Nuvaring – Weighing the Risks & Benefits

NuvaRing_compressedNOTE – THIS POST HAS BEEN UPDATED TO INCLUDE TWO NEW RESEARCH STUDIES THAT DO NOT FIND AN INCREASED CLOT RISK AMONG NEW RING USERS

You’re probably here because you read the recent article in Vanity Fair that highlights the stories of young women who suffered blood clots while using Nuvaring, and asks why this method is still on the market.

You may be wondering whether or not you should stop using the ring, and worried about what risks you’d be taking if you kept on using it.

I’m not going to get into the Vanity Fair article itself, except to say that highlighting individual stories, while making compelling reading, does little to really educate women about their own risks. Making Pharma into the bad guy is also compelling, and given how they behave in general, pretty easy to do.  But compelling reading does not necessarily make for good medical advice. Which is what women really need.

So let’s see if I can help out a bit with that.

As I see it, this issue at hand, is this – are the risk of blood clots, which are inherent in any estrogen-containing birth control method, higher in Nuvaring than in other birth control methods you might choose to use? If so, is that difference big enough for you to consider using something other than the Ring?  Or are the benefits you may get from using the Ring (convenience, compliance, and for some women, steadier hormone levels) enough to outweigh the increased risks?

 LET’S START WITH THE BASICS

You need to know a few things before we start.

1. If you have sex, unless you use birth control, you will most likely get pregnant.  The odds are about 80% in a year. So unless you plan on being pregnant, you’ll need to use something for birth control. That something is most effective if it is either hormonal or an IUD.

2. On average, your annual chance of getting a blood clot is about 3 in 10,000 if  you don’t use birth control.  This background risk varies with age, increasing from a low of 0.7 per  10,000 at age 17 to about 6 per 10,0000 at age 45. Other factors can increase your risk even further – genetics, obesity, and varicose veins can double the background risk at any given age.

3. Having a baby is always riskier that using birth control.  The risk of blood clots in pregnancy is the highest risk any woman can take, ranging from 4-28 times the background risk.

4. All estrogen containing birth control methods increase the risk of blood clots. Quantifying that risk is difficult, but it ranges from 3-6 times the background risk, depending on which study you quote and which method you are comparing. The risk is related to both the dose of estrogen (the higher the dose, the higher the risk) and the type of progestin used.

5. First and second generation pills have the lowest clot risk – These pills contain levonorgestrel, norethindrone and norgestimate, and their clot risk is about 3 times higher than the background risk. Newer pills using gestodene, desogestrel and drosperinone  have risks about twice that of levonorgestrel pills, as do the Nuvaring and Patch.  That risk is about 6 times the background risk.

6.  Overall, your chance from dying from estrogen-containing birth control methods is about 1 in a million.  

7. Birth control has benefits as well as risks. Birth control pills, the Ring and the Patch lower the risk of ovarian and uterine cancer. Birth control pills also lowers the risk of colon cancer and do not increase the lifetime risk of breast cancer. Birth control pills, the Nuvaring and the Patch are effective treatments for heavy menstrual periods, endometriosis, PMDD, acne, menstrual cramps and fibrocystic breast disease.

8. If you don’t want to be pregnant, and don’t want the risk of estrogen containing birth control, there are other methods you can use. These include condoms, progesterone only pills, spermacides diaphragm, and IUD. These methods each carries their own set of benefits and risks, but do not cause blood clots.

NOW, WHAT ABOUT NUVARING? 

A large Danish study suggested that the risk for a blood clot among users of the Nuvaring is about twice that of older levonorgestrel-containing pills, and is about the same as that from using the Patch, Yaz or pills containing desogestrel.  Initial data from the FDA in 2011 suggested the same thing.

However, when only new hormonal contraceptive users are studied, that increased risks is not seen. Two newer studies – one funded by the FDA, the other by the ring manufacturer, have shown equivalent risks between the ring and older pills. This data makes mores sense clinically than the Danish study because prior research has shown equivalent estrogen levels in the ring compared to pills.  It is important in studies of clot risk to compare new users to new users, since clot risks are generally highest in the first 6-12 months of hormonal contraceptive use.

At this point (As of update 2/16/14), the FDA has not changed the RING labeling other than to include the data from these last two trials. The manufacturer, however has settled lawsuits pending against it. (See this post for more)

BOTTOM LINE

Only you (hopefully with your doctor) can decide if the benefits you are getting from using Nuvaring warrant the risk of clots inherent in all estrogen containing contraceptives. For now, that risk seems that it may not to be larger than that in older pills, at least in two of three studies published to date.

For those who cannot remember to take a pill, or who have gotten pregnant due to missed pills in the past, the convenience of the Nuvaring may far outweigh their concerns about the potential for added risk. I have patients who have been through most of the major pills brands, and only found satisfaction on the Nuvaring. For such women, the relative difference in risk seems small in comparison to the benefit they are getting.

But if you’re considering starting hormonal birth control for the first time, and especially if your are over age 35, most experts would say to start with a low dose levonorgestrel, norethindrone or norgestimate containing pill first. If these pills work for you, why take an additional risk by starting with the Ring (or the patch, or Yaz or a desogestrel pill), even if  that risk is a small one?

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Additional Reading

Additional Reading on Clots & Contraception from TBTAM

A Dignified Plea for Death with Dignity

Just 8 days prior to his death from a brain tumor, physician and researcher Donald Low filmed a profoundly moving and important interview,in which he makes a most cogent plea for the legalization of physician assisted suicide in his home country of Canada.

I’m going to die. What worries me is how I’m going to die.

There is no place in Canada where you can have support to have dying with dignity, as there is in several countries and several states in the United States…. A lot of clinicians have opposition to dying with dignity. I wish they could live in my body for 24 hours, and I think they would change that opinion.

Low was a world renowned microbiologist who came to public prominence during the SARS crisis in Canada.

“During the SARS crisis Low became known as the expert who was the most easy to understand and the most understanding of the public’s fear, while showing no fear himself. ”

“What many of us in Toronto don’t recognize is the loss he leaves behind to microbiology and infectious diseases in Canada, and to all of his research work in emerging diseases around the world.”

Unfortunately, Low did not have the death he had hoped for. Although not in pain, he became completely paralyzed and was dependent on his family for everything in the last days of his life.

Low’s wife, Maureen Taylor, a physician assistant who speaks quite candidly about Low’s last days, has vowed to continue to fight for death with dignity in Canada.

Taylor said her husband was in favour of laws that allow patients to be prescribed a lethal dose of barbiturates after they’ve had a psychiatric evaluation and had their terminal illness confirmed by two doctors.

In this scenario, the medication sits at the patient’s bedside, giving them the option of a pain-free death they initiate themselves. She said that in many cases, the medication is never used.

“I won’t stop this fight. If I can do anything to bring this forward in the political sphere, then I will do that,” she said.

I urge you to watch Don’s and Maureen’s  videos, and to share their message so that the discussion doesn’t end here.

Valley Green

Valley Green

I love this place.

Hands down, best place on earth to run, bike, walk or horseback ride. Even at its busiest, its never as crowded as Central Park.  I caught this empty stretch last Sunday morning during a long walk with Jane after breakfast at Bruno’s and a little post high school reunion debrief.

If we ever move back to Philly, Valley Green will be one reason why.

Trash Picked – Large Lamp

Lamp
Yet another in a post series of great things we found in the trash.

What: Large Wood Carved Lamp

Where and When : 63rd between 1st and York, sometime in July 2013

Why We Picked it  – We needed something for the big round table in the cottage

Why We Kept It –  The big primitive carvings echo the large pineapple print on the sofas.  (See?) I’m looking for a larger white shade for it, and may need to replace the switch, as it seems to be a bit fussy in action.

Lamp and Sofa

Big Apple Apples (and a recipe for Apple-Pear Sauce)

BIg Apple Apples

We’ve got a real bumper crop of apples ripening on the tree on our roof right now.

I’m not sure who or what to credit, since laisse faire has been our unintentional gardening principle this year.  I think maybe I fed the trees twice and you can tell by the color of the leaves that I never sprayed them.

Container Garden Apples

Maybe it was the rain. Or the sun. Or someone has bees nearby. 

APPLES IN THE SUN

Regardless, these little macintoshes are white and unblemished inside and while not as crisp as say, a ginger gold or granny smith, they have a nice flavor,

APPLES

and make a very good applesauce, especially when you add in a couple of small overipe pears you found sitting on the counter.

APPLESAUCE JAR

Apple-Pear Sauce

1 cup orange juice (plus a little water if needed for larger apples)
6 small macintosh apples
2 small soft pears
1 cinnamon stick

Rinse the apples and pears in water and dry. Do not peel. Cut into quarters, removing the occasional brown spot, and core. Add the fruit to a heavy saucepan. Pour in the orange juice and toss in a cinnamon stick. Cover the pot and cook over low heat till the fruit is soft (20-30 mins), stirring occasionally to be sure all the fruit spends some time immersed in the juice.

Remove cinnamon stick. Using a large slotted spoon, remove the fruit from the juice and run it through a food mill (or press through a fine mesh strainer). Add back some of the juice if you need it to thin the sauce. The juice you don’t use, pour into a glass and drink slowly – hmmmm…..

If possible, serve the apple-pear sauce warm.

Trash Picked – Small Fan

Fan
Another post in an ongoing series of things we found in the trash, either on the streets or in our building.

What: Allaire desk fan

Where & When :  In the trash room by the service elevator last week.

Why We Picked It:  It’s pretty!

Why We Kept It:  It works! Extremely quiet, and most importantly, keeps me cool enough while working at the desk that I don’t need the AC.

Early Mammograms – New Study Misses the Mark

mammogram2A recent study has concluded that women with breast cancer who failed to get annual mammograms are more likely to die from their disease than those who had annual mammograms, and argues that more frequent mammograms are warranted in women under age 50. Unfortunately, despite all the media attention this study is getting, I don’t think the researcher’s conclusions are supported by the study results.

The researchers did a retrospective medical record review on deaths that occurred among breast cancer patients receiving care at Mass General or Brigham & Women’s Hospitals in Boston between 1990-1999 and followed until 2007. They call this a Failure Analysis.

Invasive breast cancer failure analysis defined 7301 patients between 1990 and 1999, with 1705 documented deaths from breast cancer (n = 609) or other causes (n = 905). Among 609 confirmed breast cancer deaths, 29% were among women who had been screened (19% screen-detected and 10% interval cancers), whereas 71% were among unscreened women, including > 2 years since last mammogram (6%), or never screened (65%). Overall, 29% of cancer deaths were screened, whereas 71% were unscreened. Median age at diagnosis of fatal cancers was 49 years; in deaths not from breast cancer, median age at diagnosis was 72 years

The authors concluded that because most deaths from breast cancer occur in un-screened women under age 50, initiation of regular mammograms before age 50 years should be encouraged.

Where this Failure Analysis Fails

Despite its strongly worded conclusions, the study raises more questions than it answers, and has a number of severe limitations.

  • The study fails to tell us what percent of women who did not die got annual vs not annual mammograms. This is akin to reporting that 80% of auto accident deaths occur among those who started their trip at home vs a public parking garage, without telling you what percentage of all car trips originate from home.
  • The study did not compare breast cancer treatments between women who died and those who did not die. The researchers just assumed that all women got standard of care at their medical center for their cancer. That’s a huge assumption to make without any proof.  It would have been actually quite easy to review a statistical sampling of charts to determine if this assumption was correct, but the researchers did not do this.
  • Women who don’t get regular mammograms may differ from those who do in other ways that increase the risk for death from breast cancer death, including low socioeconomic status, lack of health insurance, and distrust of medical treatments.
  • The researchers try to make the point that among those who died of their cancer, those who had not had mammograms prior to diagnosis had later stage cancers. Given that this analysis was confined to patients died of their cancer, I’m not sure stage at diagnosis mattered.
  • The entire analysis is conducted among women who died, either from breast cancer or from other causes. Since death from non-cancer causes is rare in women under age 50, breast cancer deaths will be over-represented in younger women in the sample. Older women not getting mammograms may be not getting screening because they are ill from other causes and are also more likely to die from these other causes during the follow up period, making breast cancer deaths less common in this group.  Who knows which way the data ultimately skewed as a result of these biases, but regardless, it is skewing every which way as far as I’m concerned. All of which muddies the conclusions.
  • The study was conducted at a Mass General and Brigham and Women’s Hospital using records from their breast cancer registry. Both these hospitals are referral centers likely to attract younger women with more aggressive cancers for treatment, who may not be representative of the general population of women presenting for mammogram screening or who are diagnosed with breast cancer. Indeed, the study population was over 90% white and of high socioeconomic status, pretty standard for a referral population if I ever saw one.

One thing that is evident is that breast cancers in younger women tend to be more aggressive than those in older women, an idea that would support more aggressive screening in younger women since each life saved carries more years of life saved. However, this is countermanded by the argument that breast cancer, despite being more aggressive, occurs much less frequently in younger than older women. Add in that mammograms are much better at detecting slower growing, less fatal breast cancers than the more aggressive cancers, and that screening is less effective in the denser breasts of younger women, and you have a sense of the screening conundrum we face for this cancer that claims so many women’s lives each year.

Unfortunately, this retrospective analysis is not going to solve the issue.

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Webb, M. L., Cady, B., Michaelson, J. S., Bush, D. M., Calvillo, K. Z., Kopans, D. B. and Smith, B. L. (2013), A failure analysis of invasive breast cancer. Cancer. doi: 10.1002/cncr.28199

More on mammograms –

Trash Picked – Painting

Trash picked painting
First in a new series – Trash Picked, or great things we found in the trash, either in our building or on the streets.

What: Still Life Painting

Where: East 63rd between 1st and 2nd, one fall evening a few years ago while walking home from the theater.

Why We Picked It: I liked the colors and the primitive style. Probably someone’s art class assignment…

Why We Kept It:  It looks great on the wall going up the stairs at the cottage, and goes perfectly with the carpet on the stairs. (See?)

PIC AND STAIRS

Seared Scallops with Mushroom Cream Sauce

Seared Scallops in Mushroom Cream Sauce

An elegant and actually quite easy preparation from Emeril Legasse. The sauce has cream, but lemon used in the scallops lightens the flavor considerably.  (Half and Half would probably work just as well as the cream if you want to lighten it calorie wise as well.)

Mr TBTAM prepared this last week – it was so good,we used the leftover sauce, seared a few more scallops the following night and had it again.  The sauce can be made a bit ahead, making it an easy dish to serve company.

We had it with Farro and brussels sprouts. Made for a real pretty plate.  Recipe here.

Shallots, Farro and Brussels Sprouts

New 2-Stage Ovarian Cancer Screening Strategy Looking Interesting

Normal ovaryOne study does not a recommendation make, and results of a larger clinical trial are pending, but a new 2 stage approach to ovarian cancer screening is starting to look like something reasonable for ovarian cancer screening.

In a multi-center study led by researchers at MD Anderson Cancer Center, over 4,000 women were followed with annual Ca125 levels for 11 years, using an established algorithm (ROCA or Risk for Ovarian Cancer) that stratifies women into low, intermediate or high risk for ovarian cancer based on changes in ca125 levels over time, even when Ca125 levels are in the normal range.  Based on the ROCA, which was re-calculated after each periodic screening, low risk women continued with annual Ca125 levels, intermediate risk women had repeat Ca125 levels done in 3 months, and high risk women went to immediate sonogram.

By confining sonogram use to only those women with concerning increases in Ca125 (0.9% annual rate of sonogram referral), the researchers were able to avoid the high rates of unnecessary surgery for false positives that has kept sonogram from being an effective screening tool for ovarian cancer. Their results are impressive for the small number of surgeries done – only 10 over 11 years – and the relatively high rate of pathology found at those surgeries –

The average annual rate of referral to a CA125 test in 3 months was 5.8%, and the average annual referral rate to TVS and review by a gynecologic oncologist was 0.9%. Ten women underwent surgery on the basis of TVS, with 4 invasive ovarian cancers (1 with stage IA disease, 2 with stage IC disease, and 1 with stage IIB disease), 2 ovarian tumors of low malignant potential (both stage IA), 1 endometrial cancer (stage I), and 3 benign ovarian tumors, providing a positive predictive value of 40% (95% confidence interval = 12.2%, 73.8%) for detecting invasive ovarian cancer. The specificity was 99.9% (95% confidence interval = 99.7%, 100%). All 4 women with invasive ovarian cancer were enrolled in the study for at least 3 years with low-risk annual CA125 test values prior to rising CA125 levels.

If the cost of Ca125 screens is low, this strategy could begin to make sense as a screening strategy for ovarian cancer. This all depends  of course, on whether it actually reduces mortality. The answer to that question will await the results of the much larger UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), which will randomize over 200,000 women to either Ca125-ROCA (as in the Texas study), annual sono or routine care.  Enrollment in that study has closed, and initial results are expected in 2015.  It’s also important to note that other ovarian cancer markers are currently under investigation, both alone and in combination with one another and Ca125, and may prove superior to Ca125 alone.

Bottom line

Interesting, but not yet practice changing. Stay tuned.

Caring for Pregnant Disaster Victims – Lessons Learned in Haiti and Japan

Israel_Defense_Forces_-_First_Baby_Delivered_at_IDF_Field_Hospital_in_Haiti

Israeli Defense Forces deliver a baby at field hospital in Haiti

In a landmark article in this months Green Journal, Israeli and Canadian Ob-Gyns who deployed with international relief efforts to Japan and Haiti earthquake areas have summarized the lessons they learned in the field there.

The objectives of this report are to emphasize the often overlooked need to include obstetrics and gynecology personnel among essential medical aid rescue teams and to provide recommendations and guidelines for obstetrician–gynecologists who may find themselves working under comparable extraordinary natural disasters.

The article includes a list of recommended supplies (and amounts) to bring, and a layout for an Ob-Gyn field hospital. While I urge you to read the entire article, here are excerpts from their 10 essential lessons learned –

1. An obstetrics and gynecology team is invaluable however scarce its resources, because the provision of even the most basic prenatal care plummets after a natural disaster. ..as many as 10% of the victims seeking medical assistance may need an obstetrician–gynecologist.

2. The mix of cases that the obstetrics and gynecology team will confront requires that they are highly trained specialists prepared for and trained in dealing with emergencies in a suboptimal environment.  Miscarriages, premature deliveries, intrauterine growth restriction, low-birth-weight neonates, gender-based violence, and undesired pregnancies increase after natural disasters….Approximately 50% of the cases the Israel Defense Forces hospital team encountered in Haiti were complicated deliveries.

3. Preparations for treating extreme prematurity should be made before departure to the disaster zone. … increased seismic activity could increase delivery rates and preterm births up to 48 hours after an earthquake and a significantly higher rate of premature births was reported over a 7-month period in the wake of the earthquake in Japan.

4. Foreign aid relief teams operating in a disaster area will inevitably encounter unique and difficult ethical dilemmas, often arising from insufficient medical resources. … not every victim in need would be able to receive the necessary treatment. … the dilemma of whether to impose a minimum weight threshold for preterm neonates to receive treatment is an ethical issue, which obstetrics and gynecology teams operating in natural disaster conditions should be prepared to deal with.

 5. Obstetrics and gynecology teams treating pregnant women under natural disaster conditions should be especially sensitive to the catastrophic environment’s effect on maternal mental health.

6. Indications for cesarean delivery in a field hospital … will differ from the typical paradigm. … For example, fetuses in breech presentation with estimated birth weight less than 3,500 g were to be delivered vaginally. …with only one available fetal heart rate monitor, monitoring had to be carried out intermittently, possibly meaning some abnormality might have been missed. Potential contingencies such as these must be addressed and discussed before the team is deployed.

7. The delivery “suite” should be prepared for emergent cesarean deliveries in the event that a designated operating room may not be immediately available.

8. The likelihood of quickly obtaining additional equipment and medications is remote once the team has arrived to the disaster zone; …a list of recommended essential equipment and medications for obstetrics and gynecology relief teams is provided.

9. An outreach obstetrics and gynecology team with a portable mobile ultrasound machine including vaginal and abdominal probes not only detects problematic pregnancies, but also provides enormous psychological comfort to pregnant disaster victims.

10. The team must be briefed by someone knowledgeable about local cultural sensitivities and taboos, including local volunteers who serve as translators.

Kudos to the authors for providing an essential global resource for disaster planning.
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Image from Wikipedia

Gluten-Free Low Fat Spinach, Leek & Mushroom Quiche

GLuten free quiche
This quiche serves 6 at only 235 calories a slice.

If, like me, you find yourself planning to make a lasagna for a friend recovering from surgery, stop for a second and consider, as I did, making something healthier. You just may find some amazing meals out there, including this delicious quiche from Cooking Light.

I was going for something not too high in fat, then realized that this quiche is also gluten-free*. Not that I have a gluten allergy, but any opportunity to replace processed white flour with whole grains is worth taking, as long as the result is edible.  And this is not only edible, it’s delicious!

*Oats and Oat Bran are naturally gluten-free. Cross contamination, however, can occur with gluten-containing products during storage and manufacture.  If you must, be sure to buy brands that are certified gluten-free.  

GLUTEN-FREE LOW-FAT, SPINACH, LEEK & MUSHROOM QUICHE

My recipe is a little different from the original in that I increased the leeks, skipped the dill, added a few sprigs of fresh instead of dried thyme, and also hot pepper flakes and fennel seeds. I skipped rolling out the dough and simply pressed it into a well greased tart pan. As you can see, the crust baked up beautifully (I placed the filled quiche on a baking sheet in the oven), and slipped out of the pan with no fuss at all. Maybe that’s because I used butter instead of cooking spray, so if you do that, add on a few calories. 

Crust

  • 1 cup regular oats
  • 1/3 cup oat bran
  • 2 tablespoons chilled butter, cut into small pieces
  • 3 tablespoons cold water
  • Butter or cooking spray for the pan

Filling

  • 2 large leeks, cleaned and thinly sliced
  • 1 1/4 cups sliced mushrooms
  • 1 cup evaporated fat-free milk
  • 1/4 cup (1 ounce) grated fresh Parmesan cheese
  • A few sprigs of fresh thyme leaves
  • 1/4 tsp fennel seeds
  • 1/2 tsp salt
  • 1/4 tsp ground pepper
  • 1/8 tsp red pepper flakes
  • 3 large egg whites
  • 2 large eggs
  • 1/4 cup Parmesan cheese
  • 1 (10-ounce) package frozen chopped spinach, thawed, drained, and squeezed dry
  • 1/4 cup (1 ounce) shredded Gruyêre cheese

Preheat oven to 375°. Grease a 9 inch tart pan with butter (or spray with cooking spray), being sure to get it into all the side grooves.

Combine oats and oat bran in a medium sized bowl; cut in butter with a pastry blender until mixture resembles coarse meal. Add water; stir. Press mixture gently into greased pan – it will seem like you won’t have enough, but you will, so just be patient, keep pressing it around and it will cover. Bake crust at 375° for 7 minutes. Remove from oven and let cool; leave oven on.

To prepare the filling, brush a cast iron skillet or saute pan lightly with olive oil (or spray with cooking spray), heat and add leeks. Saute for a few minutes till soft then add the mushrooms, salt, pepper, thyme and fennel and saute till the mushrooms start to release their liquid but are still plump and juicy. Spoon veggies into a large bowl and let cool.

Combine milk, Parmesan cheese and eggs in a blender and process until smooth. Add the spinach and pulse a few times to mix well.  Add to leek-mushroom mixture, and stir well. Pour into prepared crust (best to put the tart pan on a cooking sheet first, as it may leak a bit when you pour in the filling) and sprinkle with Gruyêre cheese. Bake at 375° for 35 minutes or until a knife inserted near the center comes out clean. Let stand 5 minutes, then remove pie from tart pan. Serve warm.

Teen Gyno

This was totally me at age 13 – except it wasn’t summer camp, it was the the local swim club, where I stood outside the bathroom stalls coaching my classmates through inserting their first tampon.

I had taught myself by reading the pamphlet that came with the box of tampons I bought,  after a 3 mile hike with what felt like a hoagie roll between my legs convinced me there had to be a better way.

Hey, someone’s gotta’ go first.

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(The video is part of a marketing campaign for HelloFlo, a company that lets you send monthly care packages timed to the menses. Very cute idea. I like how it’s taking menstruation out of the closet so to speak…)

The Fish Whisperer

The Fish Whisperer

It all started the end of last summer, when I tasted smoked trout in Saltzburg, served with a horseradish sour cream and dill.

And remembered that they stock our lake in the Endless Mountains with trout every year.

I had a mission.

Getting a fishing license 

Easy-peasy.  Just go online, buy it and print it out.  Make sure you buy the extra trout permit as well.

Getting a fishing buddy

Not as easy as getting a licence. My husband? Not interested. Most of my friends? Thought I was nuts. After all, Russ and Daughters  is just a few stops away on the F train.

Except for Paula, the Eull Gibbons of New York City, who knows more about nature than anyone I’ve ever met.  Here she is on a bike ride we took on the Croton Aqueduct Trail a few years back,  explaining how to use black walnuts as dye.

Of course Paula thought catching trout was a great idea, and actually knew how to fish! Yes, it had been over 20 years since she’d last cast a line, but who’s counting?

What Book to Read

The Science of FishingIf there is an antique fair in town the weekend you decide to become a fisherman, you must buy this book. The Science of Fishing -The Most Practical Book On Fishing Ever Published by (are you ready?) Lake Brooks.

If there is no antique fair, you can download the free kindle edition.

Getting Bait and Supplies

Fortunately, the country store down the highway sells hooks, weights, floats, night crawlers and red trout worms. Meghan, the young girl behind the counter,  shows you how to pierce the worm onto the hook, wrap it round and pierce it again, a skill you master well.

NIght crawler on a hook

Your brother-in-law left his fishing pole behind last time he stayed at your place. You’ll need a second pole, which luckily, an antique store in town has for just $10. The owner graciously oils the works for you and gives you a weighted hook from the glass cabinet for free.

Learning to Cast

Practice in the street across from your house  (sans hook, of course…) Your neighbors will have all kinds of advice, and everyone has a fishing story, so it’s a great way to pick the collective community brain on technique and timing.

When to fish

If you are Paula, who gets up at 5 am every day, or Peggy, who wants to be able to have enough time to smoke the trout for dinner that night, the answer is obvious – in the morning.

Everyone else will be asleep, so be sure to leave a note.

gone fishing

And mornings on the lake?

Eagles Mere Lake 1

The best.

Eagles Mere Lake 2

How to Fish

I had visions of me laying by a fishing pole propped up against the dock, hat turned down over my eyes Huck Finn-style, waiting for the big tug on the pole, at which point I would jump up and reel in a massive trout.

Turns out this is not actually how one fishes.

The Fish Whisperer Casts

You need to be constantly casting, reeling, tugging and tweaking the line. A few minutes in one spot, then reel in and try another. Watch the still waters for little ripples that indicate a swimmer, then cast in that direction, intermittently twitching the line and hook as you gently reel it in. Watch for the float to bob and drop, indicating that something is grabbing at the hook, then pull back sharply to snag the fish and then reel it in.

What we caught

Me? Not a damned thing in two consecutive mornings.  Seriously. Nada. Every worm, eaten off the hook.  Not counting the one still hanging from the tree near the dock. And the ones caught under a rock or tangled in the grass in the water.

But Paula, the fish whisperer?

Two sunnies

Pumpkin Seed Sunny

and two little perch.

Paula's perch

We tossed the sunnies and kept one of the perch.

How to Clean and Cook Your Fish

We followed the technique in this video entitled “How to clean a perch in 10 seconds!”  (The best part is the guy with the Minnesota accent saying “Gaw! No way!)

Our perch was way too small for smoking all by its’ lonesome, so we coated it with a teeny bit of mayo, tossed it in flour seasoned with salt and fresh ground pepper and pan-fried it in butter and oil.

Pan fried floured perch

Little bites of heaven.

Pan Fried Perch with lemon

PERCH ON A CRACKER

But not trout.

There’s Always a Catch…

In this case, it turns out that the best place to snag a trout is not in a lake using a worm, but  in a cold running brook using a fly.

Which, I expect,  is why they stock our lake each year. Except that they didn’t stock the lake this year, given the recent sunfish die off  – caused by stress around the time the lake turned,  but by the time they figured that out, it was too late to stock. (The water, thankfully, is as pristine as ever.)

But as it turns out, even if they had stocked trout, warm summer mornings are not the time to catch them.

Better in the fall and in the evening. And in a boat out on the lake.

So no trout.

For now.  But I’ll be back.

Hopefully the fish whisperer will be there too.

WHen the catch is done