Dr Wes is hosting this week, and what a week it’s been.
I was stunned to read about what has been going on over at Neurodiversity – the blogger whose reporting into the legal machinations behind the vaccine-autism debate has led to attempts to intimidate her by subpeoena. A must read for anyone who believes in first amendment rights.
Head on over for this and much more. Truly the best of the medical blogosphere.
So, here’s what I’ve been thinking lately.
We all have to die, right? Really. We cannot live forever, even if we think we can.
So no matter how good we get at health care and taking care of ourselves, we are all going to die of something. And there will always be a “#1 killer of women” and a “#1 killer of men” for us to be afraid of.
And a cause to fight or a new drug to sell or a headline to scare us or funding that is needed from the government for treatment and research.
So when does it stop?
I mean, what happens when we’ve cured cancer and found the perfect statin or perfect diet? What will we do when the word “plaque” only refers to a thing you get to hang on your wall ? Or when diabetes is discovered to be from a virus and we get the vaccine, and when stem cells make Alzheimer’s and Parkinson’s obsolete…will there be anything left to die from?
Or will we all live forever?
And if we don’t live forever, how long will we all live? To 120 years old? 150?
At that point, will there be a group of people who are living to 150 and still look great but a whole lot of people will still be dying at 95 from heart disease because they can’t afford the best health care?
But that’s already happening, isn’t it? Just on an earlier scale.
I mean, here we are, just plowing ahead curing everything right and left, leaving many of us to live longer and longer while women and children are dying at young ages from thing like malaria, measles and infant diarrhea. Diseases we in the developed world left behind in the history books years ago.
Really, really think about that. While we sit here worrying about which statin to take because we won’t get off our fat ass to exercise, kids are dying all over Africa from malaria and measles.
That’s because there’s no master plan. There’s no prioritizing where the money is going on a worldwide basis.
Now I know those laisse faire capitalists out there are saying “Leave it alone. Let it evolve. It’s working, just not at the pace everyone wants it to. And not equally everywhere, but give it time. We’re figuring it out…”
But are we figuring it out? Or are we just figuring out best how to make money doing it?
Because if it’s really all about making money, then we should not be surprised that we spend so much on it. And we should all just shut up and spend the money and see where it takes us.
But we really don’t want to spend the money, do we? We want our cash for other things, like I-phones and HDTV and oil guzzling minivans and movie downloads.
Of course we can’t say that, so we talk about the uninsured and the poor who can’t afford health care.
But really, how much would it cost for us just to take care of those folks? Not much compared to what we are paying overall for health care we would rather get for free so we can spend our money elsewhere.
And certainly pennies compared with the billions we spend trying to hang onto every last second of life because we really haven’t come to terms with the fact that we all have to die. And that if that death happens to be unexpected, it doesn’t necessarily mean that someone did something wrong and we have to find someone to blame.
How many times have I heard people speak these words – “Why haven’t they found the cause of … yet?” or “Someone has to have figured this out by now” or “”How come they don’t know …?”, all spoken with the expectation that it’s someone’s responsibility to have figured these things out, and if it’s not done, then by god, someone’s not doing their job!
All of which leads to lawsuits and raises the costs of health care even further.
Or do I have it all wrong? Maybe health care costs so much because the system isn’t free market enough. After all, the price of most things goes down with time – like I-Phones and laptops. But health care just keeps getting more expensive.
Maybe the answer is to just set the beast free. Get rid of insurance companies and go back to the days when folks just paid the doctor. Then who knows what health care would look like? Maybe I’d become obsolete because someone else has figured out how to deliver health care more cheaply.
Uh, oh. This thought train is taking a turn I don’t like. I think I’ll stop and make some soup.
A woman I know has a second home in the mountains that she rents out when she and her family are not using it. In the house, they keep a guest book for renters to sign and write remarks, thank you’s, suggestions etc.
Recently she and her family were at the house and she decided to look through the guest book. In doing so, she came upon this entry from a recent tenant which read something like this –
“We had a wonderful stay at your lovely home. It will always be part of our family memories. While we were here, I gave birth to my third child while in the jacuzzi overlooking the mountains. It was an experience I will never forget.”
Neither will my friend, after spending an hour cleaning the afore-mentioned birthplace with clorox before she would let her kids use it that weekend.
I don’t know if there are any rules of Jacuzzi Etiquette, but if there were such a thing, this has to violate it. Plus, I thought “home” birth means you do it in your home, not someone else’s.
Time to add some new language to the rental agreement…”No home births, please.”
While Hillary and Obama are debating how to save health care and we all rail against the drugstore clinics, a quiet revolution in primary care delivery is happening right under our noses.
I’m talking about employer-based health clinics. In-house clinics operated on site at the job, usually staffed by mid-level practitioners and maybe a doc, sometimes including a pharmacy.
What got me thinking about workplace clinics?
Well, a few days back, a young patient who I had not seen in 3 years arrived for an appointment, abnormal pap smear in hand, requesting a coloposcopy. She had been referred back to me by the nurse practitioner at her job, where she had been getting free pap smears since I had last seen her.
That same day, I hear that Walgreens has bought both I-Trax, Inc (CHC-Meridian) and Whole Health Management, two of the county’s largest operators of workplace health clinics.
“These announcements mark an important strategic initiative for us,” said Walgreens Chairman and CEO Jeffrey A. Rein. “Walgreens Health and Wellness division will marry our store clinics and pharmacies with worksite health centers and pharmacies. Our unique offering will allow large employers and health plans to provide care to employees and plan members at their worksites, and to dependents and retirees through our Take Care Health Clinics at local Walgreens drugstores.”
Are you thinking what I’m thinking?
Two Ways to Look at it
Now, there are two ways to looks at the situation. The first is to believe all the press releases and see this as a win – win for both patients and employers. Employees get inexpensive, on-site, convenient health care. There is opportunity for development of long term relationships with patients, which enhances interventions to treat chronic diseases, especially those that have a lifestyle component. Combine this with on-site fitness centers such as those offered by I-Trax and Whole Health, and you have a model for the development and maintenance of a healthy workforce.
Of course, the cynical way to look at it is to say that Walgreen’s acquisition of employer-based clinics is just another way for them to capture the prescription drug market. In this regard, it will be very interesting to see if Walgreen’s keeps I-Trax and Whole Health’s employer-based fitness center products as part of their business model. I suspect that they may not. A recent survey of employer based clinics found that while older clinics were more likely to include physical therapy and mental health benefits, newer ones were more like to to offer pharmacy benefits.
Workplace-based clinics have the potential to destroy ongoing doctor-patients relationships that employees may have outside the workplace (as happened to my patient and myself). Not to mention that they are gleaning the healthier patients, leaving the community-based docs to deal with the sickest patients while losing the revenue generated from primary and acute care.
One might also argue that this is more of what NHS Blog doctor calls the “dumbing-down of health care” – the shift away from highly trained and experience doctors towards lower level, cheaper providers. Because the truth is that most workplace clinics are staffed by mid-level practitioners “supervised” by an MD, who may or may not be on site. Thus, in return for convenience, employees will receive the bulk of their primary care from someone other than a doctor. Of course, that’s the way it is anyway in most managed-care primary practices these days (except of course, Dinosaur Doc’s ), so maybe this will be nothing new.
How big is the movement to employer-based clinics?
According to a recent article in the Milwaukee Sentinal, 23% of 600 large companies surveyed reported that they were providing health care on site for their employees. These include companies like Sprint/Nextel, Qualcomm and Pepsi, just to name a few.
Walgreen’s is not the only company getting in on Employer-Based Clinics. Some medical centers offer on-site care to large employers, guaranteeing their continued place in the provision of primary care and a nice referral base for their hospital and specialists. Individual physician practices may also contract with local employers to provide on site care.
What happens next?
Something tells me that pharmacy run employer-based health care is fraught with conflict of interest that may not necessarily be aligned with those of the employers or employees. But I think the business model is making sense for employers, at least from what I’ve gleaned in my readings on the topic. And if I were a medical center, or a primary care practice in an area with a big employer, I’d be thinking about scrambling to get those employer contracts for myself before Walgreen’s snatches them all up.
As for my patient, I was more than happy to do her colposcopy, and she decided she would stay with me rather than go back to her employer for follow up.
Still, I called her workplace nurse practitioner, gave her the biopsy results and sent her some of my cards. I figured at least I might be able to get a few more referrals before she puts me out of business.
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Other Blog reactions to Walgreen’s announcement
Healthbeat Blog – “Health care is a public good, and as such, should be delivered by non-profit organizations overseen by government organization that reviews quality and is accountable only to the public.”(via Kevin, MD)
Brian Kleppert – if the physician community remains scattered and dis-united, it could spell the end of medicine as a cottage industry, and the next big phase of true corporate medicine in America.”
Listen to an NPR story on Employer based clinics
Follow the links around the medical blogosphere and enjoy!
It’s been 21 months since I was forced to convert to an electronic medical record, and I have just now reached the point where I can say that the EMR has had a positive impact in my practice.
Converting to the EMR is not easy. This conversion is not like getting dunked in the river and seeing the light. It’s more like going through Dante’s Inferno. It’s taken me almost 2 years to ascend through the Circles of Hell and I am in Purgatory right now – things aren’t perfect, but I can see Paradise in the distance, and I’m glad I’m here.
Here’s what’s happened, and what is different.
1. When things get hectic, I no longer reach for a pen.
This change took about a year, because you have to get to the point where you don’t have to think and everything is automatic. Now I just head to the computer and type like a madwoman.
2. I am getting really good at typing while looking at my patient.
And at spell checker.
3. Most of my visits are now closed by the end of office hours.
When you are converting to an EMR, every patient is like a new patient, because you need to input their history into the computer at their first visit on the EMR. There was no time to do this during office hours, so I would catch up at the end of the day, evenings or weekends. Since most of my patients only come once a year or so, it’s taken this long to get everyone in.
This is the largest and final circle of EMR hell. But the payoff for all that hard work is that now visit documentation is a breeze – just update the meds and history, click on the exam elements, type in my notes and I am done.
4. Most of my patients’ prescriptions are now in the system.
I can bang though my refills in a few minutes by just pointing and clicking. Pretty soon, those refills will be going straight from my computer to the pharmacy, though for now my secretary is still calling them in. Cleaning out meds lists, though, is becoming a little maintenance chore.
5. My colleagues are helping me (and vice-versa).
About once or twice a day I see a patient who also sees another member of our faculty, and that doc has already completed the history, meds and allergies. That just makes me smile.
6. The EMR is changing my referral habits.
I’m starting to learn which of my colleagues uses the EMR the way I do, and which just short-cut their way through.
When you first convert, it’s extremely tempting to just start creating text notes using the text editor and macros, ignoring the custom fields for history, meds and allergies. It gets your charts closed faster. But if you just use the EMR as a fancy word processor, you’ll never see its true benefits. Plus you’ll make my life harder.
So, if I need to refer a patient to a colleague in another specialty, all other things being equal, it’s going to be the one who uses the EMR the same way I do. The docs who update the history and allergies and clean out the medication and problem lists once in awhile.
7. EMR creates transparency between practices
This is something I had not anticipated with the EMR. More often than not, I am impressed with the care my colleagues are giving. And I’m discovering some great new docs this way who I had previously only known by name.
8. Communication between docs is a snap
Just forward on lab and path reports with a brief note. No more phone tag. I even messaged my own doc to ask for some refills to mail in to my online pharmacy. Cool!
9. Of course, things aren’t perfect.
10. Because of the EMR, I’m making more money.
Gotcha! (Check the date of this post.)_____________________________________________
To read my previous posts on the EMR, go here.
It’s been 3 weeks since my Mohs surgery, and I’m becoming addicted to this little tube of silicone gel that my plastic surgeon gave me to use.
“Apply this 2-3 times a day to prevent scarring and redness” he said, uncapping the tube, smearing it’s contents on my newly-healed Moh’s incision and then gently rubbing it in. “Rub it in, pressing down to the bone. Let it dry, then you can apply make-up over it.”
As I left, his nurse commented – “Ah – I see you got “The Tube”. He loves that tube!”
It’s pretty cool that I can actually do myself to help the healing process along. It’s also oddly comforting to stroke my scar and feel the silicone covering on it. But the other night, as I applied the silicone gel, I found myself curious as to how this stuff worked. Was it just a little plastic surgery witchcraft or was it really doing something to prevent scarring and redness? So I headed to Pub-Med and did a little reading.
What I found was that this stuff really does work. Numerous controlled trials have shown that silicone sheeting treats hypertrophic scars or keloids and prevents such scars in the first place if used prophylactically. There is less data on silicone in other forms, such as gels and creams, but several studies suggest that they work as well as the sheets. My tube is just one of many brands of silicone products that now sell over the counter. I don’t know if there’s a difference between brands, thought I suspect they are probably all the same.
How do silicone sheeting and gels work to prevent scars?
No one knows for sure, but here is the current thinking – When a wound heals, the new skin that is made is immature and not as good an osmotic barrier as older skin. Thus, water is lost from the deeper layers of the skin. It is theorized that water loss from the stratum corneum leads to production of cytokines, which in turn increases the amount of collagen laid down by the fibroblasts there. (Collagen is the stuff of which scars are made.)
Silicone sheets and gels are thought to create an osmotic barrier that prevents evaporative loss of water from the wound, thus leading to decreased collagen and scar formation. Silicone sheets are the most studied, but are harder to use on the face where visibility is a problem and on joints where movement dislodges them. Silicone gels have the advantage of being easy to use, and the gel dries nicely to create a countered covering. Some specialists recommend using the sheets at night and the gels during the day.
Can’t I just Use Vaseline?
Nope. Apparently, Vaseline does not work to prevent scar formation. Nor do plastic sheets and other occlusive dressings. There is something about the osmotic barrier in silicone sheets and gels that makes it “just right” for the job. That something may not be the actual silicone itself, but the vehicle or matrix that it forms. Indeed, more recent studies using some non-silicone gels have shown similar efficacy to silicone, suggesting that the gel’s the thing.
What about steroid injections?
The other well-proven treatment for hypertrophic scars is steroid injections. But steroid injections are used on already formed scars, as opposed to silicone gel, which can be used to prevent scarring.
How about the rubbing?
The rubbing that I am doing is also helping my wound heal prettily by preventing the formation of collagen bands in the scar.
This young girl, whose parents have a wonderful site showing the evolution of her cleft lip and palate from birth through repair to age 10, rubbed cocoa butter on her scar. She looks great – a testimony to the use of pressure and rubbing (or 10 year old skin…)
Comments? Corrections?
This is my own little foray into a completely different field of medicine from that for which I was trained, so I hope that I have not made any glaring errors. I would love to know what my plastic surgery colleagues think about this topic (RL?). I don’t know, for instance, if one brand or type of gel is better than another, or what one should look for in a gel to be sure it will work.
That’s it? No shocking photos of scar tattoos?
Oh, all right – here. Just don’t say I didn’t warn you.
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Dr Crippen has managed to get the BBC to change a headline, merely by criticizing it in his blog. He then got an apology from the writer of the article in question, which was about how MRI has a high false positive rate. This, of course, is not news. It is why MRI is not yet ready for prime time breast cancer screening. But like any good news outlet, the BBC had managed to make this piece of information sound utterly frightening, with the headline “Mri scans commonly wrong”.
This is not the first time the BBC has responded to Dr Crippin’s criticism by changing a story.
I find this entire episode amazingly encouraging. Our voice can matter, folks. Keep writing, keep taking on the powers that harm, and we will be heard.
I promised photos of the paint job, and here they are.
The final color we chose was Benjamin Moore’s Richmond Gold with Cream Froth for the trim and contrast walls. (It’s really hard to get a photo that captures the color as it looks in real life, so I’m putting up a few to give you the idea. The first one below is in daylight and all the rest are in the evening.)
And then I saw this amazing wallpaper, and had to have that too.
I have to admit that as the paint was going up, I was a little scared that I did not like it. But as soon as things got up on the walls and the rugs down, I knew we had made the right choice.
Our prior color had been yellow, which I loved, but I think this new look is better. Look at the before photo below to see what I mean. (Don’t think the place looked this good before we painted – that before shot is almost 10 years old…)
Here another shot…
Need to get a runner for that back hall…
The living room is still a work in progress. We’re looking for something new to hang on the wall over the sofa. And a wood coffee table. And some new lamps. And a bigger rug. And another big comfy chair…
Thanks again for everyone’s suggestions and support through this process. I feel as though I’ve given birth.
This is a little variation on a Tapas recipe I found on Epicurious. It was my contribution to Easter Brunch (with a little help and some beer from brother Joe), and went well with the quiches, Apple French Toast and salad that were served. This sauce was so incredible, I’m trying to think of other ways to use it.
Grilled Sausages with Figs for a Crowd
To make a slightly classier version for a smaller group, use less sausages, cut them lengthwise and plate individually with a few figs and the sauce drizzled over them.
2 cups red wine vinegar or balsamic vinegar (I used a half and half mixture of both)
1 1/2 cups sugar
12 oz. dried black Mission figs
1 cinnamon sticks
3 whole cloves
Pinch of salt
2 teaspoons water
1 teaspoon cornstarch
20 assorted sausages (Sweet Italian were the best)
Enough beer to cover the sausages in a saucepan plus a little water
Heat vinegar with sugar over medium heat till sugar is dissolved. Add figs, cinammon stick, cloves and a pinch of salt. Bring to boil; reduce heat to medium low and simmer until figs are softened and vinegar is slightly syrupy, about 45 minutes to an hour. Mix water and cornstarch in small bowl; stir into fig mixture. Boil and stir to thicken slightly, about 1 minute. Let stand 1 hour. Fig sauce can be made 1 day ahead. Cover and chill.
Bring the beer to boil in a medium sized saucepot. Add sausages and simmer for 15 minutes while you fire up the grill. (If you need more liquid, add a little water). Remove sausages from beer, shake dry and grill, about 5 minutes per side, till cooked through and brown.
To serve : Slice up sausages, toss with figs and sauce and serve in a bowl family style.
Dounle click the arrow to watch the elephants enter Manhattan!
If you found yourself with nothing to do around 1 am on Tuesday, you could have met us in Midtown Manhattan for one of those Only-in-New York events – the Ringling Bros. Circus Annual Elephant Parade.
The elephants come into New York via train, and then need to get from Queens to Manhattan. Apparently the only way to do it is to walk. So the NYC DOT closes the Midtown Tunnel to traffic from midnight to 2 am and the elephants walk right into Manhattan and across 34th Street to the circus grounds at Madison Square Garden!
Animal rights activists aside, watching the elephant walk was one of the most fun things we’ve ever done as a family. I just can’t believe it took us 15 years to finally do it. (Although having to stay up past 1am on a school night may have had something to do with that…) Thanks to Mr TBTAM for being the energetic one to get us all going.
There were no more than a few dozen folks at the Midtown tunnel exit on Third Ave when we arrived around midnight, making it a great spot to wait for the privilege of being among the first to see the pachyderms as the exited the tunnel at 1 am. Then it was a short run up to 34th Street (those elephants move a lot faster than you think!), to join the many hundreds who gather along the rest of the route. It’s quite a surreal experience, actually, to see the animals strolling along 34th street, not to mention the fact that so many folks are out there with you at that ungodly hour.
Of course, I needed to cook a little something to commemorate the event, and found a wonderful dish from the Elephant Walk Cookbook from the chefs at this renowned French-Cambodian restaurant in Cambridge, Mass. I’ve never eaten at the Elephant Walk, but since we’ll likely be heading up to Boston on college tours next month, I think I’ll check it out then. From the reviews I’ve read, the cookbook also looks worth getting.
Elephant Walk Butternut Squash and Pork Stir Fry
This is a very simple dish, but extremely flavorful. I thought about adding more things to increase its complexity, maybe some peanuts in honor of our long-nosed friends, but in the end just left it alone as it was. (Well, I did use red pepper flakes instead of black pepper and increased the scallions…) Amazingly, my younger daughter, whose palate can be a bit limited, loved this meal. Maybe it’s the magic of the elephants….
3 tablespoons vegetable oil
3 garlic cloves, smashed
1/2 pound pork tenderloin or fresh ham, cut into small strips
2 tablespoons fish sauce
1 teaspoon sugar
1 1/4 pounds buttercup squash, peeled, seeds scooped out, julienned
4 scallions, cut into 1 1/2 inch pieces
1/4 teaspoon red pepper flakes
Cooked Basmati Rice
Heat the oil in a large skillet or wok over medium-high heat and sauté the garlic until golden brown, 5 to 10 seconds. Add the pork, stirring well, then add the fish sauce and sugar. Fold in the squash gently and stir-fry until it is cooked through but still slightly crunchy, 4 to 5 minutes (or longer if you prefer a soft texture).
Add the scallions and pepper and stir well. Serve hot with rice.
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Recipe found at Rediff.com
Dounle click the arrow to watch the elephants enter Manhattan!
If you found yourself with nothing to do around 1 am on Tuesday, you could have met us in Midtown Manhattan for one of those Only-in-New York events – the Ringling Bros. Circus Annual Elephant Parade.
The elephants come into New York via train, and then need to get from Queens to Manhattan. Apparently the only way to do it is to walk. So the NYC DOT closes the Midtown Tunnel to traffic from midnight to 2 am and the elephants walk right into Manhattan and across 34th Street to the circus grounds at Madison Square Garden!
Animal rights activists aside, watching the elephant walk was one of the most fun things we’ve ever done as a family. I just can’t believe it took us 15 years to finally do it. (Although having to stay up past 1am on a school night may have had something to do with that…) Thanks to Mr TBTAM for being the energetic one to get us all going.
There were no more than a few dozen folks at the Midtown tunnel exit on Third Ave when we arrived around midnight, making it a great spot to wait for the privilege of being among the first to see the pachyderms as the exited the tunnel at 1 am. Then it was a short run up to 34th Street (those elephants move a lot faster than you think!), to join the many hundreds who gather along the rest of the route. It’s quite a surreal experience, actually, to see the animals strolling along 34th street, not to mention the fact that so many folks are out there with you at that ungodly hour.
Of course, I needed to cook a little something to commemorate the event, and found a wonderful dish from the Elephant Walk Cookbook from the chefs at this renowned French-Cambodian restaurant in Cambridge, Mass. I’ve never eaten at the Elephant Walk, but since we’ll likely be heading up to Boston on college tours next month, I think I’ll check it out then. From the reviews I’ve read, the cookbook also looks worth getting.
Elephant Walk Butternut Squash and Pork Stir Fry
This is a very simple dish, but extremely flavorful. I thought about adding more things to increase its complexity, maybe some peanuts in honor of our long-nosed friends, but in the end just left it alone as it was. (Well, I did use red pepper flakes instead of black pepper and increased the scallions…) Amazingly, my younger daughter, whose palate can be a bit limited, loved this meal. Maybe it’s the magic of the elephants….
3 tablespoons vegetable oil
3 garlic cloves, smashed
1/2 pound pork tenderloin or fresh ham, cut into small strips
2 tablespoons fish sauce
1 teaspoon sugar
1 1/4 pounds buttercup squash, peeled, seeds scooped out, julienned
4 scallions, cut into 1 1/2 inch pieces
1/4 teaspoon red pepper flakes
Cooked Basmati Rice
Heat the oil in a large skillet or wok over medium-high heat and sauté the garlic until golden brown, 5 to 10 seconds. Add the pork, stirring well, then add the fish sauce and sugar. Fold in the squash gently and stir-fry until it is cooked through but still slightly crunchy, 4 to 5 minutes (or longer if you prefer a soft texture).
Add the scallions and pepper and stir well. Serve hot with rice.
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Recipe found at Rediff.com
Looking good. Photo here.
Primate brain before (left) and 48 hours after estrogen (right) Just to add a couple of my own anecdotes to the pile…
The Breastfeeding writer
A 35 year old newspaper columnist, 8 weeks post-partum and breastfeeding, calls me. “I can’t write! I’m sitting here staring at my computer and nothing is happening. I have a deadline tomorrow and I just can’t find the words I need to express myself.”
Breastfeeding is a time of low estrogen levels, and breastfeeding women will often complain of vaginal dryness. But this was a new complaint I had not heard before. She sounded just like my menopausal patients. So I gave her some estrogen. She called me several days later – “It’s like someone turned on a switch! I’m back!”
The Peri-menopausal Exec
49 years old, high functioning, multi-tasking, juggler of many things. This is a woman who can talk on the phone while typing an important email and hold a meeting all at the same time. Carries names in her head like a roladex.
Her ovaries were removed 6 months ago along with a hysterectomy. A totally unnecessary piece of surgery, by the way. All she needed was the uterus removed, but her doctor told her that if she were his wife, he’s take out the ovaries, so that’s what she agreed to…
Now, she finishes the day and realizes she has barely gotten anything done. Someone who could easily do three things at once is now down to one-at-a-time tasking, and even that is going slowly. “I can’t keep up with my pace. My brain just won’t make the connections fast enough” All her lab values are normal, including her thyroid functions and hematocrit.
We give her estrogen. Within a few weeks, she is almost back to her old self.
The Human Research Data
Now, these two stories are not typical. Most peri-menopausal and menopausal women don’t have such dramatic deficits or recovery. Some have no symptoms related to brain function at all. Those that do typically complain of problems with word recall or names, or a feeling of “fuzziness” in the brain. “Clogged up” is a phrase I hear often. These symptoms are sometimes relieved with estrogen, and sometimes they are not.
Results from research studies have been contradictory. No studies have found an effect of estrogen on memory in populations of women undergoing normal menopause. But in studies of women undergoing surgical menopause, estrogen has been found to improve memory, particularly verbal memory.
In my opinion, most of the studies that have been done to date have not used testing that measures the kind of brain function estrogen seems to affect. Most have used dementia screening or Alzheimer’s screening or basic tests of overall memory.
Menopausal women are not complaining about dementia or losing their memory. What they complain about is problems finding words and names, problems making sophisticated verbal constructions, problems writing fluently, and problems multitasking. And fuzziness.
I don’t think we have a good objective measure of brain fuzziness.
The Primate Data
Whenever I think about estrogen and the brain, I think about monkeys. If you look at the brains of primates, what you find is that estrogen increases the number of dendritic outgrowths – connectors, if you will – between brain cells. (They’re the little red things up there in the photo). The increase in dendritic outgrowths is rapid – within 24 -48 hours of giving estrogen, there is a measurably dramatic change in the number of connections between brain cells.
Take away estrogen, the number of brain cell connections decreases. Interstingly, if one adds progesterone continuously to the regimen, you attenuate the estrogen effect.
It’s the best evidence I’ve seen to date that correlates with what my patients tell me. Loss of estrogen leads to loss of connectivity between brain cells. It takes longer to find a word, find a name. Harder to write. Harder to multitask.
Now What?
I’m not going to belabor the whole “Should I take HRT?” question here. You can read what I think about that issue here.
What I will say is that the story on estrogen is far from over.
What I believe is that for some women, estrogen is important for brain function. Who those women are, how to identify them and how to weigh this against the potential risks of HRT as we now know it, are all questions whose answers are too individual to answer for women as a whole.
Stay tuned…
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Photo from J Neuropsychiatry Clin Neurosci 13:313-317, August 2001
