Month: March 2020

“I’m in a good place, but I could be even better.”

It seems like it’s getting more and more uncommon to hear someone say that they are” in a good place” and leave it at that with no qualifiers. That statement is usually followed quickly by another describing what may still be wrong with their life, their body, their career, etc. So, do they actually mean that they “are in a good place?” What do those words mean anyway?

I think that when most people say that they are in a good place, they mean a mentally good place. At least that is what I mean when i say it. When I say I am in a good place, I am referring to a mental and emotional good place. I mean that mentally and emotionally I fall somewhere between satisfied and wrecked, more so toward the satisfied end. I mean that overall I am pleased and satisfied with how I am taking life in stride and how I process the world input around me. It means that I am not crying myself to sleep every night in a little stress ball. It means that I don’t walk around feeling like I am going to have a breakdown. It means that when I encounter stressful situations, I am able to handle them and effectively promote good change. It means that I am looking forward to the future. It means that there seem to be more good days than bad days.

What is doesn’t mean, is that everything in my life and mind is perfect and no change is required. I would still like to keep striving with my career success. I would like to be able to pay my bills without worry. I would like to summon up the courage and stamina to work more on my body and physical appearance with some consistency ( The rare workout sessions that occur now when I am able to roust myself by 5 am in my only window of time for that do not count.) I would like to be even a bit closer to the perfect mother and wife. ( So far I think I am hitting that target at least over 50% so that is something.) I would like to spend less time being modifying my behavior because I am worried about how some jerk might respond and just do what is right. I would like to have perfect balance in work and in life.

Wow, when I start going over that list out loud, it sounds kind of overwhelming doesn’t it? It sounds like literally everything is still a work in progress. But, that’s ok. Life is not supposed to be perfect. Life by definition encompasses everything around us. Flaws and imperfections will always be there and that is part of what makes life interesting. If we had nothing to fix or work on, what would keep us going? Most humans I know do not really know how to just sit and enjoy for any significant period of time anyway.

Besides that, everybody’s definition of perfection is different. Some people’s idea of perfection would be a life with all business and no emotional attachments whereas others might think perfection is a chaotic household full of kids and being a stay at home mom. From now on, I am going to refer to “perfection” in quotes, just to drive this point home. As human beings, we need goals to keep moving forward, to continue to progress in life as individuals and as a society. In order to accomplish these goals without driving ourselves crazy in the process, they need to be attainable and sustainable. We also need a baseline of healthy mental perspective to allow us to strive for these goals and attain them at our own pace without feeling like a total failure all the time. So, I guess what I am really saying is that being “in a good place” does not have to mean that everything is perfect. Otherwise, we might not ever allow ourselves to get there. Have a fantastic day folks!

Dr. Katz

(Making) love hurts

So many women out there suffer from pain with intercourse…and most of them suffer in silence. The few that are brave enough to speak up and visit a doctor are often greeted with statements like “It’s all in your head” or worse, they are confronted with a physician that is just uncomfortable with the subject so they avoid it. Thus, the suffering goes on. Sex becomes something to dread, not something to enjoy, something to get through rather than something to look forward to. Relationships waiver and relations become strained. As much as we like to think that sex should not be the most important thing in a relationship, it is actually important. We cannot deny it. It is the most personal, intimate act that we can share with another person. At it’s finest, it is imbued with love and trust as well as physical satisfaction. It is the ultimate release. It is an essential part of a healthy relationship. Even the best-matched couples on the planet begin to suffer somewhat when sex becomes unpleasant or taken off the table all together.

So let’s talk about painful sex and what we can do about it. I am proud to say that I am one of the Ob Gyn physicians that is not uncomfortable with the subject. Treating pain with intercourse is a large part of my practice. I devote entire office visits just to this. Most of the patients that I see have been suffering for years and seen several doctors only to be dismissed. For whatever reason, they decide to give me a try and then are pleasantly surprised and grateful that i am wiling to embrace the subject. Some of them even bring me flowers or cards when everything goes well. That is just an added perk, but not the point of course.

What are the causes of painful intercourse? There are more than you think. Let’s break them down and what we can do about them. One of the most common causes of pain with intercourse is psychogenic pain. This occurs when the woman has real pain with intercourse but no physical cause can be found. I know what I said before about women being told that it is all in their head and how terrible that was, but let me explain. Women with psychogenic pain often have a history of trauma such as rape or rough sex or an abusive relationship. Most of the time they have never told a soul about it and have never had the opportunity to have any closure about the incident. On top of that, the trauma from those incidents was so devastating that it left a psychological scar that never healed. In their minds, even the thought of sex takes them to a dark place with pain and fear, not pleasure. Until that is addressed, some of them will never be able to have a healthy intimate relationship. Sometimes a psychogenic pain response can be triggered by a lack of trust in the relationship. They are fearful of adultery and possible exposure to sexually transmitted infections. To make matters worse, these women begin losing their sense of self worth, wondering why they are no longer good enough to satisfy their partner. Again, unless these issues are addressed, no amount of treatment will help them have a satisfying and painless sexual relationship. These are some of the first things that I privately ask about in our first interview. I get them help and counselling. We work on empowerment strategies, anything they need to process their traumas and either mend or leave their toxic relationships.

Another cause of painful sex is endometriosis. Endometriosis is a disease in which retrograde menstrual flow goes backwards up through the fallopian tubes and back out into the pelvis. In the right woman with the right environment and genetics, those implants of endometrial tissue set up shop all over the pelvis and cause pain and inflammation. The best way to diagnosis endometriosis is with a laparoscopy and actual visualization and biopsy of the implants in the pelvis. The trick is, that if you were to biopsy normal appearing peritoneum in the pelvis, up to 20% of the time you could find endometriosis. The other tricky part, is that some patients can have incredible pain with just one visible implant while others can have a pelvis full and have no symptoms whatsoever. We are ever striving for better, quality of life enhancing treatments for endometriosis. Most of them involve hormone modulation or shut down with the thought being that shutting down hormones will shut down growth of the implants and “starve them.” However, a lot of the treatments can only be continued for so long because of side effects. The only permanent treatment for endometriosis is hysterectomy with removal of both ovaries. We try to save that for the most drastic cases that have completed childbearing already.

Another cause of painful sex is pelvic inflammatory disease. Pelvic inflammatory disease usually occurs as a result of the spread of sexually transmitted bacteria from the vagina, through the cervix, into the uterus and then through the tubes and ovaries. The bacteria can spread to the rest of the pelvis and cause inflammation, abscess and scar tissue. All of these things can cause painful intercourse with cervical motion tenderness and pain with deep penetration. Once the infection is treated, there is an 88 percent+ chance that the pain will go away. Antibiotics are the way to go.

Yet another cause of painful sex is simple vaginitis or vulvitis. These occur when there is inflammation or discharge which can cause itching or pain and thus, pain with intercourse. This pain and inflammation can be caused from reactions to household things like detergent, soaps or personal cleansers or an actual bacterial infection like bacterial vaginosis or yeast. Treat the infection and the pain usually goes away. Figure out which things around the house is irritating( Tide, Summer’s Eve, Vagisil, scented soaps are common offenders for example), and get rid of it and substitute it with Cetaphil or All Free and Clear, and usually the inflammation goes away in about two weeks and so does the pain. I have made up a hand dandy “be kind to your vulva” tip sheet that helps patients get this under control faster and keep them from getting irritated again.

Another cause of painful sex is something called vulvodynia. This condition is the result of localized intense inflammation around the peri-urethral and vestibule areas of the vulva and causes intense pain with initial penetration during intercourse. This condition can be easily diagnosed with something called a q tip test. The q tip is used to touch certain points around the vulva. If a patient has this condition, they will perceive the q tip as a razor blade scratching them during the examination. Knowing this ahead of time, I always make sure to show the patient the q tip before i conduct the test, because most of them are sure that i secretly pulled out something sharp instead. That is how intense the pain can be. The pain that the patients get with vulvodynia often leads to a condition called vaginismus on top of it. Vaginismus is involuntary intense tightening and contraction of the vaginal muscles in response to penetration, which then causes a lot of deep pain with penetration. The key in these patients is to treat the vulvodynia first. We have had all kinds of theories about the cause of vulvodynia over the years, none of which have really panned out. At first we thought it was related to chronic yeast. Then we thought it was related to a high oxalate diet. The list goes on. The bottom line is that we really don’t know. I have found that a short course of a tiny amount of estrogen cream goes a long way at first. I do not use it for any longer than a month to avoid any possible unopposed estrogen effects. Then i transition the patient to any one of a number of compounded ointments that i have developed over the years. Usually these contain a small amount of an anti spasmodic, something non-narcotic for chronic pain, and a bit of lidocaine. The patients can easily use a tiny amount of this ointment up to three times a day to keep their pain and inflammation at bay. I make sure to educate them that this condition is considered chronic and we need to focus on control not cure. Most patients are so happy to not be in pain that they are happy to use a tiny bit of ointment every day. I think it is also important in these patients to remove any possibility of external irritants as well, like with the vulvitis patients so I give them the ” be kind to your vulva” tip sheet also. The vaginismus is a tougher nut to crack. Even when the vulvodynia is improved, the vaginismus sometimes still remains. I think that in these cases, the brain is so used to intercourse being painful, that it cannot allow the patient to enjoy intercouse even when the primary cause of pain is gone. That is just how our brains work. In these cases, we still have options. I like to start with vibrator therapy for example. I have the patient purchase a set of medical dilators that start all the way down to pinky size and gradually increase up to the size of an average penis. The patient starts with the pinky size dilator and coats it with a small amount of steroid cream and inserts it for twenty minutes. The goal to achieve with each size is to be able to tolerate insertion for 20 minutes twice a day before the patient can increase to the next size. After several weeks, most patients can usually increase up to the final size and then can begin enjoying sex again. For some patients, we need to incorporate biofeedback therapy in addition. Biofeedback therapy uses sensors with a biofeedback monitor. In can be used for a variety of purposes. In this case, a patient is hooked up to the biofeedback monitor and then various dilators are introduced in a sequential monitor. When a dilator is introduced, the patient is instructed to look at the biofeedback monitor. They are educated about what a relaxed muscle looks like versus a contracted muscle on the monitor. They then work to achieve a relaxed muscle every time a dilator is inserted. Over time, they learn to consciously relax their pelvic muscles with insertion. These sessions are variable in price and are sometimes covered by insurance. The number of sessions that each patient requires varies.

Last but not least, another cause of painful sex is good old menopausal vaginal dryness. We can’t forget that one. This is usually caused by something called atrophic vaginitis. Atrophic vaginitis occurs when the vaginal mucosa folds straighten out from lack of estrogen causing thinning, drying, and inflammation of the vaginal walls. We can treat this with a course of vaginal estrogen in pill or cream form. I limit this to three months if they have an intact uterus or add progesterone too if they need it for longer. We now also have medications like Osphena, which is a selective estrogen receptor modulator. It is a cousin to medicines like Evista or Tamoxifen. Osphena can be taken orally. For patients that cannot take hormones I treat their vaginal dryness with water based lubricants like astro glide. You can also use extra virgin olive oil vaginally or even vitamin e gel caps as a suppository. All of these are potential alternatives for vaginal dryness. There are others, but these are the first lines in my office. For the patients that do not respond to any of the above, we can always use small amount of topical lidocaine about ten minutes before intercourse. I have the patient apply a small amount to their vulva and that way we can at least decrease the pain, even if we cannot address the dryness.

Long story short, there are a lot of different causes of painful sex and there are options for all of them. I urge all you ladies out there to stop suffering in silence. It is not all in your head. There is something that we can do for you! All you have to do is find a physician and ask! Have a fantastic day folks!

Dr. Katz

Internet Trolls

The internet troll. We have all experienced them. The typical stereotype goes something like this: Single, bitter, perhaps jobless, nothing else to do, endlessly surfing the net for opportunities to pour out some of their overabundant flow of misplaced negativity anywhere and everywhere, seemingly without any knowledge of appropriate human social graces, punctuation or proper grammar . You know what I am talking about. We run into them everywhere on the internet. We are at risk 24/7 from their lambasting attempts. These people are most often people that we do not even know in any of our business or social circles. They attempt to turn any post into something negative. They point out all your flaws, or at least the ones that they perceive that you have…without even knowing you. They can make you doubt yourself, worry about issues that aren’t even there, and even have you consider removing a carefully crafted post that you took a lot of pride in. Why I ask you? What is their purpose? What is there to gain from this behavior? What is the best way to respond or deal with them?

We even experience these creatures on our office social media. They like to comment on everything, even if they have never been to our office. We can post some great results of one of our aesthetic services, complete with a smiling and happy patient that is really satisfied and glad that they finally did something for themselves. These folks will come out of nowhere accusing us of using filters or insulting the patient’s picture. I say if you are not interested in our procedures, please refrain from even looking at our stuff! No one is forcing you to look! There are like a bazillion things to peruse on the internet. I am sure you can find something else!

I think that they fling these insults under the misguided perception that they can somehow hurt us, when in fact, the only people they are potentially hurting are the patients who were brave enough to go through with a service to make themselves feel better! Our practice will go on, believe it or not, even with their insults. I am not calling us invincible or anything, but I am saying that we will not stop providing safe and effective services to patients just because they post something ridiculous. My usual rule of thumb is to post a professional response one time and ask that they refrain from negativity, politely explain why their perception might be incorrect, and kindly dis invite them from looking at our site. If this does not work, then I am forced to block them from being able to comment. It may sound like a childish move, but sometimes that is the only recourse we have.

I find these creatures to be particularly pervasive on internet marketplace sites as well. Let me be clear. When I have some gently used piece of junk that I want to sell, I do not spend hours researching what the true value is. I just fling it up on the marketplace site, pick a price and make it clear it is negotiable and see what happens. I promise with my whole heart that I am not trying to “pull a fast one” on anybody. I am just trying to see if I can sell some crap on the internet like everybody else. If you don’t like what I listed or you think the price is not right? MOVE ON! NO ONE IS FORCING YOU TO MAKE AN OFFER! I am especially fond of those who get so excited with slinging criticisms that they seemingly forgot how to speak or type in English for the moment. If you can’t spell outrageous( often spelled as out rages) , I am officially taking away your privilege of accusing me of it…..lol. Have a fantastic day folks!

Dr. Katz

Happy, Independent, and Legal

Remember how you were when your first born arrived on this planet. You peered into their amazing newborn blue eyes and you adored and stared at them, musing over your endless dreams and expectations. You just knew that they were going to be an astronaut, a doctor, a professional musician, and a pro-athlete. They were going to go to the most prestigious Ivy-League universities in the world. They were going to win the Nobel Prize in Physics. They were going to be President some day. They were going to be perfect. The sky was the limit and nothing less would do! They were going to be the best at everything and entitle you to infinite bragging rights. A little often unacknowledged voice inside of you also pointed out that there were opportunities to live vicariously through them and that they would be able to accomplish all the things that you couldn’t. Anything seemed possible. Ah how times change!

Ok now let’s fast forward into the toddler years(3-4) when you get the brilliant idea to enroll them in some kind of activity for self-enrichment. Then you realize that what you really signed up for is struggling to get them into a uniform or costume, trying to observe what they are doing without disrupting the whole activity or class as they press their nose against the window to look at you instead or run off the field because they wanted a snack…..or just sit down on the field and pick their nose. That is a personal favorite. Of course NONE of my kids did ANY of those things…lol. Ok they did, my now amazing tapper actually got kicked out of her first dance class at 3 for being “disruptive.” I remember at first being upset at the time that she was going to miss out on something great. I thought her dance career was over for sure. Then I also wondered how the hell the instructors expected 3 year olds to pay attention for 45 minutes when the average attention span of a 3 year old is more like 10 minutes? And by the way, her “disruptive” behavior consisted of occasionally running to the window to look at my husband. It’s not like she was inciting a revolution or anything. I felt a little gypped to tell you the truth. I was ready for her to be a star and they just “didn’t get it.”

But, life churned ahead to the elementary school years. Now sports started to get a little more interesting for my one daughter and soccer games became something to cheer about. Dance found its way back into my other daughter’s life and there were actual performances to attend! Whoo! I had them at exclusive private schools and they were getting the best education. Now we were really getting somewhere! Those Harvard and high profile job dreams could once again lift off and take flight. At that age, both girls were still somewhat receptive to guidance. This is when I first began to struggle against my inner “stage mom” nature. I was determined not to over push and make sure that whatever they were involved in was something for them and not for me. I was by no means perfect in that regard, but I think i did a reasonably good job. I tried to be involved but not control everything that they did. While my friends were forcing their kids to continue playing an instrument or never letting them see their friends in lieu of studying, I was trying to let my kids be kids. Did they sometimes bring home less than desirable grades? Yes. Were there consequences? Yes. I also still objected when activities ended or they lost interest in something. We had minimum participation requirements( finish out the season at least, etc), but I did not force them to continue any particular activity just for me. I allowed them to own the consequences and regrets of their actions, within reason. I mean, I wasn’t allowing them to commit crimes, run the streets at all hours and swear at adults or anything, but i did allow them their own mistakes.

Then, we took a turn in the middle and high school years. By the time both my girls were in their teen years, they had transferred to large, public schools with a whole different universe of social groups and influences. There were a lot of potentially unsavory elements in their daily lives, but i felt that it was necessary to break them out of their small private school bubble in order to give them a social education as well. I felt that they needed to be able to handle themselves in a more realistic environment. There were sporting events and dance competitions and increasingly intense pressures on all sides. There were exciting things to cheer for and just as many things to be disappointed about. It’s a weird double edged sword scenario the older your kids get isn’t it? They have more opportunities for competition in a variety of areas, but then you also have more opportunities to potentially behave badly and get out of focus when they don’t perform like you hoped. They didn’t always get the grades that I was hoping for or win the scholarships that I thought that they should. But sometimes they did. I finally had to ask myself the big question: How much did that really matter? They were trying to adjust to their new environment while adjusting to fluctuating hormones and evaluating just what they expected of themselves, much less what i expected.

This was a difficult time. Their moods changed and they became intermittently sullen and argumentative. Their confidence wavered, social anxiety soared and I had to adjust my expectations about performance to what was actually going on around me. Both of my girls went on very different journeys toward their own happiness and health. Their paths were not what I thought they would be. They both went through significant traumatic experiences that affected how they dealt with the world around them. I had to decide if it was worth it to battle it out about grades and scholarships and contests and risk the communication going to zero, or embrace them for who they are and support them as they went forward into their own future. I decided that, as fun as it was banging my head against the wall and being frustrated over what I thought my kids should be doing, I needed to put it all back into perspective. I did have plenty of stuff to brag about, even if it wasn’t the stuff I thought it would be. But, was that the whole point? Wasn’t their life supposed to be about them?

I kept using the argument that grades and scholarships were the key to a bright future, and that is true, but it all depends on which future you have in mind. Also, who is to say that the future they are choosing for themselves is better or worse than the one i would chose? I had to realize that, believe it or not, the world wasn’t going to end if my daughter did not head off to an Ivy League school on a full scholarship if she wasn’t ready or that wasn’t her path? In fact, I am fortunate enough that she has decided to work full time at our office, pays her own bills, and manages all of our large animals at the barn. She is productive, happy and using parts of her brain that I think she forgot existed when she was in high school. That is downright fantastic! I have seen her take tremendous strides just in these last 6 months, figuring out who she is and what she wants to do. This is a much better option than me trying to decide for her and forcing her to go to college. That would have been a disaster. I mean, I am all for flushing money down the proverbial toilet but why? I guess what I am really saying is that I have had to take a step back and alter my expectations over the years with regard to my kids. I have let go of all the crazy expectations that potentially set both myself and my kids up for a failed social relationship. Don’t let me fool you, my stage mom side has not been completely exorcised from my body or anything. I am still me. I just finally realize that the ultimate future goal for my kid is for them to be happy. They also need to be independent, because they can’t live in my house forever! Oh yes, and I would prefer that they do not do anything illegal. Beyond that, it’s all gravy. Have a fantastic day folks!

Dr. Katz

Perimenopause is not for pussies!

Hello all you perimenopausal power women out there! I know there are millions of you at any one time, trying to suppress labile emotions, fighting “power surges.” lamenting over vaginas of sandpaper, etc. Even though menopause is not a pathologic process per se, sometimes it sure feels like one! Fear not! You are not alone! I am right there with you!

Let’s shed a little light on the overall perimenopause and menopause process. First, let’s not get all hung up on terminology. For the sake of this blog, let’s define perimenopause as that magical period of time during which the ovary’s waning hormone levels and decreasing population of eggs to shoot out of a corpus luteal cannon cause a variety of unexpected and unpleasant symptoms. Let’s then define menopause as the point when “it’s all over.” The FSH( follicle-stimulating hormone) is consistently over 30. The last egg has left the gate. The uterus has shed its last lining, along with the last hope for babymaking. The last period is at least one year in the rear view window. Although I am going to tell you upfront that just because the last egg left the building and periods have stopped, the symptoms are not completely gone, but we will get to that later.

So, why the heck do we care about hormones anyway? What do they actually do? Do we need them? What the hell is a hormone anyway? A hormone is defined as a regulatory substance produced in an organism and transported in tissue fluids such as blood or sap to stimulate specific cells or tissues into action. It can also be defined as a synthetic substance with an effect similar to that of an animal or plant hormone. What? Heh? Let’s narrow this down and talk about the big 3: Progesterone, Estrogen, and Testosterone. These are the key hormones in our bodies, all of which are made by the ovaries. Yup, that’s right, even testosterone. It’s not just for guys anymore ladies. So now let’s talk about what each one of those hormones does. As it turns out, hormones help with over 400, that’s right 400,bodily functions. To go over all 400 would be a little bit beyond the scope of this blog, but let’s at least break some of the main ones down. I bet there are some that will surprise you.

Let’s start with estrogen. So, estrogen alone has like 400 different functions in the body. They include the following: 1) simulate the production of choline acetyltransferase( an enzyme that helps fight Alzheimers), 2) increase metabolic rate( don’t we all miss this one?), 3) improve insulin sensitivity, 4) regulate body temperature( hello hot flashes), 5) maintain muscle, 6) reduce risk of cataracts, 7) aids in formation of neurotransmitters like serotonin which decreases depression, irritability, anxiety, etc and 8) maintain bone density. Ok so you get it. There are a ton of things that estrogen plays a role in.

Now there’s progesterone. It helps with many things too, although it is not quite the rock star that estrogen is and has been vilified and then praised back and forth in many studies. Let’s talk about a few of the good things it can do. It helps balance estrogen. It helps to improve sleep. It has a natural calming effect. It helps lower high blood pressure. It increases metabolic rate. It can help the body use and eliminate fats. It is a natural diuretic. It also protects the uterine lining from excess estrogen effects. These are just some of the things that progesterone can do.

Then there is testosterone. Yes ladies. I was shocked too when I first learned that my ovaries made testosterone. Isn’t that for dudes only? Nope. We need testosterone too! Testosterone helps increase our sexual interest. It increases our sense of emotional well-being. It increases muscle mass and strength. It helps maintain memory. It helps stop skin from sagging. It elevates norepinephrine in the brain. It helps decrease excess body fat. Sounds pretty great right?

Ok, these hormones sound pretty useful don’t they? I can see why we would miss them when menopause comes and they all start circling the proverbial drain like a clump of hair in the shower. Keeping these hormones in balance is pretty key to our quality of life, if nothing else, as well as keeping some important bodily functions on track. When they get out of balance we start feeling pretty miserable. I get that some very important, although in my opinion skewed, studies have really muddied the waters as far as how to approach menopause and hormone therapy. I for one, remain a fan of hormone therapy in the right patient with the right risk profile who is also compliant.

So what happens when these hormones all start decreasing and /or getting out of balance? That’s right! The road to menopause has begun! That’s when we start getting all the traditional ones like mood swings, hot flashes, and vaginal dryness. But let’s not forget some of the lesser known symptoms like flatulence( farting too much), palpitations, hair growth on our faces, weird dreams or not sleeping at all, osteoporosis, peeing on ourselves, or forgetting what we were saying. I mean. Who doesn’t enjoy announcing your presence in a room with a not-so-silent, deadly episode of farting? Yup, we can blame menopause whenever we let one rip ladies. Enjoy!

So when can we expect this little bundle of change joy? Well, average age of onset of menopause in a non-smoking female in the United States ranges from 35 to 55. That is a huge range. Average duration of the transition of perimenopause into menopause ranges from 6 months to several years. The expectation is that once you are in menopause, you should be symptoms free right? Well, this may be true in terms of some of the symptoms like hot flashes, but I can tell ya that there are still days that I fart like a champion and can’t fall asleep despite a bottle of Benadryl. Ok. I am kidding. I do not drink a whole bottle of Benadryl, but you get the point. On the other side of the coin, I have some unfortunate patients who are still having hot flashes into their 80s and swear that they would die without their estrogen patch.

Take heart, ladies! There are options to restore your quality of life. A lot of women out there are afraid of hormone therapy, but it is a viable option. Current national recommendations say to use the lowest dose for the least amount of time, whatever the hell that means. It has always sounded a little obtuse to me. I do use hormones in my practice, after I have counselled the patient on the pros and cons, evaluated their personal risk profile and their family history, and have assured myself of their compliance. Some of my patients are on traditional/commercial hormone therapy. What I call traditional hormone therapy is the prescription hormone therapy that your insurance covers like estrace, provera, etc. Some of my patients are on bioidentical compounded hormone therapy. The differences between the two are not as extensive as one would think. I know that people like to refer to bioidentical hormone therapy as more natural, but be careful of the word natural. I think sometimes that people hide behind the word natural as if it implies some kind of increased safety. That is not necessarily the case. There are plant based products on both sides. There are possible side effects and risks on both sides. Estrogens are estrogens, whether they come from horse pee or yams. Both of them affect body receptors. Personally, I think that the one advantage bioidentical hormones have over traditional hormones is that I can individualize dosing in hundreds of different ways, as opposed to the 4 or 5 dosing regimens available with most commercial hormones.

Hormone replacement therapy really is the best option for quality of life. Having said that, some of my patients cannot take hormones because of their own personal risk profile. No biggie. We have other options. Sometimes I use herbs, vitamins and supplements. Sometimes I use serotonin uptake inhibitors like Prozac. I realize that Effexor is what is in vogue right now, but I prefer Prozac any day. It is the only one with a weight loss side effect and the weaning process is a lot less brutal when you are ready to be off of it. If I can be less emotional, less hot flashy, and lose some weight in the process? Count me in! We can protect your bones with other medicines like Alendronate or Denosumab so we have that covered as well. We will get you through somehow!

To sum up, menopause can sometimes really get you down. It’s not a disease. It’s a transition. You are still you! Those hormone imbalances can overtake you, put you on the emotional roller coaster from hell, make you sweat and win you first prize in a flatulence contest. The process is different for everyone….but we have the tools to help you get through it. Happy farting!

Dr. Katz

Does it matter that I am a white woman?

I saw a study the other day outline in Contemporary Obgyn magazine. The study was originally published in JAMA Network Open. This study attempted to evaluate the possibility of gender and racial bias in patient selection of their physicians. In other words, does it matter if the physician is male or female? Black or white? Here’s how the study went. They took about 3600 online US respondents from a very geographically diverse population. Two different crowdsourcing platforms MTurk and Lucid were used to recruit participants. Each participant was shown a clinical scenario of a gastrointestinal issue being evaluated by an emergency room physician. The participant was supposed to play the role of the patient. They were shown pictures of the different ER physicians with different diagnoses: one with a diagnosis of gastroenteritis and a conservative treatment plan and one with a diagnosis of appendicitis and a more aggressive plan. The researchers did what is called a random assignment of the participants to images of physicians with different genders and races. 823 were assigned to black female physicians, 791 to black males, 821 to white females, and 835 to white males. They used a total of 10 different faces for each of these groups from the Chicago Face Database. This means that they were trying really hard to determine whether a participant’s reaction was truly due to a particular skin color or gender, rather than one specific face. None of the participants knew about the purpose of the study. In research terms, that means that they were “blinded.” Each participant then had to rate each simulated physician on confidence in him or her, satisfaction with care, likelihood of recommending the physician, trust in the diagnosis, and the likelihood that they would request additional tests.

I found the initial report of the results as reassuring. They did not find any significant difference in participant satisfaction and confidence based on race or gender. Ok that sounds good at first, but it is not time to celebrate just yet. They went on to say that about 40% of the participants endorsed some type of white superiority. It does not explain how they knew that. So then, they essentially threw the accuracy of the results out the window and said that it was possible that the participants actually knew the purpose of the study and hid their prejudices in their answers to look more socially acceptable. Mind you, that this is by no means the first study evaluating gender and racial bias in patient physician selection. Also keep in mind that a lot of these studies are failing to show any systemic bias in regards to gender or race, but we keep looking anyway….and then not believing the results. I don’t get it. Would we prefer that there is bias? Are we unhappy that we can’t prove it? Are we looking for yet another race or gender inequality issue to be upset about? There are plenty of real issues out there with regard to race and gender that desperately need to be addressed. Maybe we should leave this one alone if we cannot truly prove that it is there in the first place. Have a fantastic day everyone!

Dr. Katz

Crying by the dumpster outside of Olga’s

I just have to relay this story a patient told me the other day. Let me set up the scenario. So, this patient has a large family. Her children’s ages range from elementary school to college. Some of them are still at home. Some are off at college. She has always had a close relationship with her kids. You could even say that she values them even more than she values herself. She is a perimenopausal woman with let’s say more than her share of hormonal and mood lability, as all of us perimenopausal and menopausal women do. To say that she can be oversensitive at times is probably true. We all can. Let’s add to that the fact that college age kids who have moved out have a very different sense of what is appropriate and acceptable with regard to conversation and “house rules” than elementary age kids do. It’s a recipe for absolute peace and harmony right? That was rhetorical. Of course it isn’t.

Ok now that I have the stage set, let’s look at what happened. The college kids came home for the weekend, one of whom had not been home in months. The whole family goes out to dinner. My patient is super excited to see everybody and hang out. She has already had an emotional day and she can’t to hug the college kids and maybe even play with her daughter’s hair like she used to. She gets totally rebuffed. Now she is already hurt and trying to hide it while they are all sitting there eating, but the hurt is slowly welling up, threatening to take over just the same. Then the conversation starts and she hears her older children making conversation that is just plain uncomfortable for her. She is not sure if they are just trying to be sarcastic and funny or just plain hurtful. When she tries to interject, they just look at her like she is from another planet with that “What’s the problem” expression. Finally, she feels herself losing emotional control and announces that she is going to just go home rather than cause some sort of fight during what was supposed to be a nice family night out. They look at her and laugh and remind her that she doesn’t have a car because they drove. By then she is really embarrassed but can’t back out now and leaves the restaurant, only to find herself crying outside by the restaurant dumpster.

Oh the humanity. That story completely sucks right? It embarrassing. It’s humiliating. There is miscommunication everywhere. The kids probably didn’t realize that the mom was already emotional. The mom probably didn’t realize that the kids were just trying to act grown up and show off their intellectual prowess. It’s just a no win scenario. You are thinking to yourself, I would never do that. I say au contraire! I am willing to bet that there are a lot of moms out there that have been in a similar situation. C’mon you can admit it. Being a mom to college age kids or any kids that have moved out of the house is way harder than you think. Whatever scenarios you thought you had handles when they were teens living at home have paved the way for a whole new set of scenarios to slog through best you can. They have been living on their own without supervision.( Yes that’s right. I am saying that dorm resident advisors are not all they are cracked up to be.) They have been setting their own rules and curfews. They are probably having sex. They have linked up with all kinds of kids from all over the world with all kinds of opinions that you probably don’t share. On top of that, those opinions may or may not be based on any known facts, but they sound cool to spout out with their friends. You as the mom are no longer their primary influence and you are definitely not as cool as they once thought you were now that their horizons have widened. Ugh! Now add on top of that the fact that you are probably at least perimenopausal if not postmenopausal with hot flashes, labile moods and fluctuating hormones and, even on a good day, you could rocket from singing with the radio to screaming or bawling your eyes out in less than 10 seconds. These are the kinds of elements that lead up to the story from above. These are the kinds of elements that foster miscommunications and misunderstandings of epic proportions if you are not conscious of what’s at play. My poor patient and her family were set up from the start from both ends. She was all emotional and ready to bond ” with her babies.” . The kids were ready to joke and act like their interpretation of grown ups. It was set up to fail.

Raising college age kids sounds like a misnomer doesn’t it? A lot of people think that once they are 18, your job is over. Likewise, a lot of college age youth think that they are ready to be fully in charge. Well, neither perspective is really accurate. Our kids will always be our kids and we will always be their parents. We will always have some level of investment in how they end up in the world. That being said, we also have to be ready to modulate our mutual roles in a way that is acceptable to both parties if possible. Sometimes it is not possible, but we have to at least try. As much as I miss picking up my kids and tossing them into the air or playing with their hair and cuddling, I realize that they are just not as up for it as they used to be. I can try to resort to emotional blackmail, but it won’t get me anywhere. I have to realize that these things don’t mean that they don’t love me or love me any less. They are just evolving in how they chose to bond with me. I can sit there hoping that one of them is going to jump into my lap one day and want me to read them a story, but it is not likely to happen. Instead, we might have a conversation about politics(yuck) or what’s going on at school or I just listen to long, what they think is eloquent, speeches about what is important to them at the time. I am just kidding, I love hearing about what is important to them an I love to watch how their thought processes change over time and the evolution of their responses to certain situations. What I don’t love, is if those speeches turn snarky, satirical and hurtful without purpose. If they do, it is up to me to remind them that no matter what opinion they have, it is still their responsibility to voice it responsibly and remain a good human being. Sometimes, as they are espousing away, they don’t even realize that the person listening might think they are just being a jerk, rather than impressing the with their intellectual brilliance. In terms of voicing things responsibly, I also realize now that I am better off if I give people a heads up if I know I am having a perimenopausal emotion buffet day before I head off to any family outings. This system is not fool proof, but it is worth the effort, if you want to still bond with your kids as they get older. The old adage by Khalil Gibran says that ” If you love somebody, let them go for if they return, they were always yours. If they don’t, they never were. ” I think this means that we have to loosen the reigns and adapt a bit within reason as our kids get older. Then hopefully, they will come back some day, realizing just how cool we really were the whole time! Have a fantastic day everyone!

Dr. Katz

Mom you’ve got 4 eyeballs!

Well that’s not something you hear every day! Nope. Only when your poor child is post anesthesia from oral surgery and is laying there somewhere between laughing and crying and begging for chicken nuggets….which you know would be an absolute disaster. Sometimes you get lucky and they also start spouting about how much they love you and that you are the best mom ever. So, it must be true right? Yup, those are the times ripe for future blackmail material. The temptation to pull out my phone and take a quick video is strong. I just want a few minutes to save for later maybe when all hope seems lost in the middle of a teenage argument devoid of reason. What harm could it do? Well, no harm except for your teenager vowing to never speak to you again, but how many times have you heard that one only to have them yelling at you about something else moments later? Oh yes. Empty threats at best. We have all been there.

So, let’s talk a little bit about anesthesia for a minute. Anesthesia is somewhat of a magical and frightening creature at the same time. It allows us to drift off to another place to allow necessary and painful procedures to be performed safely. It allows us as physicians to get a glimpse into the uninhibited treasure trove of thoughts that are racing around in a patient’s mind, the things that we never get to hear at the office. Sometimes these anesthesia ramblings help physicians with a diagnosis or help us uncover a stressful social situation for the patient that we didn’t know about. As patients, it also somehow absolves us of any accountability for what we might say or do under it’s effects. On the other hand, it is kind of a frightening thought that you could have carried on a whole conversation, done terrible things and had no idea that it even happened. I have been under anesthesia many times for different reasons and each experience has been a little different. I have felt like I was thrown abruptly back into my own body from somewhere in the hinterlands while struggling to rejoin a conversation that I had apparently been having for the last 20 minutes. I have woken up bawling my eyes out for no apparent reason. I have woken up surrounded by staff members looking really somber, thinking that I must have just been diagnosed with something terrible, only to find out that they were just disappointed that I wasn’t funnier under anesthesia that time. (Apparently I am quite the cut up usually.)

I have to admit, I have heard some juicy tidbits over the years from patients that could fill a whole book of memoirs. And yet, all their secrets remain safe with me. It’s a code of ethics and honor man. Sometimes I get lucky with patients and they say wonderful things about me and about the staff and how much they love me. I have to admit, these are pretty great moments. I stand there thinking okay! This is what they really think! Yes! I must have done something right! Whoo! I already said that anesthesia was like truth serum right? Then, those same patients wake up fully and are as crabby and onerous as ever and you think to yourself, ” Oh well. We’ll always have Versed. “

Have a fantastic day everyone!

Dr. Katz

Hey Doc! You can borrow my shoes!

Sweeter words were never uttered. I was in the office the other day. It was very busy with a combination of aesthetics patients and obgyn patients. We were bustling along when we found a potential baby in trouble. The ultrasound didn’t look good and imminent delivery was required by c section. This, of course, puts everybody into full on spring into action mode as it should. I realized that I had seriously miscalculated my fashion choice with my wardrobe for the day. High-heeled shoes were not exactly conducive to performing a c section. We quickly and safely got the patient over to labor and delivery so that they could get her ready. I rushed around the office notifying the other patients and directing the staff for a minute. I made a joke at the front desk about my “Sunday Best” attire for c sections and that I did not bring any spare emergency shoes that day to the office. One of the other ob patients sitting in the waiting room hears me and yells out,” Hey doc! You can borrow my shoes! I like being bare foot!” She was dead serious. She was willing to sit there barefoot, pregnant as all get out, in my office until I was done with the c section so she could lend me her sneakers. Ladies and gentlemen hold your horses. Those words were music to my ears. They were kind, loyal, altruistic and just good stuff. This is the kind of happy and kind patient that you dream of. This is the kind of patient that actually thinks enough of you to want to help out in any way that they can. This the patient that comes along just in time to remind you why you are practicing medicine in the first place. You may only get a little sprinkling of them here and there. Enjoy them and appreciate them. You just don’t see that every day.

Of course, I couldn’t take her up on her offer, as amazing as it was. I just couldn’t leave her pregnant, shoeless, and stranded in my office. I thanked her and told her how awesome her offer was and that she was one of my favorite patients ever! I meant every word of it too. She smiled and then left….with her shoes on….and I went clicking down the hall to do my c section.

This patient really is one of my favorite patients, not because she offered me her shoes, but because she is a genuinely nice, kind, grateful patient who seems to understand the value of the care she is given. She seems to appreciate the time that we spend with her. She is also nice to the staff. That is like gold right there. There are way too many patients out there who take some sort of sick pride in treating the staff horribly and then gliding into the exam room without missing a beat and kissing their doctor’s proverbial butt to get what they want. The less astute physician then blithely goes along thinking they have this great patient, without realizing that the staff either cringes in horror or swears under their breath whenever that patient comes to the office. Here is where the communication piece potentially breaks down. I insist that my staff communicate to me immediately if they are treated poorly by a patient.( Yelling, screaming, cursing, etc) I can only fix what I know about. If they continue suffering in silence, there is nothing that I can do. When I am made aware of such behavior, I have an immediate conversation with that patient. I carefully and directly outline the behavioral expectations of respect in our office. I explain to them that I expect each patient to treat the staff and myself with respect and we will do the same. Otherwise, my office may not be the right place for them to seek medical care. I even have a phone script ready for my staff to deal with a belligerent patient. They are allowed to say,” Dr. Katz has given me the authority to terminate this conversation. Should you wish to call back when we can interact in a more civil manner, I would be more than happy to help you.” Then they are allowed to say have a good day and hang up. Yes that’s right. I do not feel that my staff should have to be some sort of whipping post for patents to unleash upon. It is just not right. I will actually dismiss patients for that. I don’t care if they have one of the few great insurance plans left on this earth. There is just no good reason to put up with that. Those couple of intolerable patients can bring down your whole office morale.

There is another species of patient that is difficult to understand. This is the one that somehow has to let you know that you are unnecessary. I see this more often with my ob patients. There are certain ob patients, who really secretly want to have a home birth by a lay midwife before they even come in for their first visit. These are the ones who already resent me and what I represent as soon as they come in to the office….even before we have met. These are the same patients that will shake their finger at me and point out that women have been delivering babies for thousands of years before people like ME came along….complete with raised voice and the whole works. Those are the patients that I just look at them and smile politely…and then I point out that that same thousands of years strong group of women that delivered on their own had a 50 percent mortality rate during childbirth. I encourage them to play those odds to their heart’s content if they desire to. I am not here to get in their way. I also inquire at that moment as to who forced them to come to my office? I politely point out that I do not see any ligature marks from the rope that tied them up and dragged them in and that I did not actively recruit them with a sandwich board and a bell. I remind them that they are free to leave any time. Sometimes, if they are particularly belligerent and out of line, I remind them that my practice will go on even if they leave. This sort of dialogue usually results in one of two things. They either storm out or they sit back down on the table and actually allow me to do my job. Of course, it took me over 20 years to finally summon the cajones to actually have those conversations and to some of you, it might seem a bit drastic, but I don’t regret them. Sometimes they are just necessary. Have a fantastic day everyone!

Dr. Katz

Doctors are people too.

As a doctor, I am very fortunate in that I do not have to give bad news that often( Baby is not ok, you have cancer, etc). When I do though, it hits me really hard. I find myself, depending on the patient reaction, fighting back my own tears when I see them upset and overwhelmed and wondering what to do. This is because I care so much about that patient that I would literally trade places with them if I could. I also find that when it comes to patient emotion, I am very easily projected upon. If the patient is taking the news badly, I am doing the same internally. If they are crying, I want to cry. If they are being “a trooper,” I find it that much easier to do the same. But, regardless of what I am feeling, I immediately do a mental and emotional pivot to convert my outer appearance to one of a comforting, calm, empathetic doctor without the emotional display. I guess there is a part of me that thinks it would be disrespectful to get too emotional or cry, like I am stealing their thunder or somehow making the situation about myself instead of concentrating on them. Of course, that is not what I would really be doing, I would be reacting because I care. I just don’t think patients would see it that way. I also think that at that moment, with that particular life-changing news, that patient needs someone strong to lead them through, not a blubbering mess. I think on some level, that they would possibly appreciate that I care so much, but that would get old quickly. Trust me though, I do blubber eventually, depending on what the news and the prognosis is. I just do not do it in front of the patient. This is why I could never be an oncologist. Just think about it. The majority of their job is to deliver bad news on a daily basis. There are those precious times when they get to celebrate a recovery or cure, but the bad seems to vastly outweigh the good. I just know myself. Burnout would come fast and furious as my emotions would overtake my clinical judgement. I admire those folks tremendously.

So, what is the role of emotion in medical practice? Are we really supposed to be outwardly cold and impassive and directly to the point in the case of bad news? Do patients really want us to save all the emotional display for themselves? Do they ever want to see our reaction? Do they even want to realize that we are human as well and are affected by the world around us? My guess, except for a handful of my patients, would be no. Most of my patients would tell you that they expect me to care, but they don’t necessarily want to “see it” because it would put them at risk for completely breaking down and not even hearing what I am trying to tell them. It’s like if I let my metaphorical wall down, my display of emotions alone would blast through the wall they are trying to put up to soak in the news that I am giving them.

A lot of patients have somewhat of a superhuman expectation of doctors. They do not expect them to ever be sick, have an emergency, miss a day of work, or show any emotion. I have been unfortunate enough to have had some serious illnesses in my past, causing me to miss extended periods of work, only to come back to find out that patients left my practice to go to another physician. Keep in mind that while I was gone, I had extensive coverage arrangements to satisfy all patient needs and that it was made clear that I was returning to my practice. But, it was still not enough. Patients got nervous, heard through some rumor mill that I was not coming back, figured that I had dropped the ball somehow and was going to let them down and left anyway. Situations like that get me thinking: Hey wait! I don’t drop them when they are gone or noncompliant for years and then want to come back! I give them a chance. Doesn’t that work both ways? Mind blowing news alert!: We are actually human! Just like our patients! Whaaat?! We have feelings, illnesses, life events, the whole nine yards. Sometimes I think it is more convenient for patients to view their physicians as something other than a human being. It’s a bit of a cop out really. It allows them to justify whatever unrealistic expectations that they have and use them to move on to another physician when they don’t get what they want. Now, let me be clear. I am not saying in any way, shape or form that it is somehow the patient’s responsibility to care about how i am doing or feeling on any given day. I just want them to realize, if only for a second, that doctors are people too. Have a fantastic day folks.

Dr. Katz