A Virtual Choir

Composer/conductor Eric Whitacre has created a virtual choir. He videotaped himself conducting, then asked singers to record themselves singing their respective parts and send it on to him. He then merged their voices and videos electronically. The end result is the amazing recording above – 185 singers making exquisitely beautiful music together.

Adding such joy to the world. That’s not virtual – that’s real.
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You can be part of Whitacre’s next virtual choir performance – no auditions are necessary, according to info on his facebook page, where he states he wants to compose an original piece and assemble a choir of hundreds, even thousands.  Watch for the announcement, either on his facebook or youtube pages, then make and send in your recording. You can be sure I’ll be sending in mine!  

Forskalin for UTI? Maybe – If You’re a Rat

A patient came into the office the other day carrying a small clipping from a reputable Women’s Health newsletter touting new research on an herbal remedy for urinary tract infections. Having recurrent bladder infections, my patient naturally was wondering if this was something she should try.

The article was entitled “Herbal Remedy Effective for Urinary Tract Infections”, and began with this startling revelation –


The common herbal extract forskolin can greatly reduce urinary tract infections and could potentially help antibiotics kill the bacteria that cause most bladder infections. 


but advised that the “popular” remedy was not FDA approved for this indication, so she should “ask your doctor.”

Googling it, I quickly discovered the research study being touted in the article – a small pilot study from 2007, in which researchers instilled a solution containing the herb Forskolin (Who thought of that name? Sounds like Foreskin…) into the bladders of lab rats previously infected with e coli, then sacrificed the rats and compared their bladders to those instilled with saline solution. Their findings – less bacteria in the forskolin irrigated rat bladders.

Needless to say, once I simply explained the research findings to my patient, she had absolutely no desire to try this untested herbal remedy.

“I’m no rat and I’m no guinea pig” she said.

Smart woman.

OBS Housekeeper’s Pulled Barbecue Chicken – From Philly to NYC

A few Fridays ago, I decided to drive down to Philly for the evening – my grade school was closing, and how could I miss the final party?

But I was having my Musical Theater Class over for our cast dinner on Saturday evening. And I wanted visit my Mom before leaving Philly on Saturday morning. How could I get it all done?

Enter my wonderful sister, the OBS Housekeeper and her amazing Pulled Barbecue Chicken!

Not only did OBS put me up Friday night, but Saturday morning while I visited with Mom, she (along with sis Basket Mom) shopped, then cooked the chicken for me to take back home to New York City, packing it in a covered aluminum tray for safe transport.  I popped it into the fridge when I got home, then whipped up some red pepper crostini, lemonade and a cucumber salad. My guests brought more sides, beer, wine, appetizers and desserts. (Thanks Ronnye and Paul for coming early and helping!) The rain held off till after dinner was over, and we had a great time singing around the piano during dessert.

Thanks, OBS and Basket Mom for making my weekend. And my party. I couldn’t have done it without you!

OBS Housekeeper’s Amazing Pulled Barbecue Chicken 

Actually, the recipe comes from Rachel Ray , but OBS makes it better that Rachel does, I’m sure. It is absolutely delicious! Serves 6-8, but adjust accordingly for a crowd. You can make it in the morning the way OBS did for me, refrigerate till ready to serve, then reheat quickly on the stovetop and you’re ready to go! Goes great with cucumber salad. 

4 boneless, skinless chicken breasts
salt and pepper
Water to cover
1 medium onion, finely chopped
4 cloves garlic, finely chopped
1 1/3 cups barbecue sauce (You can use pre-made, or make Paul’s recipe)
1/2 cup apple cider vinegar
hot pepper sauce
6 ounces mild cheddar Cheese, shredded
8 rolls

Wash and dry chicken breasts. Season with salt and pepper and place in a heavy pot with the onion, garlic. Add just enough water to cover, then the barbecue sauce, vinegar and a few drops hot sauce (more or less to taste). Bring to a boil, then reduce the heat and simmer until the chicken is cooked through, about 15 minutes. Remove the chicken from the sauce and shred with two forks.

Boil the sauce, skimming occasionally, until reduced by half, about 15 minutes. Season with salt and pepper. Add the shredded chicken and heat through. Serve in a crock pot or casserole dish with the rolls and cheese on the side. Let guests assemble their own sandwiches. Enjoy!

DrugWatch.com = Ambulance Chasers

I don’t know about the rest of you medical bloggers, but I’ve been getting emails from folks who run a website called “DrugWatch.com”, asking for reciprocal links and promoting themselves as the go-to place for patients to get up to date info on medication safety.

Tucked into the website is this promise – “We will never accept advertising from the pharmaceutical industry”.

Right. Because the whole site is a front for a bunch of Orlando lawyers trying to sniff out potential clients for medication-related lawsuits against the pharmaceutical industry.

DrugWatch.com is sponsored by The Peterson Firm, LLC, which is licensed by The Florida Bar to practice law in the state of Florida. The Peterson Firm, LLC’s main office is located at 2317 North Wickham Road in Melbourne, Florida, 32935. If you indicate to your Patient Advocate your desire to speak with an attorney about your legal rights, he or she may recommend various law firms and recommendations may include law firms from around the country including The Peterson Firm, LLC. If you decide to retain The Peterson Firm, LLC for the handling of your legal claims, The Peterson Firm, LLC may utilize experienced co-counsel (at no additional cost) to assist in the prosecution of your claims. If a Patient Advocate-recommended law firm is retained, The Peterson Firm, LLC may co-counsel and assist with the prosecution of the claim at no additional cost to the client. The Peterson Firm, LLC handles cases on a contingency fee basis, and there are no costs or fees charged to the client unless a recovery is made.

Big Pharma has their disease awareness websites. Now the lawyers have their drug side effects awareneness websites.

And the game goes on….

Gorilla Opera

Flash Brindisi – Members of the Opera Company of Philadelphia break into song at the Reading Terminal Market in Philly.

Food and music together? It doesn’t get any better than that!

Spring Supper Salad – Scallops, Green Beans & Baby Reds on Lettuce with Miso Dressing

Perfect for a light meal after a warm Saturday afternoon biking the West Side Greenway Trail. Stop at Fairway on the way home for provisions, then eat al fresco with a cold beer. Ahh, spring!

Scallop, Green Bean and Baby Red Spring Salad with Miso Dressing

The dressing is modified from Museum Cafes & Arts, a little gem of a book of recipes from museum cafes illustrated with gorgeous prints of famous works of art.  The rest of the recipe we made up ourselves. Although I’ve listed the weights of the potatoes, scallops and beans we used, you should just buy what you think you need. The dressing will serve at least 6. 

1 lb small red potatoes
salt and pepper to taste (just a tiny bit – the dressing is salty)
3 tbsp canola oil
1 1/2 lbs large scallops
Fresh lettuce
1/2 lb green beans
Miso Dressing (recipe follows)

Wash and dry potatoes well. Don’t peel. Cut into half (or thirds, however you want, to uniform size) Toss with 1 tbsp canola oil and 1/4 tsp salt and pepper. Spread on a baking sheet and bake at 400 degrees, turning halfway, for about 30 minutes, or until browned and cooked. While the potatoes are cooking, make the dressing, wash and dry the lettuce. Steam the green beans over boiling water till warm, bright green and still a bit crisp. Drain and set aside. Remove cooked potatoes to a bowl and set aside while you cook the scallops.

Heat 2 tbsp olive oil in a skillet until very hot but not smoking. Add the scallops and sauté until nicely browned, about 3-4 mins. Turn to the other side and cook one more minute.

Arrange the greens on a platter. Arrange the scallops, browned side up, on the bed of greens. Scatter some green beans atop the greens and place the potatoes on the side. Drizzle dressing over the scallops, beans and greens and serve immediately. Serves 4.

Miso Dressing

I happen to love this dressing, but if it’s not for you, make my warm tarragon vinaigrette instead.

1 tsp sugar
1/4 cup white miso
2 tbsp rice vinegar
1 tsp wasabi paste
1 tsp fresh lemon juice
1/4 cup light soy sauce
1 teensy-weensy drop sesame oil (optional)
1 1/2 tbsp canola oil

In a small bowl, whisk together all ingredients except the canola oil. Gradually whisk in canola oil.

Autism and Infertility – More Questions Than Answers

In the latest media barrage on autism, infertility treatments have come into question as a possible cause for this increasingly common developmental disorder. The reason is two research abstracts presented at the International Meeting for Autism Research this week in Philadelphia. (If you’re interested, the abstracts are on pages 9 and 11 of the linked pdf file).

One study assessed the history of IVF among 574 children evaluated at a special center for autism in Israel. The researchers found that 10% of the group diagnosed as autistic had had IVF, compared to a background rate in the overall population which they quote as 3.5%. Not surprisingly, maternal age was higher in the IVF group and the rate of prematurity was higher in the autistic children.

The second study was a look into a pre-existing database – the Nurse’s Health Study – which collects data from a cohort of nurses over time. The researchers compared the reproductive history reported by women who also reported having a child with autism and compared it to that of women who did not report having an autistic child. Of those with autistic children, 48% reported infertility with 34% having used ovulation inducing drugs, compared with 33% and 24%, respectively, in women without autistic children, a difference that was statistically significant when controlled for maternal age and self-reported pregnancy complications.

A Time article getting a lot of media play calls the results of the second study “some of the strongest evidence to date” linking autism to fertility treatment.

Unfortunately, that’s just not true.

Studies such as the one being reported this week certainly raise questions, but in reality do nothing to answer them. They are nothing more than preliminary forays that are fraught with problems when one tries to use the results for anything other than to inform further, better designed research. The problem is not necessarily with the studies themselves, which are clearly preliminary – it is with how the media is reporting the results. Which gets into the whole problem of PR and media reporting of research meetings, which I think is getting out of control, but that’s another post for another day…

For now, let’s go through the more obvious limitations of the data being presented.

1. The Nurses Study Population – A 33% rate of infertility in the control group and close to 50% in the study group? The background rate of infertility in the US is about 10%. Is this study population representative? I doubt it.

2. Recall bias – This is when an individual who has experienced an adverse outcome does a better job of remembering exactly what drugs and treatments she took than someone who has not had the adverse outcome. It’s human nature, after all, to spend hours, even days looking back and asking “What did I do that caused this?” But it means you remember a lot more than folks with no reason to be so retrospective. The Nurses Study, being a prospective collection of data, does not have this bias, but the Israeli study may.

3. Controlling for the underlying problem – infertility. The Nurse’s Study found that women having more cycles of IVF or clomid had higher rates of autism. But if you need to undergo multiple cycles of infertility treatment, isn’t it just possible that there is something about your gametes – either egg or sperm – that are the problem, and not the drugs themselves? The fact that autism is a highly hereditable disorder supports that there may be an inherent association between the state of infertility and autism. Maybe infertility is nature’s way of controlling the gene pool, so to speak, and we’re messing with it by helping folks get pregnant who maybe weren’t supposed to. Don’t tell that, of course, to the millions of normal, healthy and intelligent individuals born as a result of IVF. But it might explain small increases in certain conditions among children born after fertility treatments compared to the general population, mightn’t it?

While the researchers did control for age, that’s just not good enough. We all know that while age is an excellent marker for IVF success, it is ultimately the quality of the oocyte and sperm that is the most important factor in determining success in fertility treatment.

4. Cause of infertility – One way to tease out the effect of the gametes from the fertility drugs is to focus only on those women with tubal infertility – their eggs are fine, it’s the passageway that’s the problem. If this group had higher autism rates with ovulation inducing drug use, then that’s a stronger association. Unfortunately, the data presented were not detailed enough to address this question.

5. Consequences of fertility treatments – Ovulation inducing agents all lead to higher rates of multiple pregnanies with their associated complications of prematurity and low birth weight, both factors associated with autism. How much of the reported associations were due to these factors and not the fertility treatments themselves? 

6. Diagnostic bias – Could it be that parents who persist through multiple fertility cycles against the ever increasing odds that they may not have a child might also be more persistent in getting their child diagnosed with autism? It’s possible, I believe.

To date, well done research into developmental outcomes of children born as a result of assisted reproductive technologies (ART) has not found significant risks, but most studies have been confined to infancy and early development, prior to when some children may be diagnosed with autism. Recent studies on longer term childhood outcomes among children born as a result of ICSI (intracytoplasmic sperm injection) have been quite reassuring in this regard. One small study did find a higher rate of autism in children born after ICSI, but not IVF, and the numbers were so small (3 children only had autism), that it’s difficult to make larger conclusions from the data. A recent review article found no reliable studies of autism and ART, and calls for more research.

I would agree.
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Photo from NBC.com

Tag Team Skillet Gnocchi Casserole

How do you get a deliciously healthy family supper together when you have a late meeting and your husband has to pick your younger daughter up from a study session at a friend’s house across town? Not to mention stay on your diet?

Sounds like a job for the Weeknight Warriors! But this time, you tag team it. Here’s how we did it  –

4:50 pm – Just before heading onto your late afternoon meeting, you find a great recipe on Eating Well.com site, which features 500 calorie dinners!

5:00 pm – Call Mr TBTAM to get his agreement on the meal choice, then email him a list so he can pick things up on his way home from work. Head to your meeting.

6:30 pm – Mr TBTAM, now home with gnocchi and spinach, heads into the kitchen to prep.

7:00 pm – Mr TBTAM sets the table, then leaves to pick up younger daughter. You leave the office and head home.

7:15 pm – You head straight from the front door to the kitchen, stopping only to don an apron, and start cooking. You feel like a TV chef with a staff of kitchen elves –  the onions and garlic are all chopped, the can of tomatoes and beans are opened, the salad greens and spinach washed and everything is out on the counter waiting for you!

7:45 pm – Everyone’s home, dinner is on the table. Go Team!

Tag Team Gnocchi Skillet Casserole

Modified from Eatingwell.com. The big short cut in this meal is using prepared gnocchi, but feel free to use homemade. This dish would be good with pasta as well, but the gnocchi are really special. Serve with a green leaf salad with a light dressing to make it to 500 calories total. We made the goat cheese tomato dressing suggested on the website, but it ended up a bit too watery to post the recipe.

I modified the Gnocchi recipe from EatingWell by boiling the gnocchi first, using a tad more olive oil so the gnocchi would not stick (I use a stainless steel and not a non-stock skillet), spinach instead of swiss chard, increasing the onion to large, substituting chicken broth for water and adding some fresh basil and hot pepper flakes. My calorie count is about 20 calories more per serving than the recipe on the website, or about 340 calories. Of course, that’s only if your serving size is 1/6 of the total. Unfortunately, I think I ate about 1/5 of it, so I actually had about 400 calories. It’s all about portion size, isn’t it?

Boiling lightly salted water
1 16-ounce package gnocchi (We used Emilia brand from Fairway, also at Trader Joe’s)
2 tablespoons olive oil
1 large onion, thinly sliced
4 cloves garlic, minced
1/2 cup fat free chicken broth
6 cups fresh spinach leaves, washed and drained
1 15-ounce can diced tomatoes
1 15-ounce can white beans, rinsed and drained
1/4 teaspoon freshly ground pepper
1/4 tsp red pepper flakes
2 tbsp chopped fresh basil (or a tsp pesto)
salt to taste
1/2 cup shredded part-skim mozzarella cheese
1/4 cup finely grated Parmesan cheese

Bring a pot of lightly salted water to a strong rolling boil. Add gnocchi and cook, usually for 2-3 minutes, removing them with a slotted spoon to a colander as they pop to the top of the water. Drain.

Heat 1 1/2 tablespoon oil in a large skillet over almost high heat. Add gnocchi and saute for about 5 minutes, turning them gently with a fork as they brown lightly. (Try not to eat any.) Transfer gently to a bowl. (Surprisingly, they don’t break apart.)

Add the remaining 1/2 tbsp oil and onion to the pan and cook, stirring, over medium heat, for 2 minutes. Add the garlic and cook another minute, then the chicken broth. Cover and cook until the onion is soft, 4 to 6 minutes. Add spinach and cook, stirring, until starting to wilt, 1 to 2 minutes. Stir in tomatoes, beans, basil, pepper and pepper flakes and bring to a simmer. Cook off any excess water that may have accompanied the tomatoes (next time I will drain the tomatoes).

Stir in the gnocchi and sprinkle with mozzarella and Parmesan. Cover and cook until the cheese is melted and the sauce is bubbling, about 3 minutes. Serve hot.

I Wanna’ Be Sedated

Dr Whoo and I seem to be in the same place at the same time. We both struggle with our weight because we are using food for other than sustenance. We use it to manage stress. Overeating is, after all,  a wonderful sedative. Soothes the savage beast and all that. And it really works. I’ve probably saved my marriage and my job and kept from killing my kids and my husband by sedating myself with food.

In Dr Whoo’s case, the sedative of choice is pasta. In my case anything edible and not growing mold, but preferably bread or pretzels with something fatty, either cheese or Nutella would do just fine, thank you. Mother’s little helper never tasted so good….

What am I sedating with food? Frustration, irritability and anger that results when conflicting priorities build and I have to make choices I don’t want to make. Sleep or get the work done. Help my kid with her homework even though its 10 o’clock and the first time I’ve sat down to relax all day. Ignore the email in-box while I finish patient charts. Or tackle the email while the charting builds up. (The two tasks can never both be completed in a single day, I am convinced.) Or once again finish seeing my patients for the day only to turn and face the ever growing pile of lab and radiology results and phone calls that came in while I was in office hours.

Bad internet connections also makes me overeat if I’m trying to get work done. By the time the damned site loads I can head to the kitchen and shove in a handful of something.

During the 11 weeks I spent losing 33 pounds in a controlled research diet, the option to sedate my frustration and anger with food did not exist. It was an interesting little experiment in dealing with life. I have to say I occasionally cheated during a particularly stressful evening with a little piece of pretzel dipped in nutella (hopefully Charlie, the study PI, is not reading this blog post…), but overall, I learned to cope without the food. It also happened to be a rather quiet time in terms of conflicting responsibilities.

Now, almost a month later, I find myself turning back to food. It may be that this has been a particularly stressful time – I’ve been working with a colleague to get a grant written while seeing a full load of patients and doing all my usual administrative work in my department. Not to mention trying to be a good mom, sister and wife, hosting a dinner party mid week and performing with my chorus. Thankfully last weekend was a quiet one, and I even got in a 12 mile bike ride on Saturday. Which did not stop me from hitting the pita chips and party leftovers that same night when I couldn’t find the ideal breast cancer knowledge tool anywhere in the literature ( a slow search because the library connection was slow) and needed to come up with something to write in the grant to explain how we were going to measure that variable. I headed to bed at 4 am feeling lousy.

Sunday I awoke at 10 and made the smart decision to head to the office, where the library’s internet connection was fast and there were no windows to remind me that it was a gorgeous spring day and I was working.  I also happened to be away from any kitchen and my daughter came with me to do her homework, so no guilt was involved. I actually got a huge amount of work done, and more importantly, I made it through the day without overeating. That meant that night, instead of feeling guilty, I felt elated. I had written several important parts of the grant (which my collaborator may trash, but that’s okay, she’s better at this stuff than I will ever be), caught up on chart work and even posted a quickie blog post. My daughter got caught up on her homework and started a big project.  Not to mention that while she and I were working, Mr TBTAM had done the spring garden cleanup on the roof! I felt literally high thinking about all that we had accomplished that day. The frustration of the grant writing was over, the garden looked wonderful, and to top it all off, I did not have that cloggy brain that I get when I over eat. I felt physically great.

And then I had one of those Aha! moments.

I realized that while stuffing myelf with carbs and fat quite effectively sedates the frustration, it also squashes the joy for some time thereafer. Joy, is after all, a feeling of euphoria. Or as it has been so beautifully said – the unbearable lightness of being.

It’s hard to get that feeling if you are stuffed to the gills, your tummy bloated out with post carb gas, your post prandial brain plugged with the glue of sugar and your anger at yourself mounting because now you’ve lost momentum and gained back the weight you worked so hard to lose. True, you are no longer anxious. But you’re not capable of happiness at that point either. You’re too busy feeling lousy. Or at least I am. And that lousy feeling can last a lot longer than the frustration would have lasted if I’d just lived through it.

Don’t ask me how it took this many years of living to realize this, but I have.

Now of course, the question is this – How do I remember it the next time I find myself reflexly heading to the kitchen while waiting for the internet to load? Or my daughter to finish the math problem before I review it? Or the feeling to pass when I look at my calendar and realize that I can’t do it all?

That my friends, is the question.

The Diaphragm – Now Available at Your Local Pharmacy

7/3/15 UPDATE – THE CAYA DIAPHRAGM IS NOW AVAILABLE IN THE US. HERE’S WHAT YOU NEED TO KNOW TO PRESCRIBE OR OBTAIN IT.

UPDATE  – JANSSEN PHARMACEUTICALS HAS DISCONTINUED PRODUCTION OF THE DIAPHRAGM AS OF FEB 2, 2014. SEE UPDATE HERE.

After a prolonged hiatus, during which diaphragms became as scarce as Elaine’s treasured sponges, the Ortho All Flex diaphragm is back, and it’s now latex-free. The over one-year (at least in my area) shortage happened as the manufacturer transitioned from the old latex to new silicone diaphragms, and suppliers everywhere began back-ordering this important barrier contraceptive.

I called Ortho today, and was informed that the new diaphragms have been available for a few months now. I checked with my local pharmacy, and they advised me they could get a size 75 within 24 hours. At online pharmacies, diaphragms sell for $40-$50. You’ll need to restock spermacidal gel at a price of about $15 a tube – good for 30 or so uses.

Milex also makes non-latex diaphragms (arcing spring and wide seal), but these diaphragms must be ordered by your doctor from Cooper Surgical, as opposed to you filling the prescription at the pharmacy. I’ve been purchasing these diaphragms for my patients for the past year, and will continue to use them for patients whose anatomy calls for the added secure fit of the wide seal or arcing spring.

These days, it seems I rarely prescribe the diaphragm – most women seem to prefer other methods. In my younger years, the diaphragm was a very popular method. It’s a good option if you don’t want to or can’t take hormones. Efficacy ranges from 84-94%, but in motivated couples who use it properly (Mr TBTAM and I were in that group for years), the diaphragm can be extremely effective.  It only works if you use it properly every time you have intercourse, so if that’s not you, then look elsewhere for your birth control.

Don’t use the diaphragm unless you know your partner is HIV negative, since the method requires the use of spermacides, which can increase HIV transmission from an infected partner. Although most women use it without problems, users of the diaphragm have a slight increase in vaginal infections and urinary tract infections.

For more information and to see if the diaphragm is right for you, visit Planned Parenthood’s website.
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More reading on the diaphragm from around the web

Lung Cancer and Women

A new report on lung cancer in women has been published by the Women’s Health Policy and Advocacy Program at Brigham & Women’s Hospital.  Called “Out of the Shadows“, the report seeks to raise awareness about lung cancer, currently the leading cause of cancer deaths in women, and more importantly, to increase funding for research into its prevention, detection and treatment. (HT to Booster Shots, the LA Times’ fabulous health blog, for highlighting the report.)

I encourage you to read the report, which is well written and comprehensive. For a more scientific summary of the issues, I would point you to December’s Seminars in Oncology, a special issue devoted to lung cancer in women.

The report is quite open about the stigma that smoking brings to the issue of lung cancer advocacy, and so seeks to focus our attention instead on those lung cancers that occur in non-smokers, which are on the rise as smokers decline as a percentage of the overall population. Although this rise in lung cancers among non-smokers is not universally accepted, nonetheless one in five lung cancers in women occur in those who have never smoked. That’s a significant number of cancers that deserve our attention and advocacy as much as breast and cervical cancer.

Factors that differentiate lung cancers in women from those in men include a lower mortality in women as well as high rates of cancers among female non smokers.  Differences in hormonal mileau in men and women as well as in the presence of growth regulator genes linked to X chromosome have been suggested as explanations for these sex differences, along with other factors, including the variable susceptibility between men and women to the effects of environmental carcinogens.

Despite the fact that smoking is linked to 80% of lung cancer deaths in women, the report devotes surprisingly little space to strategies aimed at reducing cigarette smoking in women and its policy implications include no strategies towards this goal. I suspect this is because they are trying to drive us away from thinking about lung cancer as just a nicotine related disease, but it is, so let’s face it.

I also find it frustratingly that we have so little information on potential environmental carcinogens other than cigarette smoke that may be causative in lung cancer. The coincident rise in asthma among women makes me believe that the environmental connections are there and must be found if we are to prevent further increases in pulmonary disease and cancer in women.

The report does a nice job summarizing new technologies for lung cancer screening and treatment without hype, although it is not necessarily without bias. For example, while presenting screening lung CT as controversial, and acknowledging the potential for leadtime bias in early screening interventions, the conclusion tends to focus on the more positive aspects of this screening. It also discusses new non-invasive screening tests by name that are not yet FDA approved, which is sure to get more than a few folks in to their doctor’s office asking for these tests.

Overall, however, I found the report to be both informative, well-referenced and appropriate reading for both lay and professional audiences, and applaud the Women’s Health Policy Advocacy Group for taking on this important health issue for women.

The Gynecologist and Lung Cancer 

As a gynecologist, these are the things I tend to thinks about when it comes to lung cancer in women –

1. HRT and lung cancer – Although hormone replacement has been linked to an increase in lung cancer mortality in women, HRT users do not have higher rates of lung cancer than non users. This correlates with what we know about lung tumors, which is that they can have receptors for estrogens, which in turn can act as growth promotors.  This would suggest caution in using HRT in smokers or others at increased risk for lung cancer as well as a potential role for hormonal treatment in lung cancers similar to hormonal treatments used in breast cancer. (Oral contraceptive use is not linked to lung cancer incidence or mortality.)

2. HPV and Lung Cancer – Is there a link? – I was surprised to see no mention in the report of the possibility of a link between HPV infection in the respiratory tract and lung cancer. It is an intriguing theory that has biologic plausibility. With the coincident shifts in values regarding oral-genital sexual activity and the HPV epidemic among young people, there is an urgent imperative to either repudiate or validate this theory, particularly since we now have an effective vaccine against two of the cancer causing strains of HPV.

3. Smoking and Women – We gynecologists have two reasons to hate cigarettes – lung cancer and cervical cancer.  Both these cancers are strongly linked to smoking, and any effort to tackle lung cancer is a waste if we don’t tackle cigarette smoking.  To continue to allow Big Tobacco to recruit new smokers through aggressive advertising while we struggle to fund lung cancer research is just plain stupid. 
It’s time we regulated tobacco like the drug that it is – a drug with immense risks and no benefit to anyone but the tobacco industry. We need an aggressive, national plan to stop tobacco advertising both here and abroad, to limit tobacco use to prescription access for current smokers while we move them into smoking cessation treatment and to transition tobacco farmers to sustainable and healthful food crops. 
Enough is enough. 

An Ohio Country Bike Ride

A weekend visit to see our daughter at college provided a chance for an early spring bike ride in central Ohio. (It’s what we parents do while the kids sleep till noon on Sunday morning…)

Mr TBTAM and I rented our bikes from Granville Bike Rentals, who delivered them right to the B&B where we were staying in Granville, Ohio, just a few blocks from an entrance to the TJ Evans Recreational Trail. We followed the trail west to its terminus at the granary in Johnstown and back, a total of about 22 miles.

The trail, which originates in Newark, Ohio, follows the old Toledo & Ohio Central railbed and passes through farmland

and forest,

crossing a few streambeds,

 and cutting right through a corn field!

We rode past hills covered with goldenrod,

and stopped to visit with some cows, who were so close we could hear them munching on the grass.

We had some nice conversations with locals on the trail, including one man who was running the exact route we were biking (in training for a marathon.) We also enjoyed this little sign along the trail, obviously posted by a local who must have gotten a few too many visits from the fire marshal responding to calls from passing bikers.

Yep, we’re in America’s heartland all right…

Biking is a great way to settle in to a new locale when visiting, and old rail trails give a unique back-side view of the landscape that I find much more interesting sometimes than the face we see from the streets. Not to mention that the ride is usually fairly level…

By the way, during our visit, we stayed at the Porch House B&B in Granville, which has charming Victorian rooms with lovely private bathrooms and one of the best breakfasts I’ve ever had. (They use eggs from their own chickens!)  I highly recommend it.
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The TJ Evans trail official site
Ohio Bikeways has a video of the TJ Evans trail and travel tips for riding it
Heather took some pretty fall photos along the trail

The Estrogen Dilemma – Hope, Hype or Just One Woman’s Story?

It’s only Wednesday, and so far three patients have come to their visit carrying Cynthia Gorney’s article from Sunday’s NY Times called the “The Estrogen Dilemma“. The article explores the stories of three women who found relief from perimenopausal symptoms by using hormone replacement, framing the discussion in the larger context of what is being called the “window hypothesis” – the idea that starting estrogen replacement in the perimenopause and continuing it into later life may be neuroprotective and even cardio protective, in contrast to beginning its use 10 or more years after menopause, where it can trigger heart disease, strokes and dementia.

The window hypothesis is one way of explaining away the findings of the Women’s Health Initiative, and goes something like this – “The WHI enrolled women who were too late into menopause to benefit from estrogen. If we had instead studied women starting estrogen at the right time, namely the perimenopause, we would have found that it protects against heart disease and Alzheimers.” Or as I explain it to my patients  – “Think of it like exercise. If you work out vigorously and regularly from a young age, you can prevent heart disease. But take an overweight, out of shape 65 year old and have him/her run full out and you could trigger an MI”.

The Times article does a good job framing both the hope and the hype around the window hypothesis, and the dilemma it appears to pose for women entering menopause today, which is this –  If you wait for data that proves the window hypothesis is right, by the time the results are in, you’re outside the window and it’s too late to start HRT. If you start HRT now and the hypothesis is proven wrong, then you’ve been taking medication with potential risks for years without any benefit.  Or, as author Cynthia Gorney so succinctly put it-

If I make the wrong decision about this, I am so screwed.

The pharmaceutical industry, particularly Wyeth, the maker of Premarin, is, not surprisingly, working hard to get the word out about the window hypothesis. Indeed, several of the researchers working on the hypothesis who are quoted in Gorneys article have ties to Wyeth. At the risk of further hyping a hypothesis that may prove to be unfounded, I encourage you to read the Times article, and then take the time to peruse the intelligent discussion in the comments section. If anything it is testimony to just how well-informed the American public has become about HRT.

I myself have been hearing about the hypothesis for years now, but have yet to see definitive data to prove it.  Fortunately, there are studies in progress that may settle the question within the next few years.  But even if the window hypothesis proves to be correct, it will not mitigate the risks of breast cancer that accompany long term estrogen use in the menopause. That risk remains, in my opinion, the biggest concern for my patients when it comes to HRT, and it is surprisingly downplayed in the Times article.

The biggest problem I have with the article is that Gorney’s experience with both menopause and HRT is anything but typical. Most women get through the transition without major mood issues, although crankiness and irritability are common, especially in women who are not sleeping because of night sweats. When true depression hits, as it did for Gorney, antidepressants are needed, with or without hrt (Gorney takes both). I have seen the occasional woman who declares “I am back!” after starting HRT, and one particularly memorable patient whose depression was cured, but this is the exception, not the rule. Most perimenopausal women who take HRT are just relieved to be able to sleep through the night or get through a meeting without hot flashes.

But most importantly, what does Gorney’s individual experience with HRT and mood have to do with the window hypothesis? She is not taking HRT to prevent Alzheimer’s or heart disease – she is using it to augment the effects of her antidepressants. The whole window discussion thing is distracting from the real question at hand for her, which is sinply this – how long should she take HRT? That depends, not on whether the window hypothesis is true, but on how she feels when she tries to stop taking HRT.

If I were Gorney’s doctor, I’d be focusing her off the window hypothesis and onto why she is taking HRT in the first place – for emotional well being. Now that it’s been a few years on the stuff, I’d say, let’s lower your dose and see how you do. If you do well, then stay on that dose for 6 months to a year, then go off and see if you still need it. Based on Gorney’s experience with occasional missed patches, I’ll predict she’ll still need HRT, but will be able to get away with a lower dose. But if she feels just as well off HRT, then I would advise her to stay off. Do everything else she can do to prevent heart disease – diet, exercise, low salt, get enough sleep, you know the drill.

As for using estrogen to prevent Alzheimers, well, that’s a big leap of faith that I for one am not yet ready to take.  Which does not mean that I don’t have an occasional patient (usually a scientist) taking HRT because she hopes it will prevent Alzheimers. Such women, in my experience, are much less worried about breast cancer than about cognitive decline, in an attitude similar to that of Julia Berry, one of the women profiled in the Times article, who had this to say  –

I could have my breasts removed. I like them. But they’re not my life.

Recent data suggests that Berry may not need to make this Sophie’s choice between her brain and her breasts. The mental confusion so many women experience in perimenopause may in fact resolve itself once we come out the other side, irrespective of hormone use. This suggests that it is the widely swinging hormones of perimenopause that pose the most trouble for women, but that once things settle down, so do we.

Now that’s a window hypothesis you won’t hear Big Pharma talking about…
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Picasso’s Portrait of Dora Maar. From Musee national Picasso, Paris

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More from around the web on the Estrogen Dilemma

  • Patricia Allen, MD reminds us that this article is a personal essay, and that HRT is not the holy grail
  • Dr Mintz advises to read the article with caution