Unquiet Meals

I suppose Age has blunted me –or at least made me suspicious of fads, curious about recent phenomena that wear the clothes of certainty, vogues that hitchhike on the backs of something else never meant to carry the weight… But one must not be caught rubbing the poor itch of one’s opinion, to paraphrase Shakespeare. One must seek either corroboration or refutation in equal measure; one must make the time and effort to critically analyze what one would fain discard. So it was with no little frisson of excitement that I read just such an attempt in the BBC News. Gluten allergy, and its social and physiological disguises, was the subject: http://www.bbc.com/news/magazine-37292174

I have never denied the existence of true gluten allergy, Celiac Disease. Its prevalence obviously varies with the group being measured, but it averages to around 1% of the population and is a true auto immune phenomenon where the body detects the presence of –in this case, gluten- and views it as hostile. It then produces some countermeasures –autoantibodies- which, in turn, can have effects on various organs, the small bowel often being the one that results in the diagnosis.

The existence of a non-celiac gluten sensitivity, however, is more controversial. Studies –including the one the BBC reported- seem to vacillate wildly, so I suppose it is merely another example of confirmation bias as to which one you choose to believe. Me? I remain skeptical, firmly encamped in the valley floor between the two hostile mountains that glare and threaten each other from a safe distance. And if some of my patients choose to avoid gluten in their diets, so be it -I’m an obstetrician/gynaecologist, not a dietary immunologist. But sometimes my concerns peek above the mischievous gluten dust.

You know, you can’t tell the gluten-free apostles from the gluten abusers in the average waiting room. I can’t, anyway. Geraldine looked, well, normal as she sat slouched in her chair in the corner. Although my day sheet said she was in her thirties, my eyes said forties. Her blond hair was streaked with silver –although nowadays that may just be a whim- but her face was folded into little wrinkles like previously crumpled paper that had been hurriedly smoothed. She was dressed in black jeans that belied any definite attempt at ironing for the appointment, and her oversized grey sweatshirt matched her face for creases. The very idea of needing to avoid gluten apostasy did not spring unbidden to mind, I have to admit.

And yet the sullen face that watched me as I extended my hand in greeting did suggest that Geraldine was unhappy with her referral. In my practice, this is usually an indication that the patient was hoping that, contrary to what they Googled, I would still turn out to be a female. Although I am quick to disavow them of this, I find it still takes a few minutes more to gain their trust.

Once she had reslouched herself in a decidedly less comfortable seat in my office, I brought up the note from her doctor on my computer screen. It was a one word note –not terribly unusual from this particular GP, but not terribly helpful, either: ‘IMPOSSIBLE’ it said in bolded and underlined capital letters –rather striking, really.

“So, Geraldine,” I said, feeling my way along my words, “how can I help you?”

She glared at me for a moment, and then withdrew her eyes to the safety of her lap. “Didn’t my GP tell you?” It was at once hostile yet tinged with resignation –as if the GP was simply passing a rather complicated buck onwards. As if I were only one more stop on the journey.

Her answer was so uncomfortable it caught me unprepared. “Well…”

“He just wanted to get rid of me…” she said, venom dripping from the corners of her mouth at first. But she thought about it for a moment and neutralized her face. “He never listens, anyway.”

I tried to smile –sometimes it works. “Listen to what, Geraldine?”

Her eyes rose quickly from her jeans, like two birds flushed from a bush. “He doesn’t believe in gluten,” she said, a little too quietly for me to judge the temperature of the insinuation.

“How do you mean?” I walked right into it.

The cage door of her eyes flew open, and her mouth unlocked like Pandora’s box. “He refuses to believe that gluten is alive and flourishing in the world…” I’d heard similar words from religious acolytes proselytizing on street corners; maybe gluten was now another proxy for the devil.

“So…” I said, but before I could finish my thought –well, actually before I could even develop one, she interrupted.

“He doesn’t believe me. For years I was plagued with diarrhea and bloating so he sent me to a GI doctor who tested me but couldn’t find anything. All she could say was that it wasn’t Celiac Disease.” She stopped for air. “And now, whatever I tell my GP he just shrugs and says, it’s not the gluten.”

I pretended to type something on my computer screen, but I was just doodling.

“Anyway, I decided to cut out gluten in my diet, and the bloating stopped. The diarrhea stopped… But, then I started…” she added cryptically.

“Started what?” It wasn’t the most gynaecologically phrased question of which I am capable, I admit, but it was all I could think of in the moment.

Once again her face contracted like an animal about to spring. Or flee… “Started having sex!” she said, italicizing the last word. And then, mercifully, before I could gather my thoughts about why anything she’d had to say had anything to do with sex, she explained. “You can’t have sex when you’re bloated all the time, doctor! You can’t have sex when at any moment you might have to get up to go to the toilet!”

Okay, call me naïve, but I hadn’t thought of it quite like that before. It was a different world out there. “But eliminating the gluten in your diet helped, you said.”

She nodded her head vigorously. “I was a new woman.” She stared disconsolately out the window behind me for a second or two. “So I decided I’d better up my birth control method. I hate condoms and diaphragms… and I refuse to wear an IDU…”

“An IUD, you mean?” I said, attempting a gentle correction, but her eyes tried to ravage my face immediately.

“Whatever! So my GP put me on the pill!” she said, italics and contempt now mixing freely with the original venom on her lips.

“And…?”

“And I got bloating again, doctor!” Her eyes executed a predator roll somewhere near the ceiling before heading for me again. “So I did some computer research and discovered that the pills contained lactose and cellulose as fillers…” She folded her arms across her chest and waited to see what I thought of that.

“You’re wondering if they are code words for gluten, Geraldine?”

“Wondering?” she said between clenched teeth, the word only barely able to squeak through at the last moment. “Wondering?” she repeated more loudly and forcefully, articulating each syllable as if maybe I hadn’t heard her correctly the first time. “Are you another gluten atheist, doctor?” she asked scornfully.

“No, gluten exists, Geraldine,” I said, conscious of falling into her religious idiom. “But so do common side effects of the birth control pill.”

She tilted her head like a cat figuring out the best way to attack the mouse. “Nope, I know this was the same kind of bloating I got with the gluten.” Her fists clenched, daring me to contradict that.

But there was something about her face… “How long did you take the pill?”

She shrugged and then played around with her eyes, uncertain where to roost them. “A month maybe… And then I took them on and off for a while to see if they made a difference.”

“And…?”

Another shrug. “And yes, stopping them got rid of the bloating for a while.” She stopped and decided to stare at me. “And then it came back, even though I wasn’t taking them.” She took a deep breath and then sat up straighter on her chair. “I asked my GP if it could be some residual effects of the gluten and he decided to send me to you.”

“When was your last period, Geraldine?” Common things are commonest, eh?

A smile managed to crinkle its way onto her lips, and her eyes softened like sponges in water. Her expression turned almost mischievous. “I thought you’d never ask, doctor.” Even her voice, now, was pleasant.

“You’re pregnant?”

She nodded happily. “And it’s going to be a gluten-free pregnancy…” And then as a concession, “Is that all right with you?”

I smiled and nodded. No matter what I said, she’d do it anyway, so I thought it’d be safer to do it under supervision. “I’ll send you to a dietician to help you choose the proper foods for the pregnancy.”

She rolled her eyes again –but this time it looked more like a victory role. “Sorry about the theatrics, doctor –I just had to be sure where you stood on all this.” And then her face fell, if only just for a second. “Funny,” she added, “I thought you’d be more of a challenge…”

 

 

 

 

 

 

Is Beauty really skin deep?

Although love looks not with the eyes but with the mind, as Shakespeare reminds us, there is a redness of the cheek that is not as kind as a simple blush. So may the outward shows be least themselves, he also says. The world is still deceived with ornament.

Acne arrives at the wrong time of life; it usually declares itself around the same time a teenager is trying to establish her identity; trying to acquire independence; experimenting with relationships outside the family. It is a time of uncertainty when self-esteem and confidence may be suspended, like the Sword of Damocles, on that single hair of outward appearance.

Acne is nothing new; it has probably been around as long as there has been skin with hair follicles to get blocked. Oil from glands is one of the culprits and these are more common on the face and upper body. The hormonal changes of puberty may result in changes in activity of these glands -that, plus genetics, and excessive growth of the bacterium Propionibacterium acnes, all contribute to the unfortunate timing.

An article last summer in the BBC News reminded me of the consequences that affected a patient I once saw in my office for gynaecological consultation.  http://www.bbc.co.uk/newsbeat/article/36712810/doctors-warn-acne-could-become-resistant-to-antibiotics

The waiting room was full that day and I saw Janice sitting quietly in the corner, her face almost buried in a magazine. She was a tall, thin, sixteen-year-old wearing tight designer jeans with a cream-coloured baggy sweater and beautiful deep blue hijab that she wore sufficiently loosely around her head that, even when she looked up, seemed to cover most of her face.

At first I wasn’t sure what to make of this. I wondered if it might be a cultural, or religious requirement for seeing a male gynaecologist -or merely a teenage affectation. But apart from her continuing reluctance to expose her face, she seemed more at ease once she was seated in my office.

The consultation note from her GP was one word: Contraception!! -with two exclamation marks. I took that as a sign.

“So, what can I do for you, Janice?” I usually like to let the patient tell me why they were referred; it’s sometimes different than what the family doctor thinks.

She shrugged. “Birth control, I guess…” But she seemed rather unsure.

I smiled and tried to make eye contact, but she continued to look away, first to a painting on the wall beside her, and then to the other wall where I had placed a terra cotta statue of begging woman on an oak stand. Janice seemed to favour the statue.

“Is that for tips?” she said, indicating the bowl the woman was holding in front of her. It was filled to overflowing with coins.

I laughed and shook my head. Everybody seems to ask the same question, and then puts a coin on the pile. “I’m not sure why some people do that, but I empty it from time to time and give it to real people begging on the street. I like to think that’s what my patients want me to do with it.”

She turned her head to look at me and I could see a smile peeking from the shadows inside the hijab. “I didn’t bring any change…”

My smile broadened. “That’s okay, I’ll put a coin in the bowl later for you if you like.”

The hijab nodded.

I settled back in my chair. “So you want to discuss contraception, Janice?” Another nod. “What have you been using so far?”

She shrugged. “Condoms at first…” She hesitated and then sighed. “Then when we got to know each other better, I went on the pill.”

“Is that what you’re on now?”

She shook her head. “They didn’t work. Well…” She lowered her head, so all I could see was the top of her hijab. “Actually, I kept forgetting to start them again after my period…” Two eyes peeked timidly from the shadows on her face. “So I had a couple of… accidents.”

She said the last word in a whisper I could hardly hear as she lowered her head to look at her lap. Suddenly, her head jerked upwards to face me and she pulled the hijab back so I could finally see her face. Both her cheeks were rough and jagged seas of red nodules, some weeping and moist, some merely little cysts about to burst. I could understand why she had chosen to wear her hijab as she did.

“My GP tried me on several kinds of treatments for the condition, but none of them helped. In fact, it was getting worse, so she sent me to a dermatologist. And she just put me back on higher doses of some antibiotic I’d already been on: mino-something.

“Minocycline?”

She nodded, and her eyes filled with tears, so I handed her a tissue from the desk. “But she said it was dangerous for a developing baby, so I had to stay on the birth control pill.” She looked up at the ceiling for a moment, shaking her head. “I told her I kept forgetting to take them, but the doctor just shrugged and told me to write little notes for myself… Stupid woman!

“After the second abortion, my boyfriend and I decided the birth control pills didn’t work so I stopped them. When I told my GP about it, she took me off the antibiotics, too… I guess because she thought I might get pregnant again…” She wiped her eyes and grabbed another tissue from the box I kept on the desk. “And now look at me!”

Her eyes flitted around my face for a moment, and then she summoned them back. “They wanted to put an IUD in me at the time of the second… procedure, but I wouldn’t let them.” Her eyes found mine again. “They recommended the hormonal one.” She seemed on the verge of tears again. “But they told me it might worsen the acne.”

All of a sudden, she leaned over the desk towards me –as if she wanted me to really see what she had to deal with. “I can’t stand my face like this!” She sat back in her seat again. “My boyfriend has already left me; my friends whisper behind my back. Everybody is afraid to look me in the face…” She grabbed a handful of tissues this time and dabbed her cheeks when she’d dried her eyes. “I’m really confused, doctor. Nobody seems to know what they’re doing; they keep changing their minds…

“I can’t go on like this! I can’t…” She took a deep ragged breath. “I need somebody to tell me what to do before I fall off the edge… Or jump,” I heard her whisper into the folds of her hijab.

And then her eyes almost bored into my skull. “Can you help me, doctor?”

Her expression worried me; she was desperate and clearly in crisis -obviously at that edge. I had to do something.

“Tell me, Janice, when you were on both the pill and the antibiotics that last time, was your acne improving?”

She nodded vigorously. “The doctor told me the hormones in the pill sometimes help.”

I smiled in agreement, although I didn’t feel comfortable dealing with acne; I suspected she needed to go back on the antibiotics and her GP was right, she needed absolute protection against pregnancy while she was on them. Minocycline is a class D drug –meaning there is positive evidence of human fetal risk.

And then something occurred to me. “Was it only when you were restarting the birth control pill after your period finished that you forgot to take them?”

She nodded, obviously embarrassed. “There was a lot going on in those days…”

“But you were happy with the pill? I mean it wasn’t giving you any problems?”

“No… except for the pregnancies.”

“So, if you didn’t have to stop the pill for a period, would that work for you?” I watched her closely. “I mean, do you think you would remember to take them?”

She nodded carefully, and stared at me. “Yes… But you mean I wouldn’t have any periods?”

I nodded. “You can take the birth control pill every day for three or four months at time –or even more- then stop and have a period.” Sometimes the simplest solutions work the best.

She thought about it for a moment. “Uhmm… But if I didn’t get my period, how would I know I wasn’t pregnant?”

A good question. I smiled what I hoped was a reassuring smile. “Well, it’s true that Minocycline can interfere with the absorption of the pill, but the risk of pregnancy is still low. And you should supplement the pill with a condom.” I waited till she made eye contact again. “In fact, if you’re starting a new relationship, wouldn’t condoms be a reasonable precaution anyway?”

The acne made way for a face-swallowing smile. “I’ve sworn off sex… Well, at least until I get my face back.” I could tell she was blushing, even under the hijab. Even under the acne.

But I could finally hear some hope in her voice, and I was reminded of another verse from Shakespeare: ‘I will go wash; and when my face is fair, you shall perceive whether I blush or no.’ It seemed fitting, somehow…