Blog of the Society for Menstrual Cycle Research

Working Mothers

April 29th, 2013 by Paula Derry

“Working Mother and Son” Photo by Russell Chopping // Creative Commons 2.0
http://www.flickr.com/photos/russellchopping/3501039851/

Research is often reported as though it is news, as though the most recent article is the best and research that was not published this year is somehow not as interesting or is out-of-date. I recently dug out some articles I wrote about the psychology of working mothers that were based on a study I did in the mid-1980s. I interviewed psychotherapists about how being a mother had affected their professional lives. This study was qualitative research. I offer the results as interesting ideas, not as definitive conclusions.  Some points I think are still interesting:

  1. Overall, about 64% of the 25 mothers I interviewed opted for part-time work; when children were preschoolers, this was about 78%. Psychotherapists, unlike many other women, have the option of working part-time:  part-time jobs, especially for therapists who see clients in private practice, are the same jobs that a full-time worker would have.
  2. I compared the mothers with another group of 19 therapists who did not have children. The non-mothers tended to work full time (about 90%).  However, both groups of women were deeply and apparently equally committed to their jobs.
  3. Many of the mothers (about 60%) felt that work was not as important to them as it would be if they were childless. However, this did not mean that work was unimportant. For most women, it only meant that they now had two strong priorities instead of one.
  4. Almost all of the mothers (88%) felt that having children affected their work as psychotherapists by deepening their empathy, understanding, or emotional knowledge about parents and parenting. This was not simply intellectual, that they knew more facts, although this was also true. It was experiential understanding, a different experience of what facts mean. This was so even though their profession involves helping clients understand their parents or their parenting, and was reported whether they had a child while in graduate school or after they had worked for many years.
  5. One aspect of this increased knowledge was an experience of how passionate an experience mothering is. Another aspect was a less idealized view of both parents and children, and greater tendency to see the experiences of parents and children from their own perspectives. For example, in addition to seeing parents in terms of how their children felt (e.g., that the parent was mean or rejecting), the therapists might perceive more clearly where parents were coming from or that children might misunderstand or be unreasonable.
  6. This greater ability to see the position of both parents and children more clearly is what a psychologist might call psychological individuation. That is, the stereotype is that mothers are or should be all-giving, selfless, thinking only about their children. However, these mothers seemed to grow more realistic, clear about and accepting of who children as well as parents are. As I said in one paper:  “Interconnectedness, or intimacy, requires a sense of oneself and the other as separate but related. (If children really do lack a sense of this separation, that is no reason why their parents, who are adults, should identify with their perspective.)”

References

Derry, P.S. (1994) Motherhood and the importance of professional identity to psychotherapists. Women & Therapy, 15, 149-163.
Derry, P.S. (1992) Motherhood and the clinician/mother’s view of parent and child. In  J. Chrisler & D. Howard (Eds.), New directions in feminist psychology:  Scholarship/Practice/Research. New York: Springer.

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Posted in Communication, Motherhood, New Research | 1 Comment »

Understanding Research: Media Reports of Research

April 1st, 2013 by Paula Derry

The Huffington Post published a story last week titled “Last Menstrual Cycle Could Be Predicted With New Model”. The story stated that a research study had just been published about a new method for predicting the end of menstruation in which researchers developed a formula for using the levels of two hormones, estradiol and follicle stimulating hormone (abbreviated FSH), to make this estimate. This “new method for predicting a woman’s last menstrual cycle could have broader implications for menopausal women’s health”. Since “in the year leading up to the final menstrual period, women are met with faster bone loss and a greater risk of heart disease”, if the end of menstruation could be predicted, medical monitoring and interventions would become possibilities. The research was also reported as news on the medical website Medscape.

Research results are often reported as news stories, as though these results are facts. However, “dog bites man” and “man bites dog” are facts, but research results are not facts in the same way. They are “evidence” that most often must be evaluated, understood, and put into the context of many other studies. There could very well be disagreement about whether a study’s methods really did accurately make a point, or whether the conclusions the researchers drew from their work were justified. Sadly, it happens all too often that research does not make the point that the headlines claim.

Photo by clarita // morgueFile

Here, we have a study by a respected researcher at a major institution, UCLA, funded by a grant from the National Institutes of Health and other prestigious grantors. However, we do not have the information with which to understand what the researchers actually did. UCLA issued a press release which states that the study “suggests” a way to predict the final period. The Medscape article states that “A new model MAY [my emphasis] help physicians determine how far a woman is from her final menstrual period”.

Suggests? May? I have no idea what this means. As a researcher, I want to look at the published article to see what was actually done. However, the publisher does not make a free copy of the article available. Anyone who wants to look at the published article—a researcher or an informed consumer—would need to pay the publisher $37.00 to access this 20-page article for one day. Predicting the last menstrual period from hormone levels, which is what is claimed, is something other researchers have tried but failed to do, so how these researchers worked with the difficult problems is an important question.

Assume for a moment that the model was a big success, and it did predict the last menstrual period. The idea that this has important implications for women’s health is stated as though it were another fact. However, this is not a fact; this is a complicated and controversial area. Bone density does decrease in the years surrounding menopause, but professionals disagree about how big an effect this has on bone disease. For example, current guidelines recommend testing bone density beginning at age 65, 15 years after the average age of menopause, because this is when the fracture rate has significantly increased. Heart disease risk factors may increase on average in the years surrounding menopause, but professionals disagree about whether menopause is important compared with other factors associated with aging.

Assume for a moment that bone disease really is an important negative health consequence of menopause. Whether interventions would be found that must be started in the year or two before menopause is another speculation. Such interventions might be found or might not. Predicting the last menstrual period, even if the claim is valid that a method to do so has been found, is a long way from preventing disease.

The medical satirist Andrew Vickers wrote an article called “News On Cancer Drug Fails to Raise False Hopes”, which begins: “A recent article on a novel cancer therapy has rocked the newspaper industry by giving a balanced and cautious review of an early-phase trial”. Satirists make extreme statements to make a point. Media reports are often written to sound definite and to portray a study as really important. A cautious approach to medical news is to withhold judgment unless the methodology of the study is clear and the context of the study is understood.

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Medicating the Postmenopausal Vagina

March 4th, 2013 by Paula Derry

On February 26, 2013, the Food and Drug Administration issued a news release saying that it had approved a medication called Osphena to treat a problem called postmenopausal dyspareunia (pain during sexual intercourse associated with changes in the vagina after menopause). The medical website Medscape reported that the news release had been issued. How to read these announcements? It seems as though FDA approval should be enough to know that a medication is safe and effective.   However, what are some guidelines in reading and evaluating this announcement?

First, some background: After menopause, when estrogen levels decline, tissues (cells) of the vaginal lining can become thinner, drier (thus providing less lubrication during intercourse), and less elastic or flexible.

This can result in pain during intercourse, feelings of burning or soreness, inflammation, and irritation.

Andreyeva by Ilya Repin // Public Domain via Wikimedia Commons

There are a variety of solutions for dealing with this.  Regular sexual stimulation (intercourse, masturbation) is recommended to keep vaginal tissues healthy.  Water-based lubricants can help reduce discomfort during intercourse.  Expanded views of sexual pleasure that don’t include intercourse might work around the problem. Leaving enough time to become aroused during intercourse (extended foreplay), communication between partners about when sex is painful and when not, can also help. Herbs like dong quai and black cohosh are recommended, especially by complementary/alternative practitioners, although the herbs  lack a research base. A low-dose estrogen applied to the vaginal area (as a cream, tablet, etc.), is effective. Local application minimizes estrogen being absorbed into the bloodstream, traveling through the body, and having effects, some of them potentially negative, distant to the vagina. There is, however, controversy about some estrogen being absorbed.

Now, to the FDA announcement:  The FDA requires proof of a medication’s safety and effectiveness before it is approved.  According to the news release: “Osphena’s safety and effectiveness were established in three clinical studies of 1,889 postmenopausal women with symptoms of vulvar and vaginal atrophy. Women were randomly assigned to receive Osphena or a placebo. After 12 weeks of treatment, results from the first two trials showed a statistically significant improvement of dyspareunia in Osphena-treated women compared with women receiving placebo. Results from the third study support Osphena’s long-term safety in treating dyspareunia.”

Notice, first, that the drug’s effectiveness was tested for 12 weeks. This is not an unusual amount of time for such a study, but it is not very much time. Notice also that women treated with Osphena had a “statistically significant” improvement. As I discussed in a previous post, “statistically significant” means “unlikely to have occurred by chance.” In other words, there was evidence that Osphena  really did have an effect, but we don’t know how big an effect—it might be very large or very small.

Safety was established by studying the experiences of women for one year: however, one year is not a long time for side effects to develop. Osphena is a systemic medication. That means it is not applied locally in the vaginal area, it is ingested as a pill so that it travels to all parts of the body in the bloodstream. It is a selective estrogen-receptor modulator, or SERM. SERMs act like estrogen in some places in the body while not in others. The idea is that a SERM like Osphena would act like estrogen in keeping vaginal cells healthy while not acting like estrogen to increase health risks like certain cancers. However, more time than a year might be needed for health problems to show up. Indeed, the FDA news release stated that “Osphena is being approved with a boxed warning alerting women and health care professionals that the drug, which acts like estrogen on vaginal tissues, has shown it can stimulate the lining of the uterus (endometrium) and cause it to thicken…. Women should see their health care professional if they experience any unusual bleeding as it may be a sign of endometrial cancer or a condition that can lead to it.” The FDA announcement also stated that “Common side effects reported during clinical trials included hot flush/flashes, vaginal discharge, muscle spasms, genital discharge and excessive sweating” and that Osphena should be prescribed for the “shortest duration consistent with treatment goals and risks for the individual woman.”  Continue reading...

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Posted in Menopause, Pharmaceutical, Sex | 4 Comments »

Periods: A Human Oddity

February 4th, 2013 by Paula Derry

What does it mean to have menstrual periods? This is an intensely personal question, but it is also a scientific and a cultural one.

The menstrual cycle can, of course, be described in terms of a woman’s personal experience of menstrual flow. It can also be described by the complex physiology of hormones climbing, pulsating, falling. However, what are some other things we know about periods?

We know that they are an oddity in nature. Most animals, aside from monkeys, apes, and us, thicken the wall inside the uterus only after an egg has been fertilized. We have periods because we routinely build a thicker wall inside the uterus, just in case it’s needed, which must be eliminated if we don’t become pregnant. According to Ann Voda, much of this wall is absorbed back into our bodies (the same way that if you smash your finger and get a clot under the skin, that blood is absorbed into the body then eliminated). Some of it is released to the outside world in an organized manner in what we call our period.

We know that the menstrual cycle is only one part of a larger whole.  I’ve always liked the description of adolescent development in Barry Bogin’s textbook Patterns of Human Growth.

public domain image from the holdings of the National Archives and Records Administration

To summarize the content of his book: A part of the brain called the hypothalamus changes. Then a growth spurt begins (we all remember growing taller quickly): this is unique to humans, nonhuman primates and other animals don’t have a growth spurt. Then a girl begins developing secondary sexual characteristics, breast buds (the beginning of breasts) and the beginning of pubic hair. Then estrogen levels begin to rise, which leads to a particular female shape due to fat in the hips, buttocks, and thighs. The first menstrual cycle occurs some years after these other changes begin. We’re not done yet. Menstrual cycles are at first irregular and girls rarely ovulate, it is a few years before girls ovulate as regularly as does an adult. In addition, the bones of the pelvis don’t grow quickly during the growth spurt, and it is many years after menarche, when a girl is in her late teens, that the pelvis has finished growing.

To continue the summary: Reproductive maturity requires biological, social, and psychological maturation. It means being an adult.  In Bogin’s words, “[b]ecoming pregnant is only a part of the business of reproduction.  Maintaining the pregnancy to term and raising offspring to adulthood are equally important (p.212).” In cross-cultural research, behavioral and social events typically co-occur with adolescent physical changes. As girls visibly physically mature, and as they begin menstruating, they are invited into the world of adult women. They develop adult modes of thinking (for example with regard to Piagetian stage), interacting with men and women, sexuality. They refine practical skills needed for the tasks and occupations of a competent adult. Age of having a first child is often years after menarche, often around nineteen years of age among women from many diverse cultures. When compared with animals, this complex transitional stage of life from adolescence through adulthood is a human oddity.

Nobody knows biologically for sure why women menstruate, but cultures, including ours, typically assign meaning to menstruation. Personally, I’d say that getting your period isn’t a transition in the sense of flipping a switch on. However, in most cultures, menstruation is an important marker or component with multi-layered meaning for a larger, rich life stage.

References  Continue reading...

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Posted in Menarche, Menstruation | 1 Comment »

Motherhood

January 7th, 2013 by Paula Derry

I recently had the opportunity to present a talk at something called Ignite Baltimore. Scheduled a few times a year, Ignite has proven to be extremely popular. I discovered that not only had the event sold out, but people arrived early for a pre-event reception in a sprawling lobby filled with animated people conversing.

The format is this: Sixteen speakers each give a five-minute talk. During each talk, twenty slides are each shown for 15 seconds, and the talk has to be built around this constraint. During my Ignite event, the topic of talks ranged from musings about what magic is, to how to revitalize Baltimore, to mine on motherhood. For me, giving a presentation was an opportunity to experiment with using a different kind of language than I use in more academic presentations, and to experiment with a mixture of words and visual imagery.

Here’s the YouTube video of my talk about what it means to be a mother. It’s also about the idea that we exist as whole, integrated people, not isolated bits of hormone, brain chemicals, stereotyped behaviors, stimulus-response connections to the environment. The imagery is unfortunately blurred, but I hope you can make out enough, and I hope that what I say is of interest.

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Getting from the Average to the Individual When Reading Reports of Research

December 10th, 2012 by Paula Derry

We are unique individuals. Or, we are like everyone else. Which is it? For menstrual periods and the menopausal transition, as perhaps for most things, we’re a little bit of both. For me, keeping in mind that both are somehow true, and understanding the ways in which each is true, is a crucial but tricky business. Scientific findings are often reported as though they are universal truths. “The normal menstrual cycle is regular and occurs every 28 days.” “Depression is more likely during the transition to menopause.” However, research most typically examines groups of people, and results are most often average findings. A discrepancy between the average and the range of real experience isn’t surprising.

Take, for example, a study of the transition to menopause. This was longitudinal research—that is, the same group of women was studied for many years, and the patterns of change in their menstrual cycles over time could be documented. The authors conclude that there are three stages in the transition to menopause. At first women experience, perhaps beginning in their thirties, subtle changes in menstrual flow (like periods becoming heavier or lighter) without cycle length becoming irregular. Next, periods become irregular. Finally, women skip periods in the run-up to menopause. The stages are based on what, in the authors’ words, occurs “most frequently”; the average or frequent result is the basis for understanding the underlying pattern. Yet there is also a lot of variation. As reported in the article, only 39% of the women progressed in a forward manner through the three stages. Almost half seesawed back and forth. In addition, it is known that a significant minority of women report that they have gone from regular cycle lengths straight to menopause without a time of menstrual irregularity. I remember that when I first read this study I felt a certain comfort that changes in my body, like lighter periods and other changes, were predictable and fit into a pattern that other women experience. Yet, on the other hand, the findings can’t be used as a blueprint for what is supposed to happen. We share experiences with others, but we’re also unique individuals.

The average menstrual cycle is said to be 28 days—well, I don’t know many women with a 28-day cycle, and while some women describe themselves as “regular as clockwork” other women are bewildered that anyone could think that the cycle was regular. Rates of depression have been found in many studies to increase during the menopausal transition. However, the great majority of women do not become depressed (the “relative risk” has increased, but the “absolute risk” remains low). Knowing that the rate increases might suggest to a woman that she consider this possibility, but does not answer the question of whether she will become depressed, or, if she does, whether her depression is related to perimenopause or something else.

In trying to use scientific facts to understand ourselves or the world around us, the difference between the particular and the general, the predictable and the unpredictable, is important. Our individual behavior and physiology aren’t random or without form, but neither are they completely predictable.

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Posted in Menopause, Menstruation, New Research | 2 Comments »

Hot Flashes Are Weird

November 12th, 2012 by Paula Derry

I have two pretty contradictory sets of opinions about hot flashes. In a previous blog post, I emphasized one of them. Namely, that flashes are a mind/body phenomenon in which a woman’s interpretation of her physical experiences are central to her being distressed or not, of being able to cope or not, of what an experience is and means. A woman can identify her “real” self with her thoughts or her body, or she can experience her embodied self as a totality. In my first set of attitudes, the diversity of physical experiences is part of the mix: The same term, “hot flash,” is used for a wide family of experiences that range from mild to unbearable, from heat to heart palpitations, from empowerment to anxiety. However, in my second set of opinions, physical experience is front and central, and my thoughts can be summarized as follows: Hot flashes are weird.

In a conventional view, flashes are simply something that happens because of the hormonal changes surrounding menopause. They are often defined as a transient feeling of heat, sometimes accompanied by sweating or the skin turning red, that typically lasts a few minutes but can persist up to an hour. Flashes are most common in the years surrounding menopause but can begin many years before or occur many years after the final menstrual period. One theory is that fluctuating levels of estrogen affect a part of the brain that controls heat regulation. As a result, small changes in temperature are interpreted by the brain as meaning that the body’s temperature is outside the normal range; the hot flash is the body’s attempt to cool the body down. Alternatively, perhaps the hormonal imbalance affects the brain or other endocrine glands in other ways, or perhaps some women are simply more sensitive to these changes.

However, the experience of flashes is complex. A woman who is overheated for other reasons may not feel like a woman having a hot flash. A flashing woman might feel like she is on fire. Or she may feel hot only in an isolated body part, like her back or earlobes. Or the feeling of heat may start in one part of the body (like her head or upper back) and travel. Some women may not realize their feeling of gentle warmth is caused by a flash until later. Further, there are experiences in addition to that of warmth. The experience might feel like anxiety rather than heat. There may be a sharp physical shock or jolt. Some women, for example, may wake up in the middle of the night with a shock of anxiety and wonder what has threatened them. Some women report other associated sensations such as a racing heart, nausea, and breathlessness. Some feel dizzy, anxious, and unable to concentrate. Others experience cognitions and feelings such as empowerment, anxiety, and catastrophic thoughts.

Flashes are basically not understood. Beneath the scientific generalities, there is no specific understanding of what underlies flashes. They do clearly have something to do with estrogen: they increase in frequency in the years surrounding menopause, and treatment with a hormone medication is helpful. However, while fluctuating estrogen levels are assumed to be causal, clear evidence of this has been notably lacking. Further, flashes are found during the menopausal transition and postmenopausally, two very different hormonal situations, but are not a widespread phenomenon during premenstrual hormone fluctuations. For the minority of women with severe symptoms, there is no understanding that would lead to correction of underlying problems beyond symptomatic treatment with medications like estrogen. Why would a brain center regulating body heat be affected in some women but not others or in the same woman only sometimes? There are speculations that estrogen is needed for brain general health and proper neurotransmitter balance or that some women are “more sensitive” to normal changes in hormone levels. It seems that additional factors must also be at play. The large cross-cultural differences in flash frequency and the large placebo effects of medications are not understood, neither is the role of stress or other psychological or situational factors.  Continue reading...

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Posted in Hormones, Menopause | 2 Comments »

Understanding Research: Expert Opinion Isn’t Enough

October 15th, 2012 by Paula Derry

Many of us do our own health research, either because we have a specific question or simply to keep up with the news. If we don’t read the original scientific articles, we rely on experts to provide summaries in newspapers, magazines, or on a variety of websites. It seems as though by choosing sources judiciously we should be able to count on finding information that is accurate. However, relying on authority, whether this authority derives from a writer having scientific or medical training, or the writer being a professional journalist, or some other reason, is not enough.

I thought about this recently when I saw an article on Medscape, a website for health professionals, especially physicians, called “Early menopause doubles CVD risk regardless of race.” A summary of a new journal article, it was highlighted on the Medscape home page for many days. It began: “Women who experience early menopause–before their 46th birthday–are twice as likely to suffer from coronary heart disease and stroke as women who don’t enter menopause prematurely, and this finding is independent of traditional risk factors.”  Johns Hopkins University, where one of the authors is employed, issued a press release entitled “Early Menopause Associated With Increased Risk Of Heart Disease, Stroke” which also begins:  “Women who go into early menopause are twice as likely to suffer from coronary heart disease and stroke, new Johns Hopkins-led research suggests.” Similar articles appeared in Medline+ (a National Institutes of Health and National Library of Medicine website), a Blue Cross Blue Shield healthcare news website, and many print newspapers.

So, what was in the original scientific article? The article was published in Menopause, which, like many journals, does not post its articles free online for non-subscribers. Many academic libraries do not carry this journal. However, if a reader does get the original article, these are some of the details: The women in this research were studied for a number of years. The researchers collected information about many predictors of circulatory problems (smoking, diabetes, etc.). The women were also asked at what age they had reached menopause. If this was when they were younger than 46, they were classified as having an “early menopause” whether menopause was caused by surgery (ovaries removed) or occurred naturally. The researchers looked at whether the women developed heart problems or strokes, and created mathematical models to study which predictors of these problems were important.

Twice the number of women with “early menopause” had heart problems compared with women who reached menopause later. This is what is called “relative risk.” The “absolute risk” numbers were: 3% of the women with early menopause had heart problems compared with 1.4% of those who did not; for stroke, the numbers were 2.6% vs. 1%. This is still a difference, but not as dramatic as a twofold increase. In addition, the way the strength of the association was mathematically computed was to first predict heart problems and stroke with more usual predictors: age, risk factors like diabetes. The difference in risk due to menopause was in the uncertainty left after all these other factors had already been taken into account. Further, we don’t know whether the “early menopause” group had other associated characteristics leading to a health difference—if they were unhealthy in other ways. The authors, for example, state that if a woman had a family history of heart problems, and if this was mathematically taken into account before looking at menopause, then early menopause was no longer a predictor of her having a problem. In accounting for results, the article cannot distinguish between surgical and natural menopause, which differ in many ways.

It is true that, in the media accounts of this research, if a reader reads the entire article, qualifiers do appear embedded in the article in some of the sources. Some do say that the number of women in the study who developed heart problems or strokes was small; that this was a correlation, not a cause-and-effect association; or that when family history of cardiovascular disease was taken into account the relationship disappeared (although in Medscape, the author of the study was quoted as saying that “the pattern was still similar”). A piece of misinformation that reappeared in some of the sources was that the increased risk was similar whether the women had early menopause naturally or because their ovaries had been surgically removed. The research article clearly states that the authors did not have sufficient power (in research this means, basically, enough subjects to get an accurate answer to the question) to determine this.

I was puzzled why so much publicity was given to this study.  In my opinion, it did provide some interesting, suggestive results and contributed information about women from a range of ethnic groups (who have been understudied in the past), but the study’s results were modest and inconclusive.  However, what the article did do was to claim to support the underlying assumption that menopause and heart disease are related, an idea that keeps re-occurring in the professional literature, even stated as though it is a fact, although the evidence for it has been at the very best arguable and weak.  A recent SMCR blog post by Chris Hitchcock analyzed media misreporting of the results of another research project intended to test this relationship. In the study I am discussing, highlighting weak data that seems to suggest a relationship between menopause and ill health, blurring the distinction between natural and surgical menopause, contribute to this meta-message.  Ages 40 to 45 would be considered within the normal age range for menopause by many professionals, but is here defined as creating health risks.  I would hate to think that meta-messages promoting ideas that menopause is unhealthy and causes risk of heart disease contributed to the perceived importance of the article.

Reference

Early menopause predicts future coronary heart disease and stroke: the Multi-Ethnic Study of Atherosclerosis.  Melissa Wellons, MD, NCMP, Pamela Ouyang, MBBS, Pamela J. Schreiner, PhD, David M. Herrington, MD, and Dhananjay Vaidya, PhD, Menopause: The Journal of The North American Menopause Society, 2012.  Vol. 19, pp. 1081-1087

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My Aching Foot and the Menstrual Cycle

September 17th, 2012 by Paula Derry
Beth's Injured Foot

Image adapted from photo by Cyberslayer // CC 2.0

About two weeks ago, I injured my foot.  Like many accidents, it was stupid, quick, and avoidable. A heavy storm door was swinging shut, I somehow didn’t get out of its way, and it sheared open the back of my left foot, behind the ankle. Luckily, I didn’t cut an artery, the Achilles tendon, or any other tissue that would have caused a crisis or long-term problem. However, I did end up with eleven stitches and orders to stay off my feet for over a week.

If life gives you lemons, make lemonade. During my enforced inactivity, I surrounded myself with projects I had not had time for.  The reverse appliqué hand sewing I had started in a class last summer but never finished. A creative writing project I had hoped to do. My long-neglected Native American flute. Yet, as the days wore on, I found myself increasingly unable to do much more than stare into space, watch TV, or do a bit of sewing. It was hard to focus my attention and to concentrate; I felt an increasing paralysis of will to initiate and sustain activity. When I did walk around, using crutches to keep weight off my foot and to avoid flexing the ankle, I felt easily fatigued and vaguely ill.

I did also do some reading, and happened upon a recent re-evaluation of a book by Oliver Sacks called “Leg to Stand On”. Sacks, a neurologist, had written the book in 1984 after he broke his leg in a traumatic accident. He found, to his surprise, that his injury resulted in important changes in his body image. In the early part of his recovery, his leg did not feel like part of him. Although he couldn’t feel or voluntarily move the leg, and couldn’t even remember moving it in the past, it could move in response to music. He later discovered that his experience was shared by other patients. In the re-evaluation, authors Stone, Perthen, and Carson suggest that Sacks’ problem was functional (i.e., psychological not physical). Sacks, in response to their reevaluation, suggests that activity and sensation in the periphery—that is, arms and legs—is intrinsically involved in how the central nervous system organizes information, experience, and cognitive function. That is, the mind and entire body are interconnected.

There are many ways in which physical experiences other than injuries have broad systemic, mind/body interconnections. If we have a fever, we’re not surprised if, in addition to our stomachs hurting or our heads throbbing, we feel wonky, unable to concentrate, distressed. Illness is a whole-body experience. Many years ago, I had an amniocentesis. The doctor told me I could go about my business after he finished the procedure, but a nurse said to me that many people felt they needed some rest. Indeed, after having a large needle penetrating my abdomen, which felt, irrationally but unmistakably, like an invasion of body boundary, I did feel shaken and like I needed to recupe. Even my husband, a physicist, a very nice but definitely not a touchy-feely kind of guy, felt invaded by a large needle penetrating his body to take a bone marrow sample.

So it is with uncomfortable experiences associated with the menstrual cycle. Menstrual cramps, hot flashes, and menstrual migraines are not isolated symptoms occurring in far-out or isolated body parts. If we have menstrual cramps, we may be tensing our entire body, our abdomens may feel like invaded strangers rather than like parts of ourselves, the cramps may have specific meanings about who we are, our lives, or the meaning of pain or discomfort. If I have menstrual migraines, I may wonder why people don’t show me more sympathy and help me, or I may want to keep my headaches secret. Not always, but often, menstrual cycle experiences, like many other experiences, are holistic, mind/body phenomena.  Continue reading...

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Musings on Menopause and Heart Disease

August 27th, 2012 by Paula Derry

A recent article by Swift et al. looked at the effects of aerobic exercise on heart health. Midlife women with high blood pressure were assigned to one of three exercise groups—a program of exercise that met National Institutes of Health (NIH) guidelines, one that was half the amount of exercise recommended by the NIH, or one that was 150% of the NIH recommendations. The study did not examine who actually got heart disease. Instead, the researchers looked at the ability of arteries to function normally, which is a precursor to disease. Specifically, the researchers measured one component of artery health called “flow mediated dilation” (FMD)—the ability of arteries to respond normally to changes in blood flow by dilating (getting larger), which is one indicator of “endothelial (the inner lining of the artery) function.” The authors found that aerobic exercise improved flow mediated dilation. The amount of exercise was not important—the authors suggest that once some minimum amount of exercise exists, improvements will occur. They also found that women with problems benefited from exercise, but not those with normal FMD.

Well, I have to admit this isn’t an area of my expertise. I’m not going to evaluate how solid the methodology was, how close to normal the improvements brought the women, compare these results with the entire body of knowledge, all of which are important to really understanding the import of a study. However, I’d like to share some musings that the article triggered.

First, the article assumes that menopause and the menopausal transition increase a woman’s chances of getting heart disease by modifying her precursors and risk factors. The title of the article is: “The Effect of Different Doses of Aerobic Exercise Training on Endothelial Function in Postmenopausal Women With Elevated Blood Pressure”. The introduction states that their research is important because menopause is associated with worsening of heart disease risk factors. However, they are not studying postmenopausal women. They are studying overweight, sedentary women with high blood pressure who are old enough to be postmenopausal. It used to be more commonly stated, as though it is a fact, that menopause increases a woman’s chances of getting actual heart disease. However, this assertion does not appear to be supported by the facts. A recent paper in the British Medical Journal concluded that aging rather than menopause was key: “Heart disease mortality in women increased exponentially throughout all ages, with no special step increase at menopausal ages”. In 2011, the American Heart Association issued the Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update. These guidelines include a long list of risk factors and suggestions for how to prevent disease, such as modifying lifestyle factors like cholesterol and inactivity. Menopause is not included as a risk factor and is mentioned in just one sentence in the document. The line of research that has now arisen which states with equal certainty that risk factors and precursors to heart disease increase with the menopausal transition thus must be looked at critically. Do these changes in precursors really co-vary with menopause? Do they lead to actual disease? How important are they relative to other factors leading to heart disease, like aging or lifestyle?  Continue reading...

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The Biology of Reproduction Isn’t Just About You

July 23rd, 2012 by Paula Derry

Photo by Minyoung Choi // CC 2.0

A scientific paper was recently published which looked at how shifting patterns of daily light and darkness affect pregnancy in mice.   The authors were interested in this question because studies have suggested that humans who experience such patterns, such as shift workers or women who travel repeatedly across time zones, have reduced fertility. In their study, pregnant mice were divided into three groups. All groups had 12 hours of light followed by 12 hours of darkness.  The control group had the same pattern throughout the 21 days of pregnancy.  The other two groups had shifting patterns.  In one, the 12 hours of light started six hours earlier every five days (phase advanced group); in the other, six hours later (phase delayed group). In the control group, 90% of the mice had successful pregnancies and deliveries; in the phase advanced group, 22%; in the phase delayed group, 50%.

Circadian rhythms is the general term for biological activities that have a 24-hour cycle, like sleeping and waking, or like hormones whose amounts vary during the course of a day. There are many circadian rhythms in humans, animals, and plants.

They are internal, determined by the physiology of the animal or plant. However, they are also entrained (synchronized with) environmental events like the amount of light at night vs. during the day. This entrainment means the rhythms match what is going on in the environment and also can adjust to environmental change. In the pregnant mouse experiment, the light shifts were so large they disrupted the internal circadian timekeeper, which had cascading effects on mouse physiology and success in maintaining a pregnancy.

There are also many physiological rhythms that mesh with environmental patterns on longer or shorter time scales, for reproduction as well as many other aspects of biology. Zucker (1988), for example, found an annual rhythm to whether the amounts of a hormone called luteinizing hormone (LH) had a feedback relationship (that is, interaction) with the amounts of estrogen in ground squirrels. Typically in a mammal, LH increases estrogen production, and then when estrogen levels reach a high point the LH surges which initiates ovulation. For ground squirrels, who only become pregnant during January to March instead of having a regularly repeating cycle throughout the year, this relationship between hormones only exists during the breeding season. If the ovaries of females are surgically removed (so that their bodies don’t make estrogen), LH levels still go up to initiate the breeding season at the correct time of year; that is, levels of LH appear to be controlled by some environmental factor.

There are also social influences on the biology of reproduction in animals. Nelson (1999) summarized some of them: If four or more female mice were housed together in a cage, their cycles occurred less frequently. If they were then exposed to a male, they ovulated at the same time. In a study of albino mice, if a strange male was introduced into the cage of pregnant females, the females spontaneously aborted about 25% of the time. If the male who impregnated the female was re-introduced into the cage, there were no miscarriages. Female rats that were handled daily by researchers reached puberty at an earlier age than did rats who were not, and mice housed alone reached puberty sooner than mice housed with other females.

What does this mean for humans? There are not necessarily direct correspondences between animal and human research. Sometimes human physiology is simply differerent; sometimes, exactly the same. In addition, humans may have many influences where animals have fewer, so big, determining effects in animals may be mere suggestions in humans, one factor among many. On the other hand, the circadian research I discussed above was suggested by the possibility that shift workers and frequent travelers have fertility problems. Many social influences on human menstruation — synchronized menstrual cycles among college roommates, effects of stress — have been reported.

The possibility that intrigues me is this:  We are individuals, but we are also intrinsically part of larger environments. Reproductive biology is about our inner organization of hormones, brain chemicals, goals and interests, but it is also about the viability and value of conception in specific social groups and physical environments. Our physiology is inside our skins, internal to us, but is also related to maintaining a state of balance with our physical and social environments.

References

Nelson, R.  (1999). An introduction to behavioral endocrinology.  Sunderland, MA: Sinauer.

Summa, K., Vitaterna,M., & Turek,T.  (2012).  Environmental perturbation of the circadian clock disrupts pregnancy in the mouse” PLoS One 7(5): e37668.  doi:10.1371/journal.pone.0037668

Zucker, I. (1988). Neuroendocrine substrates of circannual rhythms.  In D. Kupfer, T. Monk, & J. Barchas (Eds.), Biological rhythms and mental disorders (pp. 219-252).  New York: Guilford.

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The “Choosing Wisely” Campaign: Don’t Routinely Test for Osteoporosis Until Age 65

June 25th, 2012 by Paula Derry

On June 13, 2012, the medical website Medscape posted an interview with the president of the American Academy of Family Physicians (AAFP) on AAFP’s involvement with the “Choosing Wisely” campaign.   “Choosing Wisely,” according to the article, is an initiative of the American Board of Internal Medicine Foundation that has come up with evidence-based recommendations from 9 organizations about questionable medical tests and procedures.  The organizations are mainstream medical groups like AAFP. The goal is to use these recommendations as the basis for discussions between doctors and patients.

According to the article, one of AAFP’s top five recommendations is that women should not be routinely screened for osteoporosis at the time of menopause.  In fact, except for women who have high risk factors, screening should not begin until age sixty-five. The same recommendation was made by a Choosing Wisely group in 2011 and was also the judgment of the U.S. Preventive Services Task Force. This is in contrast to a common practice among physicians to order a DEXA screening test to measure bone mineral density (BMD) around the time of menopause and to prescribe medication for women who score low on the test beginning at this time

Here’s some background:  The word “osteoporosis” at one time meant a medical condition in which bones are fragile and break easily; low bone mineral density was a risk factor for osteoporosis.  However, low BMD also came to mean that a person had the disease itself rather than a risk factor for it.  “Osteopenia” means that BMD is not as low as in osteoporosis but lower than a statistically-defined normal amount.   One perspective by physicians and medical groups has been that since menopause and the transition to menopause are associated with declining BMD, it makes sense to test BMD at this time and to begin treating women, often with medication, if a screening test shows low bone density.  Osteopenia as well as osteoporosis might be treated.  A different perspective is that osteoporosis involves bone becoming so fragile that it fractures; BMD is only one of the factors that contribute to bone fragility; many factors (including lifestyle) contribute to bone strength and to whether a woman will break a bone.  Further, since osteopenia is defined statistically, it may not really indicate a problem (as in Lake Wobegon, where everyone wanted their children to be above average).

What are factors indicating osteoporosis or risk of osteoporosis before age 65? Some of them are:  if a bone fractures for what seems like no good reason (e.g., if you haven’t had a hard fall or something else like it); if you’ve lost height; if you’ve been prescribed steroids for long periods of time; if you have certain other diseases like thyroid problems.    There are many other factors that statistically predict increase risk.  FRAX is an online tool that can be used to estimate risk. However, it is based on things like sex, height, weight, and medical history and does not take lifestyle measures (whether you exercise, have ways to avoid falls, etc.) into account.  Many websites have additional information (e.g., National Institutes of Health, National Women’s Health Network).

Some reasons behind recommending that women should not routinely be screened for osteoporosis until age 65 are:  the rate of fracture does not go up until after age 65; there is little evidence that using medication helps women with osteopenia; the medications used to treat osteoporosis are good medicines for women who need them but carry risks, so women who don’t clearly need them or will benefit from them shouldn’t be using them.   Thus, the Choosing Wisely initiative recommends that unless a woman has high risk factors to suspect osteoporosis, screening tests should not be ordered until a woman is 65.  Continue reading...

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