Monday, May 31, 2010

A Pyramid of Women

I hold myself humble before the pyramid of women who elevate me. I , in turn join my generation, in elevating another. The gift I believe my generation of women has given to the next is that of balance. I came of age in the time women didn't just marry doctors, but became them. We assumed the roles men had long held of breadwinner, protector, power broker. We did not relinquish the roles of mother, domestic manager, and nurturer. We did it all, and the consumption of Prozac is our testimony to the lesson of balance.
We, by our intelligence, efforts, and numbers changed the perception of women as the weaker sex, women's place is in the home.

 Our reproductive freedom allowed us to realize these dreams, but I think we would have found a way through sheer will, or maybe I am just dreaming.

I met the most delightful young woman today. She is all promise. Tonight she has her commissioning ceremony and becomes a Captain in the Air Force. She is graduating from Medical School this weekend. Her wedding is next weekend. I attended a wedding of a wonderful couple where the young woman will undoubtedly be the breadwinner.

What a wonderful situation to have these crowning achievements, and be so young!

I felt honored to be able to be one of the women who elevates them  and allows them to develop with imagination the only  boundary. Of course, I stand on the shoulders of an entire pyramid of women. Some of them I know, and are my family. The generations who braved immigration with no education, but intelligence and purpose. This was my grandmother who inspired me to make the journey in reverse to pursue opportunity in Europe and study. There are my mother's shoulders who elevate me. She showed that a woman can have a career and a family, and created day care out of thin air! I was never alone after school, and was always well cared for, and supervised. There are actual women who stay home from work because the nanny can't come that day. They are standing upon my mother's hands, holding them up, as they will not lose their employment due to the day's disaster. Of course, there were many women who have toiled silently beneath the grip of society's expectations to give their encouragement for those women who broke through the barriers to find new limits. Mine was the now famous glass ceiling. At the point in my career where I should have been promoted, it was to a younger woman to take the place I labored to create. I saw that as my personal sacrifice in this everlasting chain. I identified with Hillary Clinton, a capable woman who earned her place in American politics by playing the boys' game, but being brushed aside as old guard. Sometimes you just can't win.

Who has elevated you? Upon which shoulders do you stand? Who will you elevate?

Until next time.....................

Tuesday, May 25, 2010


This is a topic I never wanted to know much about.

I did learn however, from my patients how to deal with the death of a spouse. Like so many other circumstances, some do it well, and others poorly. My mother has done it well, and although I know the loss of her husband still pains her, she has filled her life and persevered. I also know she told me never to be one. I have known young widows, struck in the height of their love, and women whose husbands had been lifelong lovers and partners.

My widowhood came too early.

Its ugliness intrudes into my conciousness without invitation. Last night it was a dream about my late husband. Your dreams find you and WHAM you are pulled back into the vortex.

I suppose my recent move was a stressor and this was a way to ermind me. I wish it didn't happen, but it did and has me on the brink of tears all morning. My life is full, more or less. Certainly no less than before, just no husband. I have a job, and it is fulfilling. I am dating, and that attention is nice. I just moved into a lovely new apartment, and that is a plus. The minus is the reminder that I remain alone.

When you become a widow, everyone is very kind. They know that pain that you feel and the empty spot in your heart and soul can never really be filled. It remains, much like a scar, a weakend part of you that never heals to look the same as the rest. It is there, a reminder of damage done, real life that found its way into your existence. People forgive you your crying spells, and allow you to excuse yourself to the ladies room to bite your lip, and muffle your sobs. They do things for you, for a time. After a while, it is time to pick up the pieces of your life and find a new path. As the master of my fate ( at least this is the illusion I hold) I can chart any course I please.

 What happens if you please to be back in time?

I think that is what pops up every now and again, the good feelings of being in love and married, and safe.
The world of widowhood is frought with ambiguity, change, and vulnerability. That is much harder to bear.

Until next time...........

Saturday, May 22, 2010

Advanced Potty Training: What we know to do but don't :(

Hello there

Today I wanted to discuss a topic that my medical school professor let us 20 somethings know would be important: potty training. Actually he was talking about digestive disorders: constipation and laxatives, but for me it boils down to potty training both for urine and waste.

What? You say.......yes says I.

This is a frequent gyn problem for women who have learned to "hold it" that increase bladder capacity to a point of overwhelming the capacity of the urinary tract to function properly. Women are like toasters, they sit and pop up almost immediately. They will not always like where they are forced to void ( urinate, or pee to use the vernacular ).

From the time I became a medical student until my youngest child was about 10 I didn't have enough time to sit on the pot to wonder what day it was. I was an automaton and waited until the bladder shouted with pain to void. I also have a joke, if I can't find my nurse I say ....wait didn't she pee last week?

This is not really funny. It is life that intrudes. So I find the all too busy mother, nurse, teacher or now just woman, with a huge bladder capacity that leaks urine. This is overflow incontinence that is easily
remidable with a ten dollar watch from Wal Mart. Set it to beep every 3 hours and sit. Not for two seconds, but for two full minutes. That's a long time, especially when there is a long line of women waiting for the ladies room, but for the most part. SIT!

Sitting allows the urethral sphincter ( the muscle that controls the bladder neck ) to relax and open.
Then the bladder contracts and empties. Don't be like the soft ice cream machine, some comes out but it is full.

Same goes for number two. SIT! Find a time every day to do your business. Make it some YOU time if you must. Get a book, magazine, cell phone game, etc, you get the point. It helps if you don't have a two year old pounding the door yelling MOMMY!, but find ten full minutes to just sit. Think of it as a mental health break, as well as a digestive health break.

All too often I will see kids, teens, and women of all ages with vague lower abdominal pain that moves around. They google this stuff and are sure they have ovarian cancer. So I get a panicked woman who is constipated and wonders why I don't want to spend ten thousand dollars to assure her that is the only problem. I try to calm the world down, and say we are going to start with the cheap, frequent and easy things and then work our way up the ladder with complexity and cost. Most of the time this strategy works, occasionally they know somebody who is related to somebody who works with a woman who had the EXACT SAME THING, and her doctor blew her off and she had cancer and died.
It's like working during the Blair Witch Project. Geeze.

Sitting and potty training is important because it prevents all those vague nasty symptoms from arising in the first place, so you won't have the EXACT SAME THING as that unfortunate woman who died.

Double void, if you have to. That means, pee, wait and then pee again a few minutes later. That is a common problem among the toaster crowd. Plan on going twice. Then you are empty and won't spend all day with vague lower abdominal pain of a full bladder you only allow to partially empty.

So my advice to everyone, is that I have cured thousands of women with a few dried apricots. Four to get you going, two a day to keep you going. Natural, good for you and tastes better than prunes. Does not have the stigma of an old person's remedy. Works great.

Happy Sitting

Until next time...............

Wednesday, May 19, 2010

PMS, Prozac and Civlized Behavior

Hello dear readers,

I am, on a daily basis, asked to deal with PMS.

Since I have been in practice ( 27 years, yikes!) I have struggled with this diagnosis. When I was first in practice, and the only female gyn for many miles in any direction, I was prevailed upon to diagnose and treat PMS. It was a young problem. An English physician, Katarina Dalton, had at that time, successfully argued PMS as a murder defense in London, and this diagnosis was brought to the world stage.

Since it is a syndome, it is comprised of a number of symptoms. No objective findings are apparent for a definitive diagnosis. Calendars were kept, vitamins, exercise and every hormone in the book was used. All to no real avail. PMS is the witch within, waiting to pounce on unsuspecting males, coworkers, children, and the public.

The dawn of what I call modern mental health began when Prozac was brought to market. Here was a drug that had little toxicity, and could successfully treat depression and anxiety. The world changed. Even though your insurance company did not cover you for "nervous and mental disorders" it was worth it.

No longer was bad behavior tolerable. Self control, and its attendant civility crept into society. The behavior seen in The Honeymooners, was now considered abusive.

Your body only has so many finite resources to deal with your day to day activities. In biology, we define stress as adaptation to change. There are internal stressors, your body functions, and overall health. There are external stressors in your life. When a woman has a menstrual cycle, there are hormonal changes that are normal that occur, but contribute to internal stress. In my opinion, this is the straw that breaks the camel's back of civility, and the inner witch emerges. She is irritable, bitchy, not a nice person, sharp tongued, and quick to anger. We teach our children, not to pick up their shoes, but that women are crazy and not to be trusted.

There are three basic treatment methods for PMS. One is to control the menstrual cycle to lessen the burden of internal stress, another is to reduce external stressors from your life, and the third is to increase your stress management resources. Go to the mountaintop and commune with nature, do yoga, exercise, meditate, deep breathe, read a book. Remove yourself from society. Turn off the cell phone, TV, and don't watch the news.
Those are starters.

If a patient is unable or unwilling, or too wacky, I will offer her fluoxetine, the active ingredient in Prozac. It has been shown to be very helpful, and can be taken just around the menses. I ususally advisea woman if she feels good on the days she is taking the medicine, and then feels a let down the other days of the month, I advise her to take it every day. No sense only having a few good days.Manipulation of menstrual cycles will work, especially in adolescents, and young adults. I am always hesitant to prescribe psychotropic medications to this age group.

The bottom line is that the inner witch is no longer allowed to come out. She must be controlled, or you will wind up alone. Nobody wants to be around her. Your children will want to live with your ex husband. So my advice is to get a grip. There are lots of ways to get to being a civil person. Pick one or many, but do it.

Until next time..............

Monday, May 17, 2010

The Moving Van Cometh

This one is a personal post. I moved. Just a few block, but the effort was the same. I moved from a house with all of its attendant rooms, closets, garage and patio space to a condo. Now I wanted to do this, don't get me wrong. It was deliberate. I keep reminding myself I wanted this. The pain, the pain, the PAIN.
Packing was strung out over several months, so I would have time to throw out or get rid of all kinds stuff.
Now all of that stuff comes with memories, but I did find out that I own five cookie sheets. Where were they hiding? Were they breeding in the kitchen without permission? Had I mindlessly purchased more? Who gives cookie sheets as a gift? I must have purchased them over the last 30 years, surely.

Now there is an enormous box containing shoes that needs to be opened. I am thinking of just letting that one sit a bit longer. The closet space I now occupy is already crammed full just with clothing. Not to mention the hats I couldn't part with, nor the fifteen purses in all sizes, shapes and colors.I still have my wedding dress. And the crinoline it came with. That is going to Goodwill asap. I can't use up the space. Even if I do cry for two days and eat a pint of ice cream.

So I couldn't help but wonder ( to borrow a phrase from Carrie Bradshaw) why we attach ourselves to things. Why we impart them with emotional tags and memories that are difficult if not impossible divest.. It seems to me that as women we collect, nuture, grow, and then graduate our loved ones, and the little bits we keep become too dear.After a reasonable time on this earth that pile of memories becomes a burden. We turn a corner and start leaving the bits behind, like pioneers about to face the Rocky Mountains. Tossing away our treasures as the burden of holding on to them makes it untenable. It is, I suppose, another link in the chain of life, preparing us to give up our selves at the time of death.

What endures? Memories, feelings, and the knowledge that we did what we could.

until next time................

Thursday, May 13, 2010

The Rise of Google as a Medical Tool

I want to mention to my readers, and to the world in general my concern, frustration, and delight from Google University Medical School.

Most of my patients have access to the internet. That means they have access to lots and lots of information. Google any set of symptoms, drugs, treatments or diagnoses and lots of information will pop up.

Some of that information is good, and written for lay people to understand. Some is educational and written to teach. Most is for professionals, or so over the top of understanding, that lay people are not able to place the information in perspective. That becomes a real problem with patients who are not just their own advocates, but now become their own worst enemies.

Information is powerful, but just as we give a kid the keys to a car at age 16, many will have accidents that first year of driving until they "get the hang of it" or gain experiencethe real world situations.
It's like that for medical information. I have women who have self diagnosed via the internet requesting lab tests, medications, interventions to further their health. It then becomes a challenge to deny them what "the internet" has told them to be true. I am now the bad guy, or worse, don't pay attention to them. Lord, I am trying to save their wallets and their bodies from themselves.

Some problems such as ovarian cancer have vague onset of symptoms, if there are any at all. There has been almost no real advance in many decades for early diagnosis. Lots of research is ongoing to find a way to make an early diagnosis of this terrible illness. So far, nothing to hang your hat on. Just a lousy disease to get because symptoms are vague. So , every time someone feels bloated, full, gains weight, or has a change in bowel habits and looks this up on the internet, they will get one of the various possible diagnoses as ovarian cancer. BINGO! I need lots of tests to find out! Cha Ching! There goes $2000 of health care dollars spent on a wild goose chase. The poor lady who actually has Ovarian Cancer probably doesn't have a clue until it is advanced.

The same goes for medications. No patient is safe. Adverse effects are everywhere. Don't take any. They are bad for you, and besides someone knows someone who is related to someone who saw it on Oprah that it did harm to somebody. You might ask your pharmacist or physician about medications before you throw away your prescriptions or don't take your medications because you are afraid of them.

That is one of the teasers for compounded medications, no FDA paperwork to scare patients. Same ingredients, just no press. Misleads people into thinking that no press means completely safe. The same goes for OTC products, herbs, or supplements. People trust them because they see their doctor as the enemy. When did that happen?

I ponder the plight of my patients who do not trust me. I wonder if that is as common as I suspect. A recent study showed that 6.2% of patients do not fill or take their prescribed medication from the get go, and many more come armed to the teeth to the doctor to argue with them regarding recommendations.

The communications and teaching function of a physician with their patient cannot be overlooked, but that has to be a two way street. The covenant between doctors and patients needs to be renegotiated to include compliance and disclosure. It needs to reestablish trust on both sides.

Your thoughts?

ladies doc

Saturday, May 8, 2010

The Pill Turns Fifty

One of CNNs lead articles this morning is the anniversary of the Pill turning Fifty.

My, that makes me feel old. I do remember my mother telling me that you are not a woman until you have had a pregnancy scare.What advice! Living month to month to see if God gave you more children. Hmmm.

I came of age in 1970.

The pill had been talked about and was relatively new, as a birth control method. It was difficult to obtain for a single girl. Planned Parenthood was new then too. Family planning clinics were on the rise. Like so many other milestones in human development, this one too was given to us by the generations that preceded. My mother's generation stayed at home because pregancy was always around the corner. A woman's income was not considered on a mortgage applicaton because her employer could dismiss her due to pregnancy. That's why men ruled the roost economically. They had the only "steady" means of bringing home an income.

Birth control pills changed that, empowering women with the idea that they could control their bodies, and plan the course of their lives. IUDs  and diaphragms were available at that time as well. They were not effective, but they were available. I remember going to the Library of Medicine with a college friend to research birth control options well before we needed them, just in case. We were liberated women!

Condoms worked, but you had to ask the clerk in the pharmacy for them. No woman in her right mind would do that. There was no Wal Mart or self checkout to maintain your privacy. Conversely men would sheepishly have to ask the pharmacy clerk for Kotex for their wives. Very embarassing. A sign of true and enduring love............

My mother started to invite neighbors to her living room for "conciousness raising" events. They would talk, argue, tell their stories, and I absorbed it all. That was the living room that changed the mantra, marry a doctor to be a doctor. I was too young to really understand what was going on, but as a modern young woman, I obeyed.

The pill changed EVERYTHING.

It changed economics. Women were in the workplace, classrooms of higher learning not to get an MRS degree, but a PhD. They crept into boardrooms, doctors lounges, and military uniforms. I have cared for women who have been pipeline welders, crop dusters, police, soldiers, CEOs, surgeons, Avon ladies, professors, authors, business owners, and Moms. These are women who had choices previously denied by biology.

I consider the advent of the Birth Control Pill as significant for humanity as the invention of the wheel. It enabled people, women and men, to cast off shackles of biology and allow them to explore themselves as people first. As noted in the CNN article, much positive and negative has resulted. No longer is the family the same as it was, the divorce rate has exploded, men have women as equals in the home, and the social experimentation continues. It has only been fifty years. I wonder what the next fifty hold.

Until next time.................

Wednesday, May 5, 2010

How do you know if your hormones are working?

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The uterus is stupid.

It just does what hormones from the ovary tell it to do.

The ovary makes estrogen every day from follicles (eggs) and when the egg pops ( ovulation ) the crater in the ovary where the egg used to be is now called the corpus luteum, and that makes estrogen and progestrone.

The ovary in turn is told what to do by the pituitary gland, which is in your brain. Oh, now I see the connection! The pituitary makes Follicle Stimulating Hormone to recruit an egg each month. It then makes
Luteninzing Hormone to stimulate ovulation.

You thought we were done? NOPE

The pituitary gland is regulated by the hypothalmus. That is an area in the higher brain which pulses out one hormone, GNRH, or gonadotropin releasing hormone.

If you have regular monthly periods, all of this complicated system is in working order. You don't need a blood test to tell you that.

Hormone testing is usually rarely done, even in menopause. No eggs, no estrogen, no message to pituitary. Pituitary screams back. No answer. If you don't believe your body not having periods after age 50 with hot flashes, a test of pituitary function will tell you what you already know.
Hormones are also a moving target with huge ranges of normal. Ever get a result that says normal but you don't feel right? That's the issue.

Any questions? Place a post.

until next time....................

Tuesday, May 4, 2010

Oh I forgot to have children!

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Procreation is a funny thing. For some people it happens like rain. You know its going to happen, you just don't know when. For others it is a military campaign. Planned and executed to the T.

In my lifetime, society's expectations for middle class girls/women changed around 1970. One day the message was "Marry a doctor", the next day it was " Be a doctor". I was confused. I did both. The path to becoming all you can be and being successful delays childbearing. The unfortunate truth is that a although normal childbearing is anywhere from 15-44, optimum fertility is really in a woman's 20's. I hate to see someone in her mid thirties, single, who states she would like to have children. WHEN? TICK TICK
Reminding her that her chilbearing days are numbered is tough. Although there is ART ( Assisted Reproductive Technology), it isn't quite the same as the old fashioned way of having a baby.


Considering that adolescence is anywhere from 11 - 23, and appears to have extended further these days, that puts quite a burden on young women. In the old days, a woman was paired off when she became fertile, ie started her periods, which was about age 16-17. Women did not have access to birth control, and an average woman had 6-10 children in her lifetime. Now it was not expected that all of her children would live to adulthood. Infant mortality and illnesses we vaccinate for, took their toll on children.
Life was simpler, and life expectancies shorter.

Now periods start at 12-13 and education extends into a woman's 20's. Marriage is optional, and financial independence is tenuous. What is a young woman to do? Not forget that she carries a precious gift of fertility, and that it should not be squandered. In my opinion, it should be considered along with education, career climbing, and finding Mr. Right. Even though life expectancies are much longer, and vitality can extend into what was once considered old age, running after a two year old is for the young.

Outsourcing parenthood has been done by the wealthy for eons, yet the experience is meant to be savored by parents without gray hair. Grandparenting is for us old folks, a different thing entirely.

Cultures around the globe teach us, treat fertility as a gift.

Until next time...............

Saturday, May 1, 2010

Tales from the Clinic

OK, every job has a few tales to tell about strange things that have happened.
Here are a few of mine.

Friday a patient comes in to see a colleague. She is worried that the rotisserie chicken she ate has a tumor inside and she is "infected " with cancer. She brings in the chicken carcass for my colleague to inspect in a tupperware container. What do you do with this? Send her to the Health Dept, or show her someone forgot to gut the chicken before roasting? True.

A woman tells me she has trouble with her vaginal hormones.They are are tiny white pills that are on an six inch applicator with a half inch plunger tip. They are pre loaded. You are supposed to insert the pill into the vagina. She says she places the pill at the entrance to the vagina and they fall out. In fact one fell out in a parking garage the other day. It seems this grandmother wasn't wearing any panties. A man looked down and saw the pill ( that had now plumped up from being near but not quite in her vagina) and
bent down. He picked it up and asked her if it was a marshmallow. True. Remember your mother told you not to pick up food from the floor. That's why. I told her the applicator is meant to go into the vagina more than an inch. She said "Ohhhh".

The nurse tells a woman to disrobe and put the gown on over her head. I go into the exam room to see a woman stark naked with the gown wrapped around her head like a turban. OK, now I am supposed to remain cool. I nearly peed my pants while I grabbed a drape sheet and covered the woman.

I come into the exam room. A woman has two  blue exam gloves covering her feet. Her toes are nicely placed into each finger. She looks like the Penguin from Batman. She says she doesn't like anyone to look at her feet. She wore flip flops with her outfit. Go figure.

I can't wait till Monday.

Until next time....