The Do’s and Don’ts of the Teen Gynecology Visit

I published my new episode The Do’s and Dont’s of the Teen Gynecology Visit, please check it out
https://www.podbean.com/ea/pb-n6ibu-117e6e3

I have been really struggling with how to be a good parent lately.

Parents tired of noisy children who are running and shouting Tired mother and father sitting on couch feels annoyed exhausted while noisy little daughter and son shouting run around sofa where parents resting. Too active hyperactive kids, need repose concept parenting stock pictures, royalty-free photos & images

Wow! I have been really struggling in the parent department lately. There have been so many unforeseen and unpredictable changes in the last two and a half years that have really affected my relationship with my kids and none of them are in my control.

The ongoing pandemic has ripped us all away from our usual social environments and has taken away many traditional milestones and events. As adults, we have missed out in person interactions with work colleagues, family gatherings, and the ability to be at loved one’s side during illness or hospitalization. This has been difficult but our capacity to recover is greater because, for the most part, we have plentiful stored memories to fall back on. For our kids, they are missing once in a lifetime experiences like prom, last sports games, and in person graduations. It has been argued that they should “get over it” because these events are nothing compared to high schoolers of the past who had to leave school to go off to war, etc. Last time I checked, no one is comparing prom to Nam and they shouldn’t start now. Missing these key social interactions has caused some long-lasting psychological damage for these kids. They will never get these moments back. The level of depression that I have seen is tremendous and it affects everything.

On top of the pandemic, I got cancer and my husband had a heart attack, one right after the other. My kids almost lost both parents in one year. As much as they put up an outside facade, I know this affected them tremendously. How could it not? They don’t treat us the same way. I get the feeling that, even though we survived, a part of them didn’t. A part of them walks around every day waiting for the next shoe to drop and they can’t seem to stop. There is just a little air of underlying depression and doom almost every day. It kind of breaks my heart.

There has also been a sense of life is too short no matter what is going on for them. This sounds like it should be a healthy realization, encouraging them to live life to the fullest, but instead I worry that it has become an excuse for unhealthy choices and directions. I am just at a loss as to how to handle it.

As a parent, I feel like I should be jumping on or punishing these poor choices or at least trying to redirect them. I worry that I am not doing my job if I don’t. I am concerned that it will seem like I don’t care if I don’t react. But really, it’s not true. I talked to my therapist about this. She explained to me that punishments don’t really work in this situation. Most punishments that I could think of would really only punish me and the other people relying on my kids in the long run. Taking away phones, jobs, privileges, and cars just mean that I will have to do a lot more driving, spending, and won’t be able to communicate remotely with my kids. She assured me that I am not being a bad parent by not reacting to every single thing and leaving some things up to my kids to figure out. It doesn’t mean that I don’t care. It doesn’t erase my validity as a parent. Ultimately, the consequences of their actions need to be theirs. Making myself overly upset about it does not help anything and is counterproductive. She advised me to take a step back and I think she is right. Overly obsessing and punishing and trying to address every little thing only increases my stress, increases the negative attention impact on my relationship with my kids and gets me no where. It can only end badly. I need to put a stop to the distracting inner struggle and keep growing and moving forward. I need to refocus. I need to no longer punish myself for not being there when I was sick or my husband was sick. I need to be patient. I can help them more by living my best life by example than fighting every day. I am not saying that I plan to let them run me over. There are limits. I am just saying that I need to pace myself and realize what is really important. Everything I have been through, my kids have been going through too and it’s not over yet. This is going to be a marathon, not a sprint.

Dr. Katz

The Nissan and the Lexuses..or….why don’t I fit in?

Every morning, my little Rogue and I drive to work together. When I find my way into the parking lot at the hospital, I am always greeted by a fleet of Lexuses, Teslas, and Maseratis, etc, all parked incorrectly, the vast majority taking up more than one spot. I drive around and around, looking for somewhere to park and end up finding something a little more remote, despite my doctor’s parking pass, and I squeeze my little Rogue in and head up to my office. Sometimes I look back at my goofy little car with the Mechagodzilla on the dash and my fuzzy dice in the window and just kind of giggle a bit. It does look kind of out of place amongst all the other luxury vehicles but it’s just…more….me.

I realize at that moment that it is kind of a metaphor for how I don’t exactly fit with my colleagues at any one time. I have spikey hair. I have tattoos. I don’t act like I am better than anyone else. I talk with people not at them. I am not employed or owned by anyone. I don’t see a high volume of patients like cattle on certain days. I say what I think while at least attempting to be professional and appropriate at the same time. I am pretty goofy and I like to laugh. My job is not just a drudgery to me. I love it and hopefully it shows! ( By the way, I am not saying that everyone is like this. These are just some differences I have noticed over the years in some cases.)

I used to perseverate a LOT about the fact that I was so different. I felt this pressure to conform, fit in, be a grown up all the time, get in line….all that. In fact, I worried about that until this last year as a matter of fact. Then, I got cancer and my whole world changed. I definitely had an epiphany YOLO moment. I realized that life is too short to try to mold yourself to others’ models. Being you is your best chance to be able to live YOUR life at YOUR best. In fact, I have noticed that since embracing my uniqueness more lately, I feel like I have attracted more patients, built better relationships , and been more successful. I think the key was getting more comfortable with who I am and caring less about the opinions of others. That removed an unnecessary distraction that was just getting in the way of my own success. Now, let me be clear, I am not advising anyone to be out of control or fly in the face of every applicable convention that is laid before them. I am not saying to never go by the rules. I am just saying to enjoy….being……YOU!

Dr. Katz

Why does my dog sometimes make me happier than people do?

I think you all know what I am talking about. That wagging tail, the sloppy dog kisses, running to meet you at the door. Who else acts like the world has only just started spinning again when you walk in? Who possesses a level of sheer unadulterated enthusiasm for your very existence? I mean c’mon, who doesn’t love that attention? I know for myself that, even if I have had the shittiest human day ever, it all melts away when those furry critters come running. I can’t wait to scoop them up and love on ’em to my heart’s content. And, on top of that, they don’t push me away like my kids do at times. It’s a win win.

I have to confess something else as well. I find myself making more allowances and excuses for my dogs than I would ordinarily do for any human. Did you have an accident? That must be our fault for not letting you out on time. Did you chew up my favorite socks? That must be because I didn’t have a toy available for you. The list goes on and on. But why I ask you? I expect most humans to tow that line with the highest of standards to live by and they better not disappoint or they are going to hear it from me almost without exception! Is it because the dogs’ furry faces are that much cuter? Is it because my expectations for them are inherently low? Or, is it because no dog has ever disappointed me like humans have? Maybe its a little bit of all three.

I saw the funniest meme the other day. It addresses the difference in goodbye salutations a woman says to her dog versus her spouse. To the dog, she says Goodbye! I’ll miss you! We will play when I get home! Make sure daddy lets you out when I am gone! To her spouse she merely says Bye! and she’s out the door. Now, I tend to think I am pretty fair in my exit greetings to my spouse and my pets, but I have to confess that I am guilty of this too. Even though I have given my husband a quick peck on the cheek already and that’s the end of it, I am trying to pet or hug the dogs one last time or giving them one last treat and promising to be back soon. It’s as if I have made the assumption that they are going to miss me ten times more so I have to reassure them. It’s ridiculous I know, but I can’t seem to help myself. I bet you’ve done it too, if you’re being honest.

Dr. Katz

Why are you still all up in my business chemo?

The overall good news is that we are getting better and better at helping patients survive cancer. Awesome! Whoohoo! The double-edged sword side of this is that as people are surviving longer and longer, we are getting to know more and more about late side effects from chemotherapy.

So, what is a late side effect? A late side effect is a side effect that you experience after treatment is over. These can occur even years later. What?! These late side effects can result from any type of cancer treatment. So far I have experienced significant neuropathy, muscle pain, headache, nausea, severe hypothyroidism, renal dysfunction, “chemo brain”, stomatitis, significant fatigue, cough, shortness of breath and hot flashes. I may be forgetting a few but those are the ones that come immediately to mind. To be honest with you, I am kind of over it. Enough already!

The main types of cancer treatment so far are chemotherapy, hormone therapy, surgery, radiation, targeted therapy and immunotherapy. Let’s look at each one. Now, before I go into this, I want to remind everybody that technically we all get counselled and have to sign a consent form before receiving any kind of cancer treatment in the first place. Some places do it better than others. Most sit down and do a one on one chemo teaching session in which the patient can ask questions and get clarification. This is a great opportunity to really START to appreciate what you are getting yourself into. Unfortunately, after this great teaching session, there is usually still a 20 plus page consent form that you are supposed sign as well. I’ll tell ya, nothing undermines your confidence like thinking you just covered all your bases and then you get this huge document plunked in your lap that you are supposed to pour through to make sure you really get it. I think a lot of us do our best but there is no way to digest all that additional info efficiently in a short amount of time, but we sign it anyway because we really want that cancer gone. This is a tough spot for any patient to be in because you really want that cancer gone, but you don’t fully realize what you possibly consented for in exchange. Yes, I am talking about side effects and other potential cancers. This is what we are going to talk about.

Let’s look at the kind of late side effects that are possible with each type of treatment. First let’s look at chemotherapy. Chemotherapy can cause a multitude of late side effects like early menopause, hearing loss, increased risk of other cancers, lung disease, nerve damage, reduced lung capacity, osteoporosis, and dental problems.

Now let’s look at radiotherapy. Radiation therapy can cause all kinds of late issues as well, such as cavities, tooth decay, increased risk of other cancers, coronary artery disease, increased stroke risk, hypothyroidism, heart and vascular problems, early menopause, intestinal problems, memory problems, osteoporosis, infertility and lymphedema.

Surgery is another mode of targeted cancer treatment. The main side effect of surgery is infection risk, at the time. The main late effect of surgery is lymphedema in the area that was operated on.

Hormone therapy is another type of cancer treatment. With hormone therapy comes the risk of blood clots, hot flashes( for men and women), menopause, sexual side effects, osteoporosis and the risk of other cancers.

The last two main categories of cancer treatment are immunotherapy and targeted therapy. These are still new enough that we don’t know a lot about possible late side effects. Lucky me, I fall into this group. Actually, I fall into the immunotherapy and the chemotherapy group. I’ll keep you posted.

The point I want to make is that it is not all in your head when you are still having symptoms long after chemo. We really don’t know a way to prevent them. If you are having them though, make sure to speak up to your doctor and make sure something else is not going on. Even when your cancer is over, it is still your job to continue to advocate for your health.

Dr. Katz

Thanksgiving

The actual definition of Thanksgiving Day is a national holiday in the United States that commemorates the date in 1621 on which the colonists and the Wampanoag tribe shared a feast celebrating the Autumn harvest. There has been a lot of controversy regarding the accuracy of the retelling of this bit of history. Nonetheless we continue to celebrate it centuries later with turkey, family, football and feasting.

Why is Thanksgiving so important? The name kind of gives it away..Thanks giving. It is a day to give thanks and to celebrate gratititude. It is a day to realize the blessings you have and cherish them. It is a day to gather with family and tell stories. It is a day that is not focused on material things like gift giving. It celebrates positivity itself.

So, now that we know why Thanksgiving is important, let’s talk about the practice of it. How was your Thanksgiving? Did you celebrate family and what you have? Or did you bemoan the world in general, talk about COVID, and complain about what is not going your way? Our house was pretty peaceful and celebratory, but I am concerned that was not the norm or the majority for others. Do we still know how to be grateful and give thanks? Or is peaceful thankfulness just a distant memory for too many at this point? Sometimes I find it difficult to remember a time when the majority of people that I come across had at least one good thing to say or focus on. I am not asking for the world here. I am just asking to be able to start a conversation with someone that does not start with a complaint or some sort of discontent. I am guilty of it too at times. Most of the time, when someone asks me how I am doing I give my stock answer, “Living the dream!” I give this answer for several reasons: 1) I actually believe it, 2) I don’t want them to worry( there has been a lot to worry about lately), and 3) I know in my heart that most people don’t actually want to know. They are just asking to be polite. Other times I start rambling word vomit about everything that is going on or frustrating me before I can stop myself, even though I can tell immediately that the other person regrets asking by the look on their face.

I am not sure why I do it. I am basically a positive person and try my hardest to maintain that, even with everything that life has thrown at me lately. I really want to keep that going but even I fall into that trap that I feel like the rest of the world is in sometimes. So, I ask the big question again. Have we forgotten how to be grateful, positive, or happy? Is the norm of negativity so engrained at this point that there is no turning back? I hope not. I can tell you this though. If we don’t start looking a little harder for the things that give us joy and pushing aside the negative focus that is locking us in, the damage that we are causing to ourselves will be irreparable.

Dr. Katz

Why does my period hurt so much?(Primary dysmenorrhea debunked) The pain is real guys!

See the source image

So, what the heck is primary dysmenorrhea? Primary dysmenorrhea is defined as significant pain during your menstrual cycle without a specific or identifiable cause. To me, this is a bit misleading because there is a cause for the pain, and we will explain that in a bit. I think it should say without a specific anatomical or additional pathologic cause outside of the normal biochemical reactions in our bodies.

Dysmenorrhea can interfere with our quality of life and our daily activities and performance. You know what I mean. We all know women who have to miss work or school because of their severe cramps, pain and bleeding. Dysmenorrhea is the most common gynecologic condition affecting women. The percent is reported anywhere from 17% to 90% depending on what you read. Sometimes the pain is minimal but sometimes it literally stops the woman from being able to function. Current statistics state that up to 15% of women that have dysmenorrhea actually miss work or school or functioning in general with regularity. Even for those women that do not miss work or school, the pain is often enough to reduce focus and productivity. In the United States, it is estimated that there are about 600 million hours of productivity lost to dysmenorrhea. This translates to about 2 billion dollars annually. I think that deserves our attention. Just keep it in mind the next time a work or school colleague has to stay home because they are in pain with their period. This stuff is real folks!

So, what causes this pain? What is primary dysmenorrhea? Primary dysmenorrhea is pain with menses that has no underlying pathology. Dysmenorrhea is called secondary if it caused by another condition like endometriosis, fibroids, pelvic inflammatory disease, or interstitial cystitis. For the purposes of this blog, we are going to focus on primary dysmenorrhea.

Primary dysmenorrhea usually starts at the onset of ovulatory menstrual cycles. Usually women do not ovulate for about 6 to 12 months after menarche( the onset of menses for the first time). Sometimes ovulation does not start for up to 2 years. The pain is usually crampy, comes and goes, and increases in intensity. It starts just before the bleeding starts and lasts up to 72 hours. There can also be nausea, bloating, diarrhea and vomiting.

Who is at risk for primary dysmenorrhea? There are multiple factors: 1) body mass index less than 20, 2) smoking, 3) longer menstrual cycles, 4) irregular or heavy flow, 5) history of sexual assault, 6) menarche younger than 12, 7) age younger than 30, and a family history of dysmenorrhea. Usually it gets better with age and after child bearing

Here is the pathophysiology of primary dysmenorrhea. The pain is probably due to the increased prostanoid secretion. So, what the heck is a prostanoid? Prostanoids are prostaglandins, thoromboxanes, and prostacyclins. And what are those things? Basically, all we need to know is that these are chemicals that cause cramps. So, the process goes something like this. When we ovulate, our progesterone stabilizes something called lysosomes, which are like storage containers full of inflammatory chemicals. At the end of the luteal phase of our cycle, our progesterone levels go down and the lysosomes break down and release something called phopholipase A2. Well this phopholipase starts the cyclooxygenase pathway, which then causes production of the prostanoids that I mentioned before. Then voila! Cramps! The main prostanoids that concern us in dysmenorrhea are the prostaglandins. They are the compounds that cause uterine contractions that restrict blood flow in the uterus. Because blood flow is restricted, there is less oxygen. Because there is less oxygen, metabolites are produced that stimulate pain receptors. In addition to that, some of the prostaglandins lower pain threshold because they actually sensitize the nerve receptors. And, if that weren’t enough, the prostaglandins are also responsible for all the gi symptoms we know and hate. There are other compunds that are involved in this process as well but since the prostaglandins are the main culprit, we are going to focus on those for the purposes of this blog.

As if the prostaglandins weren’t enough of an issue, it has also been documented that women who suffer from primary dysmenorrhea actually have an altered pain sensitivity in the first place. Altered pain perception in dysmenorrhea has been studied all the way back to the 1940s. This altered perception is part of central sensitization syndromes. These syndromes are all associated with pain hypersensitivity without documented tissue injury, inflammation or an actual nervous system lesion. This include several disorders such as low back pain, tension headaches and irritable bowel syndrome. All of these conditions lead to amplified sensory input. These result in the patient having more pain with less stimuli.

I think we have now effectively established that primary dysmenorrhea sucks. So, what can we do about it? There are multiple options. Right now we are going to focus on the non-surgical ones. The goal of each option is to interfere with the prostaglandin production, decrease muscle tone in the uterus, or inhibit pain perception with analgesia. Before we go into these options, it is important to remember that the real key to success and compliance with any regimen is SHARED DECISION MAKING between the patient and the doctor. Have the patient be an active part of deciding on treatment, after discussing side-effects, efficacy, etc and this will help greatly. If the patient is invested in the option, it is much more likely to be helpful.

The first category of options is hormonal. Combined( both estrogen and progesterone) birth control pills are number one in this category. They are effective in about 70-80% of patients. They inhibit ovulation and prevent multiplying of endometrial cells, which decreases prostaglandins, progesterone and vasopressin. This applies to the pill, ring and the patch. Extended use( skipping the placebos) seems to be the most affective. There is a possible risk of blood clots with this method, although this risk is very small in low risk, non-smoking patients.

Progesterone only contraception like Depo Provera or the Mirena Iud. They also inhibit ovulation and eliminate menstrual cycles. Sometimes these methods can cause irregular bleeding. Since this bleeding is still anovulatory, it is not associated with dysmenorrhea. The risk of blood clots is lower with this method. Sometimes there is weight gain reported, but this can usually be avoided with proper nutrition monitoring. Depo Provera itself has been associated with decreased bone density, which seems to be completely reversible after stopping it. While this sounds concerning, it has not been deemed enough of a reason to discourage patient from using it.

There are non hormonal options as well for primary dysmenorrhea. NSAIDS( non steroidal anti inflammatory drugs) are a first line treatment and are effective for the vast majority of patients. They work by inhibiting the cyclooxygenase enzyme we were talking about earlier, which then suppresses prostaglandin production. It’s like stopping the cramps before they can even be created! They also have a direct analgesic effect at the central nervous system level. There is not a lot of evidence to say that one is better than the others. Usually medications like Motrin, ibuprofen, Alleve, and Anaprox are among the first choice options. More expensive medications like Celebrex are reserved for second options. Ideally, these are taken as needed only. One suggested regimen is to start the medication 2 days prior to the onset of menses and continue for the first 72 hours of the menstrua cycle. The key is not to wait until the pain has already gotten started and try to catch up to it, but to act proactively.

Another possible non hormonal option is Magnesium. Magnesium appears to reduce the amount of prostaglandins in menstrual fluid. It is also a muscle relaxant and causes blood vessel dilation. This sounds logical but there is not a lot of data just yet.

Calcium channel blockers like Nifedipine can cause muscle relaxation and decrease prostaglandin production and possibly reduce uterine contractions. More data is needed here as well. I personally would feel hesitant to prescribe a blood pressure medicine for cramping.

Vitamin E, in some small studies has been shown to reduce dysmenorrhea. It has been shown to increase oxygen delivery to uterine cells, decrease prostaglandins production, and inhibit cyclooxygenase. This should result in reduction in pain and cramping. Unfortunately, so far the majority of this data is in the mice population.

Ginger also inhibits cyclooxygenase activity and decreases menstrual pain. The added bonus to ginger is that it is also an antiemetic( anti nausea) so it may help with the gi effects as well. Thus far the doses studied have ranged from 750 to 2000 mg a day with the same efficacy as NSAIDS. Go Ginger!

There are some other proposed non hormonal options for dysmenorrhea as well. All of these require further study but they are interesting prospects. The first is transcutaneous electrical nerve stimulation(TENS). This is hypothesized to work in three ways. 1) it sends electrical impulses to the nerve root, elevates the pain threshold, and the pain sensation is not felt. 2) It stimulates the release of endorphins which reduce pain. 3) It increases dilation of blood vessels in the uterine muscle and reduces hypoxia which also reduces pain.

Acupuncture( needles) and acupressure( firm pressure) stimulate designated locations to relieve pain. There are specific sites on the body on the auricle of the ear, the medial calf muscle, and near the medial malleolus of the ankle that have been identified as possible beneficial treatment areas for dysmenorrhea. There are no specific regimens that have been backed up by studies to recommend with confidence at this point. So far, the range varies from a once a menstrual cycle treatment to daily for 7 days during the menstrual cycle. More to follow later here.

Let’s not forget the good old heating pad applied directly to the suprapubic region. Local heat improves tissue oxygenation, dilutes the levels of prostaglandins and increases blood flow. All of these effects can lead to decreased pain as well. A lot more evidence is needed, but it makes sense.

Apparently exercise and yoga play a role here as well by increasing endorphin release, lowering stress and anxiety, and increasing blood flow. I am here to tell you that as good as that sounds, the thought of jumping on the exercise bike or doing some aerobics in the middle of a crazy period sounds a little daunting to me. I get that there is some moderate quality evidence that this helps over the long term, plus the other health benefits of exercise, but I still think I would have a hard time putting it into practice. I am going to opt to continue to follow how that plays out.

There are a number of herbal and complimentary remedies that have been suggested as well. Rose tea, fish oil, krill oil, sweet fennel seed, low fat vegetarian diet and decreased dairy intake. So far, there is no high quality evidence for any specific dietary supplement. Still, the side effects are minimal so they may be worth trying.

The bottom line is, dysmenorrhea is a real thing that affects millions of women and costs billions of dollars in lost productivity. Beyond that, it can really affect quality of life and daily function both mentally and physically. It deserves our careful attention with a thoughtful plan tailored to the patient’s specific needs and risk factors.

Dr. Katz

Does Punishment Really Work with Teens?

girl in dunce cap - student punishment stock pictures, royalty-free photos & images

What is the first strategy that comes to mind when your teenager is making you crazy and does something that really wrong and pisses you off? Punish them! Take things away! Ground them for life! Take their phone! Take their car! Am I right? You are really ticked off. You want them to “get it.” You want whatever behavior it is to stop…like yesterday. You want to yell. You want to scream. There is a part of you that wants to evoke some kind of reaction from them that gives an indication that it matters to them that you even object in the first place to whatever they did.

C’mon. Be honest. We have all been guilty of it at one time or another. Well, guess what? I hate to break it to you but the American Academy of Pediatrics says that punishments don’t actually work in the long run. They may stop the immediate behavior at the moment, but really don’t have any long term positive effect. Not to mention the fact that a lot of those punitive actions actually punish you more than they punish the offending teenager. Taking the car potentially means a lot more driving for you. Taking the phone means that you cannot reach them wither when you need them. Etc. Etc. You get what I mean. I am not by any means suggesting that there should never be consequences for poor actions. I am just saying that, as tempting as it is to punish first, it is not as helpful as we think.

Well, if we are not supposed to punish them, what are we supposed to do? What recourse do we have? Do we let our teens walk all over us? The simple answer is no. We just need to consider an alternative strategy that has greater long term benefits. The American Academy of Pediatrics suggests discipline strategies instead of verbal or physical punishments to discourage unwanted behaviors.

So, what is the difference between discipline and punishment? Punishments, both physical and verbal, are quick, often knee jerk actions fueled by anger that may stop bad behavior quickly, but do not work over time. Discipline, on the other hand, teaches our teens how to recognize and control their own behavior. Teaching them in this way helps them to learn how to avoid harm later. The American Academy of Pediatrics recommends four healthy discipline methods for teens. They are as follows:1) Be a role model for good behavior, 2) Ignore bad behavior or redirect your child away from bad behavior, 3) Set limits and expectations, and 4) Praise good behavior.

I have to say that, while I understand the American Academy of Pediatrics’ concept and the logic behind it, I find it difficult to adhere to 100% of the time. I find that nowadays the underlying intent of the Academy has been somewhat twisted and translated into overly permissive parenting with absolutely no behavioral consequences for children. I think that truly effective parenting must involve some kind of middle ground combination of discipline and punishment, maybe a 80%/20% ratio. At least that is what I am trying at the present.

Dr. Katz