Tag Archives: hormones

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To this hour bewail the injury

It seems I grew up in a male purdah -I think all men did, and perhaps most still do. And yet, the triumph of women in academics, business, and sports in particular, has begun to open the male curtain a little. No longer would most of us be surprised to find women competing at the highest levels in sports as disparate as, say, rugby and tennis, soccer and hockey -albeit in their own leagues for now. Still, this is a fairly large departure from the days when sports were largely -if not completely- male dominated.

Women were not thought to have either the temperament or the musculature important for effective competition that their male counterparts so obviously possessed. Add to that their differing hormones which suited them for the roles to which society had long assigned them, and males felt they could relax in their smug complacency, secure in the knowledge that there were things that women just could not do -and also had no desire to.

Furthermore, because of the nuisance of the cyclic fluctuations in female metabolism, sexual differences were often discounted as too expensive and too variable to be taken into account in medication design and testing, so many of the drugs available on the market that were only tested on males were assumed to work as well in either sex. Unfortunately -although predictably- this led to problems in both outcome and side effects. In fact, I discussed some of these issues in an essay I wrote several years ago: https://musingsonwomenshealth.com/2016/10/12/women-are-from-earth/

More recently however, although many sports have become increasingly aware of the different types of dangers in their respective competitions, it comes as no surprise that there was an assumption that the occurrence of concussions in female athletes mirrored the frequency, symptomatology, and outcome in their male cohorts.

I don’t wish to embark upon a gendered jeremiad, because studies and evidence of sex difference is slowly accumulating, and in the more gladiatorial sports, there still seems to be a preponderance of men, so perhaps it makes sense to start with the effects of concussions on them -but nevertheless…

Thank goodness there was an interesting essay on female concussions in an article in BBC Future entitled, helpfully enough, Why women are more at risk from concussion written by David Robson: https://www.bbc.com/future/article/20200131-why-women-are-more-at-risk-from-concussion

‘Concussion is changed neurological function as the result of a bump, blow or jolt to the head. The violent movement of the head causes a momentary release of various neurotransmitters that throws the brain’s signalling out of balance. It can also cause the neural tissue to swell and reduce the flow of blood to the brain – and along with it, the glucose and oxygen – starving our nerve cells of their fuel… The potential long-term impact of concussion is now well known and has led many sports associations to change their rules and procedures to reduce the danger of injury. But there is low awareness of the potentially higher risks to female players and the possible need for differing diagnosis and treatment, including among healthcare professionals… Recent research… suggests that female athletes are not only more likely to sustain a concussion in any given sport; they also tend to have more severe symptoms, and to take longer to recover.’

I still remember the words we once used to describe the symptoms in boxers towards the end of their careers: punch-drunk. Of course, I was fairly young then, but I don’t remember the word ‘concussion’ being used with any frequency; I assumed an appreciation of the concept was fairly recent, and yet ‘Concussion is thought to have first been distinguished from other types of brain injury more than 1,000 years ago, by the Persian physician Rhazes, but sex differences in concussion have only been the subject of serious research within the last two decades or so.’ Then again, ‘The sex differences in concussion were also obscured by the fact that many of these injuries are the result of accidents in sport, and girls and women were historically less likely to compete in events where concussion has attracted most attention.

‘Tracey Covassin, who is now based at Michigan State University, has been one of the leading researchers looking at potential sex differences in concussion… In soccer, basketball and softball…  she found that female players are almost twice as likely to suffer a concussion as male ones.’ And their symptoms were often different. ‘While male concussions are more likely to be followed by amnesia, for instance, female ones are more likely to lead to prolonged headaches, mental fatigue and difficulties with concentration, and mood changes… Female athletes also seem to require more time for those symptoms to disappear.’

The problem is that sometimes the differences were attributable to sexual stereotyping and hence glossed over. That’s a fraught subject with many of the (largely male) therapists, but where there’s smoke, there’s often fire. For example, ‘Some researchers have proposed that it may be due to the fact that female necks tend to be slimmer and less muscular than male ones… the brain is free to move within the skull – it is like jelly tightly packed into a Tupperware container – and this means that any sharp movement of the head can cause it to shift around, potentially causing damage.’ So, ‘anything that helps to protect the skull from sharp movements should protect you from concussion – and that includes a sturdier neck that is better able to buffer a blow.’ Currently, there are a few team physiotherapists who have devised exercises to help strengthen these muscles -especially in rugby players where padding and helmets are certainly not de rigueur.

There are other theories why female concussions are different. For example, ‘small anatomical differences within the brain itself. Female brains are thought to have slightly faster metabolisms than male ones, with greater blood flow to the head… if a head injury momentarily disrupts that supply of glucose and oxygen, it could cause greater damage.’

There is even some evidence that the cyclic nature of female hormone production may also play a role in susceptibility to concussions. For example, ‘Researchers at the University of Rochester School of Medicine and Dentistry… found that injuries during the follicular phase (after menstruation and before ovulation) were less likely to lead to symptoms a month later, while an injury during the luteal phase (after ovulation and before menstruation) resulted in significantly worse outcomes.’

Clearly research of female concussions is still in its early stage, but even these preliminary findings might suggest some possible mitigating strategies. For example, some studies have demonstrated the benefit of suppressing endogenous cyclicity in hormone production with, say, oral contraceptives.

And yet, perhaps the most hopeful thing is the recognition of the dangers of concussion in both sexes. It isn’t something that only occurs in high-contact sports like rugby or hockey; it’s something which crosses the gender divide with seeming ease. It’s the mask we’re beginning to see through, the condition that finds itself harder and harder to camouflage.

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Does the Best Safety Really Lie in Fear?

There are many unheralded benefits of age, one of which is invisibility -changing from a potential threat into a banality. A non-entity for whomever might otherwise be at risk. I can watch from shadows while the world strides past –on the street, in a bus, in a coffee shop. Wherever.

Men, until they age it seems, can be a liability to women –but I never thought of it like that, of course. Few of us ever do. I never thought I was a threat, but now I see I was wrong.

Does danger evolve, or is it the perception? The perceiver? Has its essence been reinterpreted, or merely renamed? Now that I am rapidly becoming a befrailed bystander in my retirement -background noise- I am also subject to harassment I never thought existed.

It’s not the same, I know. It’s not something I have had to endure throughout my life. Something woven into the fabric of each day that hides in the warp and weft of life until the pattern suddenly surfaces from the chiaroscuro like the shark’s fin in Jaws. Knowing the menace is always somewhere beneath the surface, and yet having no choice but to swim above it…

Watching from the shore, where the danger is rarely seen and never felt, it is all too easily dismissed. Maybe that’s why I’m trying to draw a parallel with the tide of years. I’m trying to understand something new to me. Frailty, thy name is Age.

For me, it’s not sexual pestering, of course, and usually not a threat of bodily harm –it’s more of a dominance thing… And yet, isn’t that what the gender divide can be about? Power? Identity insecurity? Role playing…?

I’m not even sure what role hormones play anymore –not all men are provocateurs. Not all men are cursed with the need for entitlement or the fear of losing status . Not all of us are insecure. But I think I can see what is going on –if only through a glass darkly. I think I can understand the gist of the article I found in the BBC news about women worrying about the ‘right’ amount of fear to show in public: http://www.bbc.com/news/world-41614720 The appropriate balance between sensible caution and the avoidance of a perceived threat.

Until I read it, I’m not sure I would have put it as forcefully as Dr. Fiona Vera-Gray, a researcher at Durham Law School, specializing in violence against women, and one of the 100 Women BBC named as influential and inspirational. But, I’m not a woman quietly smothered by the social blanket either thrown over my protests, or wrapped securely around my screams of dissent much as it might around a tired child’s body. It is hard to shift perspective like the article demands.

Dr. Vera-Gray had been speaking to women about how they change their behaviours through fear of sexual harassment and assault for her new book The Right Amount of Panic: How women trade freedom for safety in public. But I have to say that I had never thought about the need for the tactics she has identified that are outlined in the article. 

For example, she outlines conduct I’m sure we’ve all seen in streets and public transit –all seemingly innocuous, innocent, and yet all purposive: ‘Maybe, like Delilah, a black British woman in her early 20s who I interviewed, you stay away from wearing the colour red, to avoid standing out. Or like Shelley, a British Asian woman in her 30s, you’ve developed a death stare, looking tougher than you feel. Maybe like Lucy, a white British woman in her late teens, you’ve pulled out your phone and made a fake call with your battery long dead. Or like Ginger, a white Latvian woman in her 20s, you’ve kept headphones in without playing music so you can hear what they think you can’t.’

The European Union Agency for Fundamental Rights report (FRA) in 2017 on sexual harassment in Europe found that ‘almost half of the 42,000 women surveyed had restricted their freedom of movement based on the fear of gender-based violence.’

‘Liz Kelly, one of the world’s leading sociologists on violence against women, coined the term “safety work”, to describe the habitual strategies that women develop in response to their experiences in public. We perform safety work often without thinking, it becomes part of our habits, or “common-sense”.’ Peeking over my own male-built walls, I had no idea this was going on.

‘The vast majority of this work is pre-emptive, we often can’t even know if what we are experiencing as intrusive is intrusive unless it starts to escalate: he speeds up and crosses the street when you do, he moves from staring to touching. But as this is the very thing safety work is designed to disrupt, success becomes the absence of what might have happened. […] we know that it doesn’t, it simply can’t, always work, and those are the only times we can count. So women are stuck, made responsible for preventing harassment at the same time as unable to know when we’ve been effective.’

But, as Dr. Vera-Gray seems to conclude, ‘[…] there is no “right amount” of panic, there’s only ever too much or not enough. And with no way to know when we’re getting it right, we’ve learnt to just keep quiet.’

I don’t want to seem like a gender apostate, but I find the conclusions very troubling. As Robbie Burns put it O wad some Power the giftie gie us To see oursels as ithers see us! But, alas, we see the world, like we see the reflections in a mirror, only through our own eyes. And that’s not enough –we share the same journey, albeit sometimes on different paths. And that’s why there’s a need for signposts along the way. Conversations about the route. We all have to know where we’re going.

Maybe I will never understand; maybe I can only approach it vicariously, but at least it’s a start. I can stand in shoes that will never fit, even if I can’t walk without discomfort.

But maybe that’s what it takes –a sort of self-empathy, before it finally sinks in…

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The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

“Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”

 

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The Manopause

The menopause can be a mysterious time, although the mechanism is easily enough defined: the cessation of menses because of the lack of estrogen production by the ovary. The concept may be simple, but the ramifications and folklore that surround it less so. It has always worn its myths like a hood, obscuring the face beneath, confusing the experience like shadows on a rainy day.

Descriptions are legion, but ultimately unhelpful in dissipating the fog the definition drags with it: hot flushes, sleep disorders, irritability, worries about cognition and memory, regrets about the loss of fertility, and concerns about sexual function and desires… And although some symptoms may cross the gender divide, many -if not most- are unique to women. Unique to ovaries.

And the response to the change can be unique as well.

I hadn’t seen Elizabeth for a long time –in fact I couldn’t remember ever seeing her. Memory deficits are not the sole prerogative of the estrogen deficient –although in fairness, when I tried to look it up, it must been well over ten years since her last visit because the chart had been destroyed. The legal limit that we are required to keep records had obviously been exceeded.

She treated it as if it had only been a month or two, and greeted me with a smile usually reserved for someone who is supposed to go over some frequently-repeated test results. Someone she’d seen in the mall last week, and at a restaurant the week before. But there was a hint of suspicion in her smile.

“Elizabeth,” I said, extending my hand when I greeted her in the waiting room. “Nice to see you again,” I continued as I led her down the corridor to my office. She looked at me politely and sat down in a chair by the window across from my desk, perhaps waiting for me to reminisce.

The referral letter said only that I had seen her before and that she seemed angry about something. She was 55 years old, was on no medications, and she had some questions about the menopause.  “So, what can I do for you, Elizabeth?” A rather predictable opening, I suppose, but it didn’t commit me to anything –in other words it didn’t disclose the fact that I couldn’t remember a thing about her.

She probed me with her eyes for a moment, suspecting, I think, that I didn’t recognize her. But if she was disappointed, she didn’t betray it with her face. The ghost of a smile reappeared, and her eyes relaxed enough to twinkle through her glasses.

She didn’t look the merry type, I decided. Her hair was greying and pulled back tightly in a bun. Her outfit was severe: a black, loosely hanging dress that covered her ankles but not her jewelleryless arms. She was a thin, tall woman and sat as straight as a pole in the chair, her white skin even more pallid where it met the dress.

“How will I know when I’m in the menopause?” she said suddenly, as I glanced at the computer screen searching for more clues.

I met her eyes half way, and smiled reassuringly. I hadn’t had a chance to take a history, so I had to be careful with my answer. “Well, in many women, the symptoms can be very subtle, but generally speaking, the usual tip-off is an irregularity of menstruation and eventually its cessation. And, of course, there are often hot flushes, irritability and…

Her face turned smug and her smile condescending. “But I haven’t had a period for years, doctor…” She sat back in the chair and regarded me with some ill-disguised amusement. I must have looked confused, because she sighed both audibly as well as visually –performance art. “You took my uterus out fifteen years ago…”

I did my best to retain a modicum of Aequanimitas: I tried not to blush.

“Big fibroids,” she continued, to add to my discomfort. “You said one of them was the size of a basketball… I thought you’d remember.” I was blushing now, and about to apologize, so she backed off. “It has been a long time, I suppose.”

I attempted a smile, but I think it came out as rather forced and weak. I decided I’d better take a more detailed history before I addressed her concerns. “I’m sorry, but unfortunately I no longer have your records so I’m going to have to ask you a few questions… First, are you having any symptoms of the menopause?”

She frowned a look of concern unrolled onto her face. “Why don’t you have my records? You did my surgery…” Her eyes suddenly tied me to my seat. “Suppose I developed complications?”

I started to feel defensive. “The law requires us to keep the files for only 10 years unless there is an ongoing  attendance,” I said, rounding off the numbers for her. “I haven’t seen you for longer than that, and you haven’t declared any complications in that fifteen years that I know of…”

She lengthened herself to the full length of her spine and glared at me. “My complication may be the menopause, doctor!”

I tried to stay neutral. Professional. “I’m sorry, Elizabeth, why do you think that?”

Her face crinkled into a little wrinkled ball, like a piece of paper someone had crumpled before throwing it away. “You took my uterus out!” She almost spit the words at me, as if I should have known that was the problem.

I sighed in an unsuccessful attempt to duplicate her previous performance. “Did I remove your ovaries as well?” At forty, I wouldn’t have.

She stared at me wordlessly for a moment. “You did a total hysterectomy you said, doctor.” She said the last word as an insult, not as a descriptive, or an honorific title.

I smiled and realized she had not really understood what I had done. “A total hysterectomy merely refers to the act of removal of the whole uterus –the total uterus. A partial hysterectomy, on the other hand, means I’ve only taken part of it out –left the cervix, usually…” Her expression didn’t change. “I wouldn’t have taken your ovaries out at that age, because… Well, first of all because they would still have been working and producing hormones, and secondly there would have been no need to do so.”

I hoped that would mollify her, but if anything, her face crinkled into an even smaller bun. Then why haven’t I had any hot flushes, or irritability?” She could see one of my eyebrows start to raise –it’s really hard to control that- and hissed audibly at me. I think it was a hiss, but maybe she was  just breathing through her teeth.

I tried to relax my expression –a Mindfulness technique. “Whether or not your uterus is present, the ovaries don’t last forever. They eventually stop producing hormones.” I realized I shouldn’t have used the word ‘last’ as soon as I said it; it just sort of slipped out.

She shook her head slowly in her anger. “You men are so insensitive about the ovaries! You just don’t know what they mean to us, do you?” I suppose it was a rhetorical question, because she continued the rant without stopping for a reply. “And I’m surprised to hear that attitude from a doctor!” She stopped talking for a moment and looked at me. “You weren’t like that back then…” The scowl returned. “And to tell you the truth, doctor, I don’t remember you like this at all…” She glanced around the office. “Not even the office.”

I was about to say something reassuring to her –like that I’d probably changed a few things in here over the years- when she suddenly stood up and wrinkled her nose. It was hard to spot in her overall expression, but I noticed it immediately. Her eyes closed briefly as if she could somehow block out everything that she didn’t like about where she found herself. And then, gathering herself up to her full six foot height, she thanked me for my time and stomped out.

You know, I still can’t remember operating on her… and I don’t think she does, either.