Scientific Gynaecology


Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

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