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…”

 

 

 

 

 

 

Scrambled Eggs

Great! Test tube mothers now, is it? Not enough to eliminate the Fallopian tube, or the on-egg dating site where potential sperm candidates meet, are scrutinized, profiles scanned and competition held for first across the zona (pellucida, that is) … Oh no, now we have to eliminate the entire coffee shop. What is happening out there… or do I mean in there? It’s so confusing.

There was a time when it was simple. Well, maybe it wasn’t, but at least we were used to it. You met somebody and expectations and hormones took over. No need to put in a special request for stem cells, or people in white lab coats and masks. No need to take out a loan –although flowers and dinners aren’t that cheap anymore, either. But it was the excitement of the chase, the hunt –searching for clues about the other person that weren’t all tied to their DNA; picking them because they were funny and considerate, cute and snuggly. They had histories. Stories. Isn’t that why we get together? Wasn’t it? http://www.bbc.com/news/health-37337215

Okay, I’m leap-frogging here. We’re not there yet –I mean they are not there yet; I suspect that, despite the occasional slip-up, most of us are still going to prefer to stick to the traditional court-and-impregnate model that has served us so far. I mean, fun is fun, eh? And to be fair, there’s a lot to deal with if you want to bypass natural stuff -ingredients, for example. Right now, you need a minimum of two things to make babies: a sperm and a receptive egg (sperm always seem to be in the mood…). Yes, and you need a place for them to meet and grow together, but there are any number of uteri out of work at any given time, so, with the rise of things like Airbnb, I suspect they won’t be a problem.

And everything that is alive has DNA and its instruction manuals closeted away somewhere… Do you see the opportunities I’m suggesting? Trick some skin cell, or whatever, into thinking it’s a sperm or an egg, and poof –reproduction-lite. Better still, why not hoodwink that ordinary cell into thinking it’s pregnant? I mean, it’s got all the necessary assembly instructions squirrelled away, hasn’t it? Your argument just has to be convincing. Persuasive. It doesn’t necessarily need to be, well, necessary. You could just be doing it for fun. A prank. Or to prove that you can, I guess. Isn’t that why a lot of stuff gets done? When you tire of trying to justify something that would fly in the face of current needs and desires, you simply create a niche product. Create a want. Wants usually evolve into needs –mutate into needs, at any rate. Look at Selfies and their requirement for sticks. Or bell-bottomed trousers –no, wait, that was a while ago…

My point, I think, is that gender may be rendered redundant not by increasing social awareness of its variations, but rather because of its dispensability. Why keep something you don’t really need? History will decide, of course, but hindsight tends to come down hard on things that outlive their time. Consider phlogiston. It was the postulated fire element that was contained by combustible things and was released when they caught fire. Of course! But who, apart from old people, have even heard of it? Or want to?

And then, in keeping with the air theme, there is the Miasma Theory which just assumed that disease was caused by ‘bad air’. Simple. Elegant. No need to bring in a lot of accessory stuff like animalcules and other things you couldn’t see anyway. Germs, let alone viruses prions and the like, were simply unnecessary and unduly complicated. Why dump many unknowns into an equation that could be solved by one charming known? Why mess with E = mc 2 when it isn’t a theory of everything, especially if it needs Quantum? Explanation isn’t everything, either…

Okay, so I’ve non sequitured again, but hopefully you see my concern. Obsolescence is one thing –we often persist past our best-before dates- but unplanned obsolescence is another creature entirely. It smacks of blundering about in dark corners hoping there are no unpleasant surprises -nothing that will sting in retrospect.

I am as excited as the next person about the prospects for the future, but experience teaches caution. The principle of unintended consequences is a favourite historical topic –almost as seductive as the ‘what if’s’ so popularized in historical fiction nowadays. Maybe there is nothing enchanted about that first introduction between egg and sperm. Nothing magical. Nothing necessary. Maybe life will carry on much as before and procreation will still scratch out a living between the sheets. And maybe it’s always good to have options -choices freely made and understood. Even needed, occasionally. We have always been condemned to live in interesting times –the Past was never an Eden.

And yet…

 

What did you expect?

We have become obligate avoiders, dwellers in the middle of the field well away from boundaries –the just-right-baby-bears of the Goldilocks tale. We seek to protect ourselves from edges, no matter how pervasive, how common, how important they may be. It was for a very good reason that the American folk hero, John Wayne, felt he had to remind us that ‘Courage is being scared to death… and saddling up anyway.’

Most of us seek to insulate ourselves from every extreme: we read about our lives from the safety of a middle page while dreaming of the youth in early chapters –as if there were no beginning or conclusion to the book. I suppose it reads as well in the center as at either end, but that misses the point; the book is a story –our story- and to ignore the epilogue or, for that matter, the introduction is to miss the context in which it is written -the gestalt.

The end of life, is an example –until recent times, most people in Western civilizations died where they lived: in their own homes. Family and friends were usually there to provide comfort and support; it was not treated as an event that necessitated separation, but rather as a communal passage –something that invited witness and provided solace for all involved.  Dying, especially of advanced age, was not something to be hidden away or delegated to strangers, however skilled. Death was visible and inevitable; death was a known, if unwelcome guest in each home.

Birth, the beginning of the story, has also had a somewhat chequered history. It, too, was once relegated to the home, but with sometimes unfavourable results for both mother and baby. This led to it being assigned to areas –or assistants- with more training and facilities in case unexpected -or anticipated- problems arose. And while, as an obstetrician, I feel more comfortable in an institutional setting, there is no reason why a well-trained midwife should not be able to pick and choose the appropriate venue for the birth depending upon her assessment of the risk involved. And there is no reason, either, why family or friends should not be able to witness and support the event.

I was surprised, therefore, to come across an article in the BBC news that treated as, well, unusual, the idea of a mother’s children being present to witness the birth: http://www.bbc.com/news/uk-37020059

Clearly, some vetting might be required in terms of the children’s age and behaviour, but as long as they are prepared beforehand, and there is someone else in the room who could supervise and help them understand what is happening, I think it could be a positive experience. Birth and Death should be presented as they are: natural events –not secrets whispered behind closed doors.

*

I kind of suspected birth was no secret to Loretta’s kids. A third-time mother of six and  nine-year-old daughters, she brought them to every antenatal visit. I asked her one day while her older daughter played doctor with my stethoscope, how she managed to get them out of school each time.

She pointed to her watch. “Ever notice that I always book my appointments around noon?”

I nodded. We’d often joked about our stomachs rumbling each time we met. “But they don’t mind leaving their friends to come here?”

“McDonald’s,” she said and then shrugged. “It’s their reward for agreeing to come with me.” She was silent for a moment and then stared at me, her eyes twinkling. “Don’t look at me like that, doctor. Remember Bill Clinton?”

I nodded, puzzled by the non sequitur.

“I never inhale,” she whispered conspiratorially.

The girls were always on their best behaviour in the examining room –full of questions and wanting to try my equipment on themselves. I suspect that the visits sometimes even cut into McDonald time, but they seldom complained –they were much too curious about the growing baby. They never seemed to tire of asking me how much it weighed, and whether it could hear them through their mother’s tummy –apparently they would sing to it at home. The moment they both waited for, however, was when I would place the Doppler device on the uterine wall so they could hear the heart. Janice, the older one, would even time it with her watch to make sure my device was counting correctly. They were both as involved in the pregnancy as their mother.

One day, towards the end of the pregnancy, Loretta phoned me. “I’ve been thinking of letting my girls see the birth,” she said. I could hear a little hesitancy in her words as she spoke. “Will the hospital allow that? My mother will make sure they don’t get in the way,” she added, almost too quickly.

I smiled into the phone –I’d been expecting her to ask. “As long as they know what to expect Loretta. There’s sometimes a lot of… well, yelling as you push… and a lot of blood –especially when the placenta comes out.” I paused for a second. “They have to be told that none of that means there is anything wrong. I wouldn’t want them to become scared.”

She chuckled into her phone. “They watch deliveries all the time now on YouTube, doctor –complicated ones, scary ones, and even ones that end up in Caesarian Sections. I think they’ll be all right.”

“Then it’s fine with me.” I reminded her that I may not be on call when she delivered, but she merely laughed.

“You didn’t make it for the first two either…”

*

Obstetrical practice nowadays is a hectic melange of joy and crisis, each delivery unique and exhilarating to be sure, and yet strangely merged into the one a few minutes before and blended into the one a few minutes later when on call at the hospital. So I have to admit that I was pleasantly surprised one evening as I was rushing to yet another delivery further down the hall when a nurse informed me that Loretta had just been admitted in labour.

“She’s almost fully dilated and it’s her third baby; she won’t be long…” she yelled as I ran past her to the accompaniment of screams from the room where I was originally heading.

Obstetrics is sometimes an exercise in ad hoc triage, and the screams were becoming louder and more compelling from that room, so I had little choice in the matter. I arrived just in time to exchange the mother’s for the baby’s screams, and allow a placenta to jump suddenly into my lap while she snuggled her precious baby against her abdomen.

In the warmth of smiles and congratulations that followed, I almost forgot about Loretta until the nurse’s face appeared in the door. “They want you in Room 8, doctor,” she said, almost casually.

I removed the placenta from my lap and stood up ready to run from the room.

The nurse shook her head sternly. “Better not show up like that,” she said, pointing to my gown. “You’ll scare the girls…”

I grinned sheepishly from behind my mask. I’d forgotten about the girls.

Loretta’s room was strangely calm when I arrived. Everybody was smiling, the baby already snuggled skin to skin on Loretta’s abdomen, and the girls were standing beside their mother enthralled and staring wide-eyed at the crying baby.

Maria, another nurse, who’d been with Loretta since her admission, was just removing her gloves after making sure the newly-delivered placenta was in its little metal bowl. Even though trained as midwives, the obstetrical nurses rarely get a chance to exhibit their skills except at times like this, and she was smiling from ear to ear. Things had obviously gone well.

“Congratulations, Loretta,” I said and immediately blushed. “Looks like I missed number three as well. I’m sorry…”

“Don’t be sorry, doctor. Maria did a fabulous job.”

Maria glanced at Janice who hadn’t even noticed that I’d finally come into the room then focussed her attention on me. “Actually, I was a bit rusty,” she said with a mischievous smile and winked at me. “Janice kept reminding me what to do next…”

Janice turned her head and stared at me. “Maria did a good job,” she said approvingly, “But she dropped the placenta,” she added, her face turning serious like a teacher unwilling to overlook a mistake. “I told her it’d be slippery…”

 

The Custom that dare not speak its name

The custom that dare not speak its name… Not until recently anyway. Now it seems all the rage to study the practice –expose it, as it were. And while I confess to paraphrasing the famous euphemism used in the trial of Oscar Wilde in 1895, I’m talking about something completely different. I’m talking about… well, grooming, as it’s prosaically termed.

Not grooming, you understand, but grooming…

I suppose ‘they’ (a nice term to offload responsibility) had to come up with a suitably un-nuanced descriptor for something hitherto off limits -although it’s not meant to conjure up images of what you might do to the coat of a horse or the fur of a cat; it’s meant as more of a tidying up process…

Still, even as an older gynaecologist, I have to admit to a little surprise at it being a subject worthy of publication in the prestigious Journal of American Medical Association’s (JAMA) Dermatology: http://archderm.jamanetwork.com/article.aspx?articleid=2529574 -the title of which, I blush to confess, immediately caught my eye: Pubic Hair Grooming Prevalence and Motivation Among Women in the United States. And then, after digging around for a more popular media source from the same time period, I found an article in the Guardian that references it: https://www.theguardian.com/lifeandstyle/2016/jul/11/should-groom-pubic-hair-shaving-trimming?CMP=share_btn_link

The practice of shaving the pubic region is certainly not new. It has been practiced in some cultures for hundreds of years, and early documents have suggested that it was an occasional practice amongst prostitutes in the middle ages, presumably for ease of maintenance as well as any aesthetic benefits. But the custom, at least in North America, seems to ebb and flow in its popularity. The JAMA study suggests that currently, it seems to be most popular in younger women –especially those between 18 and 24- and to some extent, those women with more education. ‘Race was also significantly associated with grooming, with all groups reporting less grooming when compared with white women. No association was found between grooming and income, relationship status, or geographic location.’

Over my many years in women’s health, I can’t say I even notice the grooming status anymore –unless, that is, there is a problem.

I had seen Janice before; in fact, both she and her mother came to see me from time to time, but seldom together –I don’t think they got along very well, to tell you the truth. Each of them were pleasant enough to me, but I suspect that her mother may not have understood her need to develop an independent identity. That’s what Janice told me that day in the office, at any rate.

A very active 19-year-old, she usually arrived in bike gear –helmet, tight lycra shorts, and a flush on her face both in apology for being late, and as the inevitable result of both cycling from her home several kilometers away, and running up four flights of stairs. This time, however, she’d not only been on time, but was also wearing the only dress I’d ever seen her in. And she seemed very uncomfortable as she sat fidgeting in the chair across from my desk.

“Took the bus in today,” she said –in response to my expression, I suppose. “Michael thought I should.”

“Michael?” I asked, and then immediately regretted it –I’m expected to remember these things. But I never can; it’s like trying to remember what colour socks I wore on a patient’s last visit.

“Yes… my guy.” She watched my face for a moment and then capitulated. “I told you about him a few months ago when I saw you for the birth control pill, remember?”

I pretended to remember –unconvincingly, judging by her expression.

“Mom still doesn’t approve of him, though…” She noticed a tiny movement in one of my eyebrows and smiled. “She thinks he’s too controlling,” she explained, but with eyes that told me I should have remembered that as well. “I mean she should talk, eh?”

I could feel another memory accusation coming up, so I decided to smile and change the subject. “Why have you come in to see me today, Janice?” I said.

She seemed relieved that the small talk was over and she could finally talk about it. But then, quite uncharacteristically, she blushed and looked at one of the paintings hanging on the wall as if it had suddenly called to her. “I… Uhmm, I’ve got a problem in my vagina.” She closed her eyes tightly to think more about the location. “No, not really the vagina, more the area around it, I guess.”

I waited for her to continue, but she seemed to have decided that she already told me enough. “And so, what…?”

“Little cuts,” she interrupted, almost as if I should have known right away. “Michael noticed them right away,” she added, to validate her claim.

“When do…?”

Her embarrassment was making her irritated at my repeated questions, I think.

“I’ve had them now for two or three days, and Michael is getting worried about them.” She stared at the picture again. “I told him they’d heal on their own, but I think he’s afraid of catching something…” she whispered to the wall. “I’m sure that’s why he insisted I come in for a check,” she said, turning to me again.

“Well would you like me to examine you?” She’d been sending her eyes out on little excursions while we talked and I got the impression that she only wanted to discuss her problem, so she could tell Michael about it. It was her choice.

She examined me with a puzzled expression on her face, her eyes firmly perched. “Well… I feel a little awkward about them,” she said slowly.  “They’re just cuts, I’m sure.”

I kept my face neutral. “And does Michael have any of these ‘cuts’?” Sometimes sexually transmitted diseases have unusual manifestations.

She kind of cocked her head and stared at me with a wrinkled forehead. I was obviously asking silly questions. “No, of course not! Why would he?”

I was about to answer her when she pre-empted me. “I mean he shaved me,  I didn’t shave him.” Her eyes suddenly twinkled. “I’m gonna suggest it next time, though.”

It dawned on me that George Bernard Shaw was right: ‘It is all that the young can do for the old, to shock them and keep them up to date.’

 

Women are from Earth

Men are from Mars, Women are from Venus –remember that book? It was published in 1992, and although it was really talking about relationship issues between the sexes, it seems to hint at other, more physiological differences that underpin the disparity -differences that have sometimes been overlooked, or perhaps ignored, in many pharmaceutical drug studies. http://www.cbc.ca/news/health/sport-exercise-menstrual-cycle-1.3618140

The justifications seem reasonable at first glance. There are cyclic changes in women –alterations in the hormonal milieu that make it difficult to standardize conditions for studying the drug in question. For example, progesterone is only found in women after ovulation, and this might alter the metabolism or effect of the drug being studied. Or estrogen –the quintessential female hormone- might alter the effects of the study drug differently than the testosterone milieu of men. Might alter the risks. Indeed, the CBC article quotes Georgie Bruinvels, the lead author of a paper in the British Journal of Sports Medicine: “Evidence actually suggests that women are almost twice as likely to have an adverse reaction to a drug than a male counterpart,” she said. In fact, a U.S. accountability study found “80 per cent of drugs there are withdrawn from the market due to unacceptable side-effects on women.”

And then, of course, there is the risk of inadvertent exposure of an unexpected fetus to the study drug. So why take the chance? Well, for a start, except for pregnancy of course, the sexes share most of the same problems: heart disease, hypertension, diabetes, strokes, arthritis, pain… to name just a few. But if the drugs created to combat these conditions are only tested on men, the information obtained may not apply to women. At the very least, doses may have to be altered. For example, ‘In 2013, the U.S. Food and Drug Administration released a safety announcement about the sleep aid, zolpidem, also known as Ambien. It recommended the bedtime dose be lowered for men and women. It also warned that women are more susceptible to risks associated with the medication because they metabolize the drug at a slower rate than men.’

In Canada, there is an attempt to rectify the gender bias in studies: ‘[…] a policy of the Canadian Institutes of Health Research requires researchers to say how they are dealing with sex and gender when applying for research grants.’

But the issue of sex biased research applies not only to human studies, believe it or not. It can even apply to animal surrogates studied to provide drug data –laboratory mice: http://www.cbc.ca/news/technology/mouse-sex-studies-1.3545486 The same reason -hormonal cycles- is the reason given for choosing male mice as subjects, although the validity of this justification has been questioned. And the results of using male mice has had similar, if not more severe, repercussions: ‘A stomach drug called cisapride that was sold in the 1990s under the name Prepulsid was withdrawn by Health Canada in 2000 because it sometimes caused irregular heartbeat and sudden death “in women only”.’

Or, take Jeffrey Mogil, a neuroscientist and pain specialist at McGill University who ‘estimates that in pain research, 80 per cent of published studies use male mice or rats, even though 70 per cent of people with chronic pain are women.’ And further, ‘Published studies on male mice showed that blocking immune cells called glial cells could block pain. When Mogil repeated the studies on mice of both sexes, he found they worked in male mice, but not females.’

There has been an attempt to rectify this bias: ‘The Canadian Institutes of Health Research, the main federal funding agency for health and medical research, has been trying to address the sex bias in rodent research. Since 2010, researchers have been required to answer questions about whether they will account for sex in their studies.’

Given the need for drug data on both sexes before the resulting medication or therapy is safely released to the general public, what can be done? Well, in most well-designed studies, there are two groups: the group given the medication, and a ‘control’ group who is, as much as possible, identical to the studied group. The general idea is to decrease the number of variables to a minimum, so that the only difference in the study group is the drug.

So, to start with, the study could be partitioned according to the menstrual cycle in women –with the use of a simple blood test to check for progesterone if there is any doubt, or if the menstrual cycle is sufficiently irregular or unpredictable. Thus, after controlling for such things as weight, other medications, health, and past history (as one would do anyway to establish control groups) three arms to the study could be included to address the disparities: 1. Men –knowing that they would have minimal estrogen on board; 2. Women –a). pre-ovulatory (i.e. no progesterone in blood) and b). post-ovulatory women (progesterone in blood). Of course, given that there would also have to be matching controls, this would add extra costs –and probably time- to complete the study. But I would imagine these would be counterbalanced by the costs of developing a drug that might have to be withdrawn from the market for unexpected side effects -on women, say– not to mention any resulting law-suits or ethical considerations held against the company.

And what about inadvertent pregnancy exposures to the drug? Oral contraceptives themselves may interfere with the study drug metabolism so either women on this type of contraception could be added to the study as yet another arm or, more feasibly, women using other reliable, non hormonal contraceptives could be enrolled, including women who have had a surgical sterilization procedure (e.g. tubal ligation).

All of these permutations and combinations may seem daunting, and yet surely the validity and applicability of the study results are what count in the end. As Mahatma Gandhi once said: ‘It is health that is real wealth, and not pieces of gold and silver.’ I just wish he’d said it louder.

Leave Me Alone

I have lived in a hospital as an on-call obstetrician on more days –and nights- than I can count over the years; hospitals were the grudging homes for me ever since medical school and the subsequent ages of specialty training that fell upon me like unbidden hats. And despite the palimpsest of colours I was forced to wear, hospitals have been the lodestars in my ever-changing world.

They weren’t all pleasant, although each beckoned with what seemed, from a distance at least, to be tempting endowments of knowledge and experience. Gifts are gifts, no matter the source, and I accepted each with gratitude, if not a little experientially-acquired caution. But although one must often stride boldly into the unknown to arrive at a destination, adaptation follows close behind. And then comes a fondness for what seemed, initially, to be strange. Chaotic. Frightening. And yet the utility of the situation breeds an eventual reconciliation. The disturbing, becomes assimilated into the quest for advantage. The hope for reward.

At least, that’s how an employee –a doctor or a nurse, especially- might rationalize the initial anxiety in a hospital: ‘short term pain for long term gain’, as the trite political aphorism would have it. But one can only wonder how the experience might strike a person who, travelling along the avenue of illness or accident, is forced to endure the unexpected and probably unwelcome distress.

There was an interesting article in an old BBC News article that questioned whether going into hospital might actually make you sick: http://www.bbc.com/news/magazine-35131678

A Dr. Harlan Krumholz at the Yale School of Medicine became interested in in the statistic that ‘about a fifth of patients who leave US hospitals are back within a month.’ At first glance, this may seem obvious and uninteresting –the original cause for their admission may not have been completely dealt with, or perhaps there were complications from it that only surfaced after their discharge. Indeed, in many countries ‘re-admission rates are taken as a measure of the quality of care a hospital provides.’ But Krumholz realized that ‘only about a third of patient readmissions were related to the original cause of hospitalization. Patients’ reasons for returning to hospital were diverse and linked to their immune systems, balance, cognitive functioning, strength, metabolism and respiratory systems.’ He felt this was an entity unto itself and called it PHS (Post Hospital Syndrome): http://www.nejm.org/doi/full/10.1056/NEJMp1212324

Basically, it assumes that hospitals unwittingly engender stress in patients by imposing disruptive and often intrusive regimes –some of which could safely be postponed or modified at night, for example. Patients already feel vulnerable and powerless in the face of illness or accident, and few would dare complain for fear of alienating those who are the providers of their badly-needed succour.

*

Vesna was not one of those. From the moment I saw her in the Emergency department with a severe and unresponsive pelvic infection, it was obvious she did not intend to relinquish control. Indeed, it was something of a diplomatic coup that one of the ER docs was able to convince her to allow an intravenous catheter to be inserted into her arm. She had to point out one of the only remaining veins –she knew her arm well- and direct his hands when he tried, unsuccessfully, to enter the tiny vessel that was hidden under a tattoo on the skin above her elbow.

It was around 2 A.M. when my resident called me about her, and just as I entered the little cubicle, someone dropped a large metal pan by the door. Before I could introduce myself she yelled at me. “I’m not gonna use one of those f– things, doc!” and she pointed to the bedpan on the floor.

The nurse looked up apologetically. “No, I’m just taking it out of the room, Vesna. It’s not for you.”

“Do I have to stay down here all night, doctor? It’s too f– noisy!” She said this all too loudly, ostensibly so her voice would be audible above the noise, but despite the outburst, despite the angry expression on her face, for a fleeting moment her eyes seemed to betray her when she glanced at me: they twinkled contritely, as if trying to excuse the behaviour of their owner.

My resident shook his head. There was apparently a bed available for her up on the ward so she’d be moved up shortly.

At hand-over rounds the next morning, the resident looked exhausted. Apparently Vesna had complained that the patient in the bed next to hers was snoring so she couldn’t sleep. And the nurses insisted on talking in the corridor whenever they walked by; the medicine carts they pushed were too noisy; or somebody kept coughing in the next room. So, Vesna demanded a sedative. That, of course, required the okay of a doctor first. And then, later, her IV stopped working –it had been inserted into a vein that would not ordinarily have been used- and the so the resident had been called to order the antibiotics to be given by some other route. The ones she needed were not available by mouth, so the only remaining way was by injection into her muscles. Vesna objected, of course, and so the resident had to go up to the ward again and explain things to her.

The hospital food was certainly not to Vesna’s liking –she said it made her sick- although, in fact, it was probably a side effect of her antibiotics. I’ve never liked institutional food either, but there seemed no end to her complaints while she was in hospital. We learned to tolerate her, of course, but I remember deciding to buy coffee for the resident staff when we discharged her.

I suppose I fell prey to the uncharitable assumption that Vesna was simply a grumpy person –someone whose circumstances had taught her to be suspicious of everything around her; someone who had learned to be tough and difficult to befriend. It was a wall she was forced to live behind -makeup she applied to protect the skin beneath.

She was supposed to come to my office for a follow-up visit a week or so after discharge but I have to admit that I wasn’t surprised when she didn’t show up for her appointment. My secretaries had actually double-booked me for her time, suspecting as much.

A few weeks later, I saw her name on my day sheet again but the woman who sat nervously in the waiting room pretending to be absorbed in a magazine was nothing like the Vesna I’d met in the hospital. This time she was dressed in slim black jeans with a frilly light blue cotton pullover. Her auburn hair was neatly combed and her ears adorned with enormous golden earrings that threatened to snag her curls every time she moved her head. When she saw me approaching, she smiled and stood up to extend her hand.

“I’m sorry I missed my last appointment, doctor,” she said, as soon as we were settled in my office, the embarrassment written in her eyes. “I had to be admitted to another hospital so I couldn’t make it…”

“The infection came back?” I said, concerned that we had discharged her too early.

She chuckled merrily at the thought and shook her head, making the earrings dodge in and out of her curls like it was a game of tag. Then the look of embarrassment returned. “Overdose.” She took a long breath and then shrugged. “Occupational hazard, I’m afraid.” She looked out of the window behind my seat for a moment. “Interesting, though…” she said slowly and deliberately, as if something had just occurred to her. “Same source, same amount… Never happened before and my boyfriend was okay so he couldn’t have cut it with bad shii…” She glanced at me and quickly corrected herself mid-word. “…ah, stuff… so I wonder how I could have overdosed.” She sat back in her chair and shrugged it off. “Maybe somebody’s trying to tell me to change my ways while I still can, eh?” She giggled like a school girl -and for a moment, she was.

Was she a victim of PHS or, in her case at least, the recipient of an opportunity? Were the two events even related, or in my rosy-eyed naiveté, am I projecting my own hopes on an otherwise indifferent world? I don’t know, of course, because I never saw Vesna again, but I’d like to think that something changed her. But for the better this time… Could PHS do that too?

I remembered the words of Emily Dickinson:

‘Hope’ is the thing with feathers that perches in the soul                                                                                    And sings the tune without the words and never stops at all.’

 

The Trigger Warning

Call me naive, if you will, or maybe even uninformed, but not insensitive. Not indifferent; I am neither.  Unaware, perhaps comes closest. And, until recently, the concept of trigger warning was not one that I thought would have arisen in the day to day world of office gynaecology. But I was wrong.

A trigger warning, I have since discovered, is an alert to the audience (or patient) that what you are going to say might inadvertently offend or upset them –especially if they had experienced a related trauma. Theoretically, at least, it gives them an opportunity to prepare themselves beforehand, or inform you that they would rather not hear that part of your discussion. Many university lecturers have taken to issuing these warnings in their preparatory notes, or at least at the beginning of their lectures, I understand.

And at first glance, it seems the reasonable thing to do. If something in the lecture might offend or distress some students, then they should have the opportunity to opt out of that particular lecture without punitive consequences. On the other hand, to withhold some of the contents from the entire class in case it offends someone, seems like censorship. So I think that a prophylactic warning beforehand is in everybody’s best interest.

I suppose it could get out of hand, however.

Jennifer was a patient that I had seen for the first time in the hospital colposcopy clinic for  a rather long history of abnormal pap smears. I had looked at her cervix through a colposcope (a microscope with a long focal length so it can visualize the cervix even high up in the vagina) and biopsied an area that was likely responsible for the pap smear change; she had come to the office to discuss the findings.

A young woman in her late twenties, she seemed quite self assured as she sat quietly in the busy waiting room reading a magazine oblivious to the noise around her. Dressed in black designer jeans and a baggy yellow sweat shirt that said ‘Really?’ in bold blue letters, she looked capable of weathering any disturbance. But, as absorbed in the intricacies of the magazine article as she seemed, her eyes immediately locked on mine when I appeared in the room. Brown, curious eyes, as I recall; eyes that, once engaged, held their target until it turned away –or responded as I did, with a proffered hand.

When we were settled in my office, and she had inspected the room, a sudden and unexpected smile appeared on her face. It was, I suspect, an attempt to force me to give her good news about the biopsy. “So what did you find, doctor?” she said, with a lilt in her voice.

It’s often difficult to discuss an abnormality with someone who seems sure that nothing is wrong. Obviously her GP had chosen not to. “Well, you remember that the pap smear that brought you to the colposcopy clinic in the first place was abnormal…”

“Yes,” she interrupted, “but it was only mildly abnormal…”

I smiled in what I hoped was a reassuring fashion and nodded. “Pap smears are an early part of a screening system that helps us to decide whether or not to investigate further. They’re just cells that we collect by scraping the surface of the cervix after all.”

Her expression immediately changed and her previously cheerful face tightened. “What are you trying to tell me, doctor?” she said, and straightened in her chair. She stared at me for a moment, but before I could formulate an answer, words tumbled from her mouth. “Do I have cancer? Is that why you brought me in today instead of letting my GP tell me?”

I kept my eyes calm, and shook my head. “No, far from it.” Once someone has used the C word, I often find it’s important to disavow them of it immediately or it festers in the background. “You have a moderate abnormality on the biopsy I took.” I avoided using the Bethesda system’s alternate label of ‘high grade’ to help her to process the news. “It’s definitely not cancer, but if you left it for a while, it might certainly take that route…”

“Left it how long?” she asked, trying, unsuccessfully, to keep the panic out of her voice.

I shrugged, to show her that I wasn’t particularly worried. “Years, likely… but we usually treat it soon after we diagnose it… Just in case.” I added thoughtfully.

Her eyes were dinner plates and her mouth was trembling; I thought she might burst into tears, so I handed her a tissue.

“And… How do you treat it?” She managed to look out the window behind my back for a moment. “Surgery?”

I nodded reassuringly. I was about to describe a small five or ten-minute operation we do in the outpatient’s department under local anaesthetic when she exploded in tears.

“I will not let you take my uterus out, doctor!” she said between sobs. “We’re trying to get pregnant!”

“I won’t let me take your uterus out either, Jennifer,” I said, trying to lighten her mood, I guess. But it backfired.

“You seem to be taking this whole thing rather lightly, doctor. I would have hoped you would be more sensitive…”

My face fell. “I’m sorry, Jennifer. I was just trying to reassure you that removing your uterus was not the kind of surgery I had in mind. It was a rather clumsy attempt, though. I’m sorry…”

Her forehead softened and she grabbed another tissue and relaxed a little on her chair. “Remember, we want to get pregnant soon,” she said, her words tentative now. “We’ve already lost one… I had a miscarriage last year,” she added hastily for fear I might not understand. She stared at me for a moment. “Could I wait till after I’ve had a baby and then do the surgery?

I looked at the findings from the colposcopy once again. She had a rather large lesion and the pathology report suggested that some areas of the biopsy might be more severe -not cancer, but certainly meriting treatment. “You always have a choice, Jennifer…”

“But…”

I realized she probably felt there might be different opinions for management so I sat back in my chair to show her I was willing to listen, but she just continued to stare at me with a mixture of anger and disbelief on her face. “Would you like me to ask your GP to send you to another gynaecologist for a second opinion?”

She didn’t say anything, so I decided to describe the operation I usually perform for her abnormality: a LEEP (Loop Electrosurgical Excision Procedure). It involves taking the abnormal cells off the cervix by removing a thin disk of tissue. I drew on a diagram of the cervix and uterus as I was describing it so she could understand it a little better. I even gave her the diagram to take home with her.

As I was finishing, she looked up from the paper and locked eyes with me again. “And the complications?  Am I going to be able to have children?”

I smiled at her again. I had been about to discuss possible complications with her. “Well, hopefully it won’t interfere with that, but if you look it up online, you’ll see a few complications listed. In my experience they’re not very common, though.”

My attempt to put the complications into some kind of perspective for her obviously didn’t reassure Jennifer. “What are they?” She said, rather harshly I thought.

“Well, in pregnancy, the cervix has to remain strong enough to hold the baby inside until it’s ready. If too much of it is taken away with the surgery, then it might open prematurely –incompetent cervix it’s called- and the pregnancy might be lost…” Her mouth fell open and her eyes narrowed. “But,” I continued before she could say anything, “nowadays that first ultrasound you get in pregnancy can look at the cervix and pretty reliably reassure us that it’s not likely to happen.” I kept my face as neutral as I could in an attempt to disarm her growing distress. “And if it seemed likely that the cervix was shortening, or if we discovered a problem later in the pregnancy –the baby’s a lot bigger then, remember, and so it exerts more pressure on the cervix- we could put a stitch called a ‘cerclage’ around the cervix to keep it closed. Then, near the end of pregnancy when the baby is old enough to be born safely, we untie it…”

She could barely speak, she was so angry. She glared at me through predatory eyes and then, with clenched teeth and a barely open mouth, she managed to say something. “You know, I’m really disappointed in you doctor! With all your experience and with all I’ve heard about you, I’m really disappointed.”

I suppose my expression changed to one of puzzlement –astonishment, really- because she immediately began to put on the coat she’d kept on her lap.

“You knew I’d had a miscarriage –it’s on that form I filled out in the hospital for that clinic. And I told you here in the office just a minute ago. You could see I was worried, and yet you still kept talking as if it was simply business as usual…!” She grabbed another tissue and dabbed both eyes again. “I had a hard time recovering from the pregnancy I lost… But you didn’t care!”

“I’m sorry… I…” But she wasn’t listening.

“Any doctor who was sensitive to their patients –anybody for that matter- would have known to give a trigger warning…” she said and stood to leave. “I’m going to ask my GP to send me to someone more empathetic,” she said and turned on her heel and stomped angrily out of the office.

I felt terrible too; I felt I’d failed her -even though there’s no easy way to tell people things they don’t want to hear. Thinking back on it, I suppose I was insensitive to her needs. And yet…

It’s hard to be anything but humble in this field…