Sunday, June 29, 2008

Misplaced modifiers

One sports bra and a pair of orthotics. Now how could such things go missing, it's not like they travel outside the home on their own.

Thursday, June 26, 2008

Smeared memories

I explained in detail why my patient did not need a Pap this year (over 30, low risk, no abnormal Paps for 10 years). She agreed, and we proceeded with her annual physical.

We chatted away about this and that through the exam. At visit's end, I reminded her that she would hear about her Pap in 1-2 weeks.

"Uh, but I didn't have a Pap."

"Of course you did," I answered after a moment's hesitation, "but we were talking and you probably just don't remember." And then I remembered that we'd talked about no Pap.

"Well, maybe I did, " she answered, "or did I?"

At this point, she and I had a spirited discussion about Pap or no, did she or didn't she. I checked in the back, and indeed she did. Whose menopause moment was this?

Tuesday, June 24, 2008

Minding the Gap

This isn't so much a story about a memory lapse as one of judgment. If I can't share a day of apparel peril with my menoposse*, where else can I tell the tale?

During my daughter's last visit home, she cleaned out several drawers. She unearthed a good-as-new, size 6 pair of khaki slacks from Gap and dropped them in the to-go pile. I tried them on (standing all the while), and they fit like a glove. New summer pants without the agony of a shopping trip! I spirited them away to my closet.

Yesterday was the day to show the world there's no such thing as a generation gap at my house--I can wear size 6 hand-me-downs from my daughter. The first inkling of trouble, however, was my first proper sitting experience clad in khaki as I drove to work. The pants felt like concrete casing about my legs and stomach. I wondered would they stretch like denim (they did not) and would the seams hold (they did). But on arrival at the office, I got compliments from my 20-something medical assistant and 50-something medical partner. A droopy, half-century+, back end packed into stretch-resistant khaki is apparently a thing of beauty.

I spend my days talking to patients while perched on a backless exam stool. The only way my half-century+ back can handle that is by leaning forward from the hips. I found out minute one with Patient One that leaning forward was not an option. One, I couldn't breathe if I did, and two, didn't want to test the zipper strength.

Patient One and I discussed back pain, and I allowed as how I had that too. "No wonder," she noted, "look how you're sitting." Legs wound tightly round one another and dropped to one side while I leaned back with one arm resting on a chair to my other side. I told her why, and she burst out laughing.

By day's end, I was suffering from back spasms every time I moved and dreaming of a pair of travel knit slacks. Two aspirin, a muscle relaxant, and a long walk in sweat pants set my back straight. The pants went straight back to the discard pile.

*This great word is courtesy of my brother. Thanks, Bob!

Friday, June 20, 2008

PET scans prove that neurons like estrogen

We now have several lines of evidence, from independent parts of the brain, that estrogen is actually protective in a manner that is related to aging and dementia.
---Daniel Silverman, MD, head of neuronuclear imaging at UCLA

Scads of research evidence already support this conclusion. Reports from brain cells in petri dishes, as well as testimonials from aging gerbils, mice, rats, and women attest to the beneficial effects of estrogen with respect to forming new memories, learning new tasks, finding the right word at the right time, and completing a multi-step task(1) from start to finish.

UCLA scientists used functional brain imaging to visualize how well postmenopausal brains worked with estrogen compared to their activity after estrogen is withdrawn(2). PET scanning involves administration of 'tagged glucose' molecules. When busy little neurons put on their thinking caps in your brain, they suck up and metabolize sugar at an accelerated rate. The labeled glucose glows like a light bulb on subsequent scanning, identifying those parts of the brain that are successively at work.

81 women considered to be at high risk for Alzheimer's disease (AD) based on family history or genetic testing entered the study. All were initially on estrogen for menopausal symptoms. Baseline PET scans were performed, then the subjects were randomly assigned to continue estrogen or go on placebo over 2 years of follow-up. Intial "findings from the first 25 women to undergo baseline and follow-up scans were highly consistent for a neuroprotective effect of estrogen," per Dr. Silverman.

The initial scans showed that the longer the woman had been exposed to her own estrogen (defined as years from onset of menstruation to the end of the line at menopause), the higher the metabolism in the precuneus area of the posterior medial cortex. Don't knock the precuneus area just because you--and me!--haven't a clue where or what it is. Significantly diminished blood flow to this area is one of the earliest signs of Alzeimer's disease.

By study's end, women on estrogen continued to light up brain regions known to be most affected by AD whereas lights were dimming for the estrogenless group. Activity in the right inferior parietal lobe decreased twice as fast for this befuddled group. Research suggests that the right IPL is involved in the "what" (...did I come for) and "where" (...did I put it) of working memory. In fact, again per Silverman: "In [some] women who stayed on estrogen, metabolic activity in the frontal part of the cortex actually increased."
(1)Such as walking from one room to another to get something, grabbing that something, and returning with it to the original room with the thought intact as to why you wanted that thing
(2)Silverman, D et al. Society of Nuclear Medicine 2008 Annual Meeting: Abstract 973. Presented June 16, 2008.

Monday, June 16, 2008

Someone cell me a brain!

A menopause moment from Jean.

Dialed the number and walked around looking for my cell phone. Asked if anyone had seen it. I am always setting it or our house phone down and forgetting where.

Announced to whomever would listen, "Next time I'm buying a bright pink one, then I'll see it."

Wayne looked at me, "Aren't you on your cell?"

Sure enough, there was the phone clutched in my hand.

Please send me menopause moments of your own for sharing. E-mail me at:

Sunday, June 15, 2008

Mad as a wet hen!

Oh right, I was a wet hen.

I always wear a shower cap in the bath to keep my hair dry. I grabbed the cap in hand, tested the water temp, and stepped into the tub while pulling hat over head. I vaguely registered that the cap felt unnaturally weighty but proceeded to swing it up over my head.

Water poured over my hair as the cap emptied its contents down my head and face. I'd held it under the running tap as I used my index finger to check out the bathwater.

Thursday, June 5, 2008

A pasty white woman

I drive my husband nuts with my inattention to details such as tightening the lids on jars. Sometimes, however, I am hoist by my own petard.

I'd spent the evening preparing a talk on blood vessel health. Turns out, one's vascular health depends a lot on one's dental health, so I ended the evening with an in-depth flossing. I wore my strongest reading glasses as I bent towards the mirror to get a really good look at the teeth. When I straightened up, I noticed white goo on the tips of my hair. I didn't much want to touch it, but a moment's investigation confirmed it was toothpaste. Indeed, my Pepsodent tube, cap askew, had oozed paste into a puddle on the counter top.

After rinsing paste from hair, I straightened up to inspect my floss job in the mirror. Hanging from the left earpiece of my readers was an enormous gob of toothpaste dripping from glasses across onto lens and down into hair and cheek. I have no idea how my toothpaste tube launched this surface to hair missile. Was my face white!

Wednesday, June 4, 2008

Verbal fluency and hormone therapy

Verbal fluency is defined as the ability to find the right word at the right time and use it with ease when appropriate. I wrote a post on it earlier this year on Doc of Ages, my other blog.

I got an interesting comment and question on the subject today. Verbal fluency (VF) is very much an estrogen-supported brain function. Out of estrogen and you may be out of luck with respect to having your say in an okay way. This lady writes:

In the last few years I have noticed what seems to me more VF problems than my friends. I am not as bothered by it when writing which I do a great deal.

I'm 73 and have taken Premarin, .625 mg daily, since I had a complete hysterectomy at age 54 (done for multiple non-malignant reasons). Some doctors lately say I should discontinue the Premarin because it increases my likelihood of getting cancer - uterine and breast - and major clots. (I had bilateral mastectomies in my 30s for major non-malignant breast changes and a high family cancer history). I am healthy otherwise (minor heart change, excellent bone density, some arthritis).

Two questions: Why the VF problem? Discontinue the Premarin? The answers I get are vague and don't satisfy me.

I answered:

While VF is sensitive to estrogen or the lack thereof, it also falls off with age. That said, you're not that old, and I never know what to make of this citation of age as a reason for anything; it seems that there must always be an underlying problem that perhaps worsens with age but not explained by age alone. As VF is a frontal lobe function, and the frontal lobe is more susceptible to stroke damage than other parts of the brain, I wonder if you should have an MRI to look for the tiny white spots that correlate with small vessel disease in the brain.

Premarin or no, here's my take on that. While estrogen is known to support frontal lobe function, oral estrogen supplements, and in particular Premarin taken orally, are known to cause some problems even as they may benefit brain function.

Once orally-ingested hormones are absorbed into the bloodstream, they head straight for the liver via the portal circulation. The liver gears up to break these foreign molecules down and, in doing so, produces some unwanted proteins such as angiotensinogen (which can raise blood pressure), C-reactive protein (which causes inflammation), clotting factors (which raise risk of clots and blood vessel inflammation) and triglycerides (which raise risk of heart disease and stroke).

If you haven't had a major clot from Premarin, you are unlikely to get one now unless you have to undergo major surgery such as a knee replacement. You don't have breasts or uterus to worry about cancer risk. But you do have to worry about stroke.

I would consider going off Premarin. But...estrogen supports frontal lobe function. You might consider replacing the Premarin with a transdermal estradiol patch such as Vivelle Dot. That way, the estrogen you take is not foreign (like the horse estrogens of Premarin) and it does not go through your liver (causing all the above troubles). It is known that transdermal estrogen does not raise clotting factors, C-reactive protein, or angiotensinogen. It has not been studied whether or not transdermal estrogen increases risk of stroke the way oral estrogen does, but logically it should not.

The only vague part of my information is whether or not you should change hormone delivery systems or go off it altogether. That is a weighted decision best made by yourself and your doctor.