of the first few days (ok, maybe weeks) of sore nipples, engorgement and an occasional plugged duct, mothers preparing to feed their newborns have more persistent, pervasive and insidious battles when we make the choice to use our breasts for their primary biological purpose. If it were simply pain, we would gladly endure. Having already suffered through months of aching backs, episodes of vomiting, swollen feet, exhaustion and the occasional unexpected leakage of urine—surely no one can argue that we mothers aren’t willing to endure discomfort for the well-being of our offspring. Our midwives, obstetricians, pediatricians, mothering websites, what-to-expect pages and Bump apps all tell us that breast milk is the best food for our babies. We know breast is best. And yet so many of us give up, sometimes without much fight.
FIRST, THERE’S THE ADVERTISING.
Thank you, Enfamil, for reminding us we might not be able to breastfeed our babies. Thank you, Similac, for sending us a can of something we can’t bear to waste. We will put that on our pantry shelf just in case. Thank you, parenting magazines and pregnancy-related websites for accepting the generous funds offered by formula companies to promote their products in your banners and sidebars so that these products remain eternally in our periphery, reminding us they are there to save us, if breastfeeding doesn’t quite work out. Don’t get me wrong – formula can be, quite literally, lifesaving when required. But if you’ve decided to breastfeed, throw out the free sample. Or donate it, if you can’t stand to waste it. If it is on your shelf, you will use it, and sometimes before you have to. Committing to breastfeeding means being prepared to provide breast milk for your baby exclusively (unless medically indicated) for the first six weeks. If, during those six weeks, your doctor tells you to give your baby formula, go and get some. But, anticipating problems by hanging onto free formula is like filling your pantry with Girl Scout cookies in anticipation of failing at your strict Paleo Diet.
THEN THERE’S THE ‘HELPFUL’ FEEDBACK.
Cue the lifelong unsolicited parenting advice that starts with the announcement of your pregnancy and ends, well, never. Well-meaning relatives may have a negative response to breastfeeding: “women didn’t do that when I had your mother, and she seems just fine.” And friends have their own input, loaded with emotion and righteousness from their experiences: “I wanted to breastfeed, but my milk didn’t come in,” “My son was allergic to my milk,” “I was starving my daughter to death and didn’t notice,” “Thank god someone gave my baby formula—I didn’t know what I was doing.”
If you choose to breastfeed your baby, make it clear from the start, and set firm boundaries with friends, relatives and co-workers regarding the input you welcome and find helpful. Choosing how to feed your baby is one of the first major parenting decisions you will make, and it will not be the last. Nor will it be the last decision that receives cheers or jeers from the peanut gallery. Establishing clear boundaries around your choice is important and can be as simple as stating, “I have chosen to breastfeed my baby, and I would find it helpful if you would support my choice.” You can choose to offer an articulate argument on why you want to feed your baby, or you can simply stand firm in your choice. In any event, establishing clear boundaries with your well-meaning loved ones sets the stage for unsolicited and often unhelpful advice you will receive when the time comes to choose a method for potty-training, to select a preschool or to allow your child to date. Make your decision about how you will feed your baby about what is best for you and your baby, not about what makes others feel inadequate or uncomfortable.
AND THE BEDROOM…
Before there was baby, there was the business that brought you your baby. Now that there’s baby, someone else is occupying the space in your arms, and the breasts that may once have been a focus of your sexual relationship are now what’s for dinner. Before there was baby, your breasts were erotic and only occasionally tender. Now that there’s baby, your breasts are swollen, sore, cracking, leaking, and constantly at the whim of another person. You’ve traded in your red lace demi for a less sexy, very supportive thick-strapped nursing bra with its absurd latches and flaps. Partners can often feel neglected simply as a result of the distraction caused by the arrival of a new baby. As you return to physical intimacy, it is important to be open about the new role assumed by your breasts and the impact this has on your sex life. After having your breasts handled all day by your nursing newborn, you might feel less aroused (maybe even irritated) at having them handled while the baby is sleeping and your partner is initiating sex. It is important to communicate this to your partner and to both be able to keep a sense of humor about the milk that might leak from your nipples when you orgasm or the nursing pads you had to tuck inside your sexy bra.
AND THE DAILY PUMPING JUGGLE.
Breastfeeding for the recommended year requires that many moms figure out how to continue making milk after they have returned to work and left their babies in someone else’s care, generally to eat from bottles (sometimes of supplemental formula and sometimes of pumped breast milk) while we are apart. In our society, paid maternity leave is limited and laws protecting a mother’s right to the time and space to pump are only now emerging. Breast pumps are strange things that are very expensive. But your insurance will pay for one—ask your provider for a prescription. The Affordable Care Act mandated insurance coverage of this medical device to balance families’ needs to have moms return to work and babies’ needs for continued breast milk. In the state of Washington, employers are required by law to provide employees with accommodations that are not bathroom stalls and the time (30 minutes for every four-hour period worked) to pump sufficiently to maintain their milk supplies after returning to work. Make sure you let your employer know in writing of your intent to express milk when you return from maternity leave in order to have this need accommodated—and make sure you are able to prioritize pumping as you would a scheduled meeting. Ask that your pump break be integrated into your Outlook calendar and that a sign be created for the designated pumping area that alerts your co-workers of your need for privacy to avoid the awkward situation of your manager walking in on you pumping during lunch. Finally, make sure you practice pumping before you return to work so that you are familiar with all the pieces and their connections and can assemble, dissemble, clean and store the pump parts without difficulty. This will make it easier for you to juggle eating and pumping during the same time period and allow you to feel less pressured and stressed during your pumping episodes.
AND, SOMETIMES, MAMAS NEED SOME HELP.
Most of us live in nuclear households isolated from other women who have had successful breastfeeding experiences who might be able to offer advice and tips on how to improve the breastfeeding experience or normalize our concerns. In addition to all of the pressures that exist outside of biology, we are often set adrift when we are discharged from the hospital and find ourselves, days into sleeplessness and leaking boobs and a baby who won’t stop screaming long enough to latch on, exasperatedly scouring Dr. Google for answers or digging for the number of the lactation consultant who popped by just as soon as we had stepped into the first post-delivery hot shower. Even our pediatricians and obstetricians have limited breastfeeding education and the resources available to provide us with assistance in our moments of milky crisis are limited. All of this while the formula can sings to us from the pantry shelf and bottles beg to be filled and handed to our partners so we can run to the store for a moment of silence alone in the bread aisle.
Remember that help IS available. Make sure you seek that help before it is too late. Set up a lactation evaluation for three days after your baby’s delivery. You can always cancel the appointment, but you’ll have it if you need it. Visit La Leche League for helpful tips and answers to your questions. Add their local chapter numbers to your contacts and send an email to a leader asking them what availability they have to provide support. Establish your network of helpful lactation resources long before your baby is delivered. Attend a lactation class before you are struggling with a real baby with real-time demands so that you familiarize yourself with the process and have the opportunity to meet educators, clinicians and other moms who can help you along the way. If you need a breather from the constant demand from your breastfeeding baby, your partner can certainly provide a bottle while you take a break. Just remember to not skip feedings: that is, make sure you pump if the baby doesn’t nurse to maintain the delicate supply-and-demand system your body uses to know how much milk to generate.
For those moms who have had successful breastfeeding experiences: congratulations! Please, make a point of sharing your SUCCESS with your friends. Please, dissipate the negativity about breastfeeding that bombards so many women during pregnancy. For those moms who have struggled: be gentle with yourselves. What an incredibly exhausting, isolating battle it can be to fight all the social barriers to breastfeeding we face. For those moms who want to breastfeed: ask for help! Recognize early the people who may not provide support and seek out those who will. Involve your partner.
As you navigate the potential struggles that come with the decision to commit to breastfeeding your baby, remember that the ultimate goal is twofold: 1) to form the foundation for a fulfilling lifelong connection with your child, and 2) to nourish this tiny person. What this looks like for you will not necessarily match what this looks like for anyone else—your relationship to your child and all facets of your parenting experience are distinctly unique. Be gentle with yourself, and with your child, as this experience unfolds.
Research clearly demonstrates that breastfeeding IS best. We want to help you be successful – ask your provider for referrals and helpful resources. It is our job as medical providers to help you and your baby navigate the complicated path of obstacles to a satisfying nursing experience.
The Importance of Being Female: Why Gender-Specific Primary Care Matters
The Importance of Being Female: Why Gender-Specific Primary Care Matters
July 15, 2019
Recently, Megan Rapinoe, the record-breaking American professional soccer player whose adept ball-handling skills assisted the US Women’s National Team to their fourth World Cup victory, drew public attention to the gender-based pay discrepancy that exists in the world of professional soccer, which is applicable to most of us only in the sense that we may be female and we may experience a similar discrepancy, although likely not in relation to our fancy footwork. Nationally, across the board, a woman is statistically paid 79 cents for every dollar that a man is paid for doing the exact same job. This is regardless of job type, socio-economic bracket, or worker seniority. Women are also significantly less likely to hold high-level or high-paying jobs than men, and they are less likely to receive promotions to such positions relative to their male counterparts. Until 1988, women could not apply for any commercial business lending without having a male co-signer to vouch for her ability and competence to conduct business. We know a gender-related pay gap exists; we know a gender-related opportunity gap also persists. We know you know this. And we know all y’all know that there is gender inequality for sure in the performance of household chores as well as the management of work-family conflict (we can cite the highly powered scholarly studies that support this, when your oppositely gendered partners rebut). But, did you know that these discrepancies are also pervasive when women receive their medical care?
If you, as a woman, were walking down the street and suddenly collapsed, having a cardiac arrest, you would be 15% less likely than a man to receive CPR from any bystander, which means 15 women out of 100 needing CPR would be allowed to simply die, while all 100 men would at least benefit from an attempt to save their lives. If you were lucky enough to receive this CPR, you would be 25% less likely to survive from the CPR than if you had been male. The research speculation regarding this finding is that this is because women have breasts and rescuers feel odd about performing effective compressions on a female chest as opposed to a male chest.
Innocent bystanders and the general public’s bias and concern about touching your breasts aside, even the providers who have been trained to provide women’s clinical care (including touching their breasts) are less likely to respond appropriately to women. Women are significantly less likely to have been counseled on recognition of the symptoms of a heart attack because they are different from the widely publicized symptoms, which pertain only to men (who were the sole subjects of most clinical trials until well into the 1990s and remain the sole subjects of many clinical trials, particularly pharmaceutical trials even today). Even if a woman does report with symptoms consistent with a heart attack, she is considerably more likely to be dismissed and to have her symptoms attributed to “anxiety” or “agitation,” than to a cardiac source. Women are less likely to undergo tests to check their hearts or receive recommended treatments. A woman having a heart attack is 59% more likely than a man experiencing the EXACT SAME EVENT to be misdiagnosed from the outset. Even if she is diagnosed, she is 50% more likely to die. The vast majority of primary care doctors admit that they routinely rely on the “characteristic symptoms” of heart disease when preventively assessing patients, despite the fact that their entire female patient population would have a completely different clinical presentation.
You might think, because of the pink ribbons and the publicity, that breast cancer is the biggest overall health concern for women and that it is the source of the greatest mortality for women. In fact, heart disease is the leading cause of female death worldwide. A woman is three times more likely to die of heart disease than she is to die of breast cancer, and yet her PCP is more likely to focus female preventive care on a patient’s breasts than on the vital organ that lies beneath them.
Gender bias also plays out significantly in clinical pain management. Women are more likely than men to have their pain inadequately or inappropriately treated. They are significantly more likely to receive anxiety medication and sedatives in response to a complaint of pain, and men are significantly more likely to receive medication intended to treat pain when they report having pain. The results of studies examining physicians’ discrepant responses to and treatment of women as compared to men are applicable not just in the United States but in the world at large. Across the board, women are treated differently, and generally to their detriment.
In clinical trials and studies, women have long been regarded as the smaller counterparts of men. Research conducted on men has and still is extrapolated to apply to women, despite the fact that women’s bodies, metabolic processes, hormonal environments, and physiologic functioning are utterly distinct from those belonging to men. On the one hand, women continue to be treated as distinct from men, more hysterical and hypochondriacal, and on the other hand, the medical model often assumes that they are nothing more than miniature men. Most drug trials are conducted exclusively in male populations; “best treatments” that are then released to market for treatment of a general adult population are actually best treatments only for men, and we often do not have enough information to determine how well a medication might work in a woman’s body or what side effects or adverse effects a woman might experience in response.
When women are diagnosed with a mental illness by a primary care provider, they receive worse medical treatment (receiving less health monitoring and taking more potentially harmful medications) than men. Non-smoking women are three times more likely than men to develop lung cancer and five times less likely to have it diagnosed in a timely fashion. Women are significantly more likely than men to experience a stroke, and they are significantly more likely to have a delayed diagnosis or a missed diagnosis. If a woman survives that stroke, she will have worse quality of life than her male counterpart.
These are not “women’s health” conditions. These are not conditions related at all to any unique female components. Or, are they?
I would argue that all medical conditions occurring in women are women’s health conditions. And, I would argue that all medical professionals providing care to women should be trained specifically in the provision of care to women, just as all medical professionals providing care to children are required to have received specific training in pediatric medicine. The sad reality, however, is that primary care is seen as primary care: everyone gets the same average of 7 minutes per visit face-to-face with their medical provider, and, at the end of the day, the women are more likely to die simply because they are women. In most primary care settings, women are referred out for their gynecologic concerns, because “those parts” are considered “specialized,” and women’s health-specific issues and concerns are routinely neglected or ignored.
It is time to stop fragmenting care. It is time to stop relegating “women’s health” to gynecologic care. It is time to see women as whole people (who are statistically juggling more varied responsibilities than their male counterparts, are carrying more household/family/caretaking demands than men are, and are less likely to prioritize their own need for medical care as a result), and to provide integrated care to women that allows them to receive care for their physical, psychological, and emotional states in a single space that offers distinct expertise in caring for women as biological beings that are not just small men. It is time to craft a model of care that allows women to have knee concerns (in her female knees that are uniquely different from any male’s knees) in the same space that she has uterine concerns, and it is time to both promote and insist upon gender-specific, comprehensive models of primary care.
Top 10 Reasons to Move Your Body (even when you don't want to...)
Top 10 Reasons to Move Your Body (even when you don't want to...)
June 15, 2019
It seems like there are not enough hours in the day to get everything done. If you’re like me, when life gets busy, one of the first things you tend to let go of is exercise. I have all the excuses: my full-time practice, my children and their various activities, managing a household and all its demands, wanting to make sure I give time to each member of my family. But the simple, annoyingly certain truth is that I just feel better on so many levels when I exercise. There’s no getting around it. There is, however, a lot of difficulty finding ways to schedule in that “exercise.” I do not have time to dedicate to going to the gym to exercise for a full hour every day.
Luckily for me, exercise is not confined to what the media and mass-marketed fitness products have caused us to think that it is. Exercise does not just occur on the elliptical at the gym. It does not just involve running, which my asthma and my scoliosis make me HATE. Exercise is any kind of physical activity in which I move my body in ways that elevate my heart rate and enhance my strength. I love gardening and working around my house, which are both great ways to get my exercise and feel productive while I do it. This may not be true for you; you may HATE gardening but LOVE running. More power to you. For every individual woman, there is a way to integrate exercise into your life that will be fulfilling (and possible) for you. Here are the top 10 reasons for finding your own method of integrating exercise — from me to you not just as a provider, but as a person who never has enough time to exercise, but always comes back to it because it’s just that important (dang it):
1. IT MAKES YOU LESS LIKELY TO DIE.
Seriously. Research demonstrates clearly that regular exercise reduces the risk of mortality from all causes for most individuals, regardless of age. The beneficial effects are dose-dependent, meaning that the more you exercise, the less likely you are to die. The effects of exercise alone have been independently studied and exceed the effects other lifestyle changes to improve health (for instance, exercising has a bigger impact on duration of life than quitting smoking). Vigorous exercise (at least 20 minutes three times a week) combined with regular exercise (at least 30 minutes of moderate activity most days of the week) cuts the risk of death in HALF. If there were a pill we could take that would do this, every single person in America would take it.
2. IT REDUCES THE RISK OF STROKE AND HEART DISEASE.
Regular exercise decreases the likelihood of heart attacks and death related to heart problems. Heart disease is the leading cause of death among women. Not only does it make it less likely that heart disease would develop in the first place, but it reduces the likelihood that heart disease, if already present, will cause illness, impairment or death. It also significantly decreases the risk of stroke. Both of these findings are thought to be related to the decrease in blood pressure that results from regular exercise, as well as decreased overall inflammation for people who exercise regularly. For both things, exercise makes it less likely that you will get them in the first place, and, if you are unlucky enough to get them, exercise will make the consequences less severe.
3. IT REDUCES THE LIKELIHOOD THAT YOU WILL BECOME DIABETIC.
As with heart disease, regular aerobic exercise improves blood sugar levels and increases the body’s sensitivity to insulin, both of which reduce the likelihood that existing diabetes will progress and decrease the chances of developing diabetes over one’s lifetime.
4. IT DECREASES YOUR CHANCES OF DEVELOPING CANCER.
Exercise protects against the development of breast, intestinal, prostate, endometrial (uterine), colorectal and pancreatic cancer. And not by a little: you are 1/3 less likely to develop these kinds of cancer if you exercise regularly.
5. IT SHRINKS YOU.
Even if you are not dieting, regular aerobic exercise and resistance training leads to a reduction in body fat and, potentially, weight loss. Especially for women, regular exercise is associated with less weight gain in middle age, regardless of diet. If you are dieting, adding in exercise greatly reduces body fat and results in greater retention of lean mass when compared to diet alone. Beyond fitting into a particular size of skinny jeans or looking good for the beach this summer, preventing or treating obesity results in tremendous health benefits throughout your lifetime.
6. IT IS GOOD FOR YOUR BONES.
Weight-bearing exercise (activities that involve standing, squatting, lifting, running, jumping, posing or planking) results in significant increases in bone mineral density, making it less likely that your bones will break now or as you age.
7. IT MAKES YOU SMARTER.
Dementia occurs much less frequently among individuals who have exercised regularly throughout their lives. Even among younger individuals not at risk for dementia, regular exercise results in significant improvements in cognitive function.
8. IT BOOSTS YOUR MOOD.
Yes, really. Running in the rain will make you more likely to smile later. People who exercise regularly are less likely to have depression than those who don’t. And, people who are depressed report dramatic improvements in their moods and decreased depressive symptoms when they start exercising. Higher energy expenditures also result in less overall stress, and people report less anxiety when they have been exercising than when they have not made space for exercise in their lives.
9. IT IMPROVES YOUR FUNCTION.
Not only does regular exercise make it more likely that you will remain healthy and require fewer sick days from work, it also makes it more likely that you will be able to take the stairs without panting; lift heavier objects; and engage in work, play and life with greater ability and ease. Individuals who regularly exercise are less likely to require assistance with their activities of daily living and are less likely to become disabled in general. For disabled individuals, exercise improves overall function and enhances independent ability to perform most tasks.
10. IT PROVIDES NEW OPPORTUNITIES TO CONNECT.
Hiking with friends, biking with your significant other, or signing up for an organized event like a softball competition or a sponsored run with a group of co-workers are just a few examples of how to integrate exercise into your life. You’ll be exposing yourself to new experiences, creating a sense of accomplishment and fostering deeper connections with others. Some activities, like organized walks or runs, have the additional benefit of providing a greater sense of purpose when they also benefit a charitable cause. Have you always wanted to learn to dance? Bend your body like the master yogis? Ski the slopes of Mount Baker with grace? Bike on behalf of children with muscular dystrophy? The possibilities are endless.
As you undertake your commitment to lacing up your shoes, rolling out your yoga mat, or buckling your helmet, know that much more than the satisfying fulfillment of your now-months-old, neglected New Year’s Resolution is in store: the more you exercise, the better you will feel. Period. The more you exercise, the easier it will get. Period. The more you exercise, the better you will be. Period. It is worth it, and you are worth it.
May 24, 2019
Mental health is an odd concept. It is odd to think of mental health as distinct from health in general. However, this is the unfortunate siloed approach that most modern medical practices use to approach any emotional or organic mental concerns. The vast majority of medical providers will address the body and concerns related to the body as separate from anything related to the brain. The following are just ten of many reasons this approach is problematic.
1. It engenders stigma: When we perceive the brain as an organ that is utterly distinct from the rest of the body, we dismiss concerns related to brain function and mental wellness as issues that either are not “medical” in nature or are somehow within the individual’s control, implying personal weakness if something is not working well.
2. It creates a division in care services, such that individuals know where to seek assistance if they have physical pain but are often left adrift or directed elsewhere to address their mental pain.
3. It demonstrates a very narrow understanding of the essential, integrated functioning of the body and the mind, dismissing the important ways in which untreated or unmanaged anxiety, stress, depression, or other mental concerns impact our physical health and well-being.
4. It allows providers to ignore essential components of patient wellness and allows providers to remain ignorant in relief measures and treatment modalities because they view mental health services as “specialized care,” not an integral part of the care they regularly provide their patients.
5. It reduces patients to bodies, not beings, which results in suboptimal care that doesn’t consider all the potential factors that contribute to both the healing process and overall health maintenance.
6. It fractionates care. Requiring patients to see a separate provider to discuss mental concerns results in their primary healthcare provider having a very limited understanding of who the patient truly is, which limits the ability to actually partner in developing care plans or discussing care concerns.
7. It alienates and shames patients, who may be reluctant to voice concerns regarding their mental functioning because they suspect their providers may be disinterested or perceive themselves as poorly equipped to help. The reality is that everyone has mental health, just as everyone has cardiac health, just as everyone has gynecologic health. Some is better than others, and each woman is affected by different things that may compromise her health and wellbeing, on all levels. We all have mental health concerns. They are just as unique and different from one woman to the next as our other health concerns.
8. It results in inappropriate treatment or misdiagnosis. When providers are not attuned to mental health as a critical component of overall functioning, they can misattribute reported symptoms to isolated physical ailments and begin a course of treatment that may not address the root cause.
9. It results in provider hesitation to learn about management options for mental health concerns, which widens the chasm between mental health and physical health as perceived as conditions a provider is capable of treating. As the provider becomes less informed, the provider becomes less capable of addressing patient concerns.
10. It delays treatment. For all of the above reasons, women are often late to request, receive or initiate mental health treatment, which results in more advanced conditions that are more difficult to manage and require more intervention than may otherwise have been the case.
When we integrate mental health care seamlessly into our routine provision of healthcare, we take into account the whole individual and all of the factors that combine to affect health and well-being. It allows us to fully treat concerns, both mental and physical, and treat them in their earlier stages with greater response to treatment and improved outcomes. In our modern era, it is an absolute shame that we continue the archaic practice of separating mind and body, as if that were even possible, and it is imperative that healthcare providers begin to see women as multi-faceted beings, not just female-shaped flesh. We are committed to breaking this mold, and we will always view you as a complete being, from the innerworkings of your brain to the very tips of your toes.