FRIDAY THE 13th

You don’t have to be superstitious to at least give a passing thought to the fact that it is Friday the 13th and a full harvest moon. While Love and Medicine raises a skeptical eyebrow to such folklore, I like to use these cosmic events as a diving board for reflection and change.

Together with the change in seasons, we are in transition. Our bodies and minds are recalibrating. The cool dark fall nights are upon us. It’s time to get sassy and creative.

This week, for no reason at all, based on nothing, I thought I would discover the job of my dreams. One that would tap into my intellectual and creative skills, pay well and be spiritually satisfying, while allowing me to travel the world. That did not happen…yet.

At least I’m not feeling stuck. I am optimistic that I will be discovered. It’s not like I want to be a model or an astronaut – I’m being realistic, not grandiose.

Thinking we’re too old to make changes is what gets us stuck. I hear the too old excuse every day. But being older we have opportunities we didn’t have before. As a doctor with 25 years experience I’ve seen just about every complication at least once. We are wiser, we know the pitfalls. We know what we want. We also know our past does not define us.

Allow the power of the full moon to move you as it moves oceans. And don’t be afraid.

Intercontinental Parenting

My three children are adults now. They live in Australia, Los Angeles and Israel. I can’t picture any of them living in Milwaukee. They are happy where they are.

Here are some of the ways I deal with the distance. It’s not easy.

1.Trust their choices. My eldest daughter moving to Australia was tough. Australia is far – from practically everywhere – but it is where she found love. Israel is more than an abstract dream; for my youngest, it is home. My son ditched neuroscience and a medical technology company in Copenhagen to write, record and produce music in Los Angeles .

2. Blame yourself, a little. You showed them the world. You traveled as a family and never saw geography as an obstacle. As parents you fostered the confidence and independence they need to be away.

3. Visit them. Face the fact that in order to see your kids you may have to sit in a crowded metal cylinder in the sky for a full day traveling to places that you wouldn’t choose for yourself – LA that would be you.
Meeting half-way changes it up. Japan was a perfect halfway meeting point for our Australian and Hawaii a perfect place for her wedding. Europe works for our Israeli.

4. Make them come visit you even if you have to pay their way.

5. Create an active group chat. For us pictures of food and dogs dominate, with some great memes.

6. Coordinate reading the same book or watching the same series.

7. Once in a while send a card. It may take forever to get there but they will have something tangible to hold. Conversely get them gifts in their local shops and they can be delivered to their door.

8. Count your blessings if far away for you is driving distance.

9. Stay involved in each other’s daily lives. Your kids never stop needing you. Make sure they know you are there for them for everything. Don’t be restrained by time differences.

10. Never end a conversation before saying “love you”.

Sugar, sugar

Ask Dr. Annie K:

Why do I always crave something sweet after a big meal? Even if I ate enough and I feel full it seems like there’s room for a little dessert. Is there a medical explanation for this?

“Would you like to take a look at the dessert menu?”

Someone invariably in the group says yes.

It all goes back to the primal connection between our brain and our gut – why we refer to the gut as the “Second Brain”.

We could blame it all on ghrelin . Ghrelin is known as the “hunger hormone” which is produced in the gastrointestinal tract and brain. It stimulates the appetite and signals the brain to eat. New studies show that it can keep you eating, even when you are full. Consider the potential of this hormone to lead to a major medical breakthrough in weight management. It is one of many other factors that lead to overeating.

Sugar cravings happen for 3 primary reasons:

unstable sugar levels
emotional imbalance
habit

UNSTABLE SUGAR LEVELS

Eating food that is high in sugar and carbohydrates creates a quick, sharp rise in the level of sugar in your bloodstream. Insulin – a hormone secreted by the pancreas – kicks in to control blood sugar levels. As a result, blood sugar levels drop. Then the cravings start and that tiramisu is looking better and better. The sugar/insulin rollercoaster is dangerous. Besides the damage it does to our bodies, it wrecks havoc on mood and energy levels.

EMOTIONAL EATING

Any type of unbalanced emotional state can lead to sugar craving. Stress, anxiety, anger, and sadness can trigger a need of food, for comfort. Sugary desserts produce a serotonin and dopamine rush, neurotransmitters associated with mood-elevation. Feeling unusually happy can also incite cravings. A seriously great mood makes me want to celebrate with my favorite, marshmallows ;).

HABIT

Habit is a big one. If you grew up in a house where every meal ended in dessert, you may have simply developed the habit. Dessert follows dinner, no questions asked. It may be part of a tradition in your culture. This habit is now programmed in your mind.

A habit is still a choice and that choice is yours to make.

WHAT TO DO

The dangers associated with excessive sugar intact are documented facts. Sugar has been well studied. This is not one of those findings you can rationalize by saying “one day they say eggs are good for you, the next day they are bad”. FACT: High sugar is associated with obesity, tooth decay, accelerated aging of the skin, impaired cognition in children, diabetes, cancer, heart disease, depression and dementia. Type II diabetes is an epidemic in the western world.

I am not advocating cutting out all dessert. Stressing out over dessert is also unhealthy. If you need a little something sweet keep it little. A tiny dessert will relieve the craving with way less harm than the big dessert.

Stopping Antidepressants

Fran, a 36-year-old teacher, initially presented with symptoms of major depression with anxiety. She responded well to an antidepressant and I saw her twice a year for medication management. Nine years later, we discussed stopping the medication. I gave my usual spiel, recommending a one month long taper period.
Fran called a few weeks later on the emergency number. She was sobbing – feeling terrified and anxious. She was nauseated and fuzzy. Her body felt sick, like electrical shocks were zapping her brain and limbs. She was terrified she might have MS.

These were symptoms of withdrawal. We devised an immediate plan for a slower taper. By the end, she was taking small thumbnail “chips” of the pill. It took months until she was comfortable without the medication.

While some can stop antidepressants no problem or with minimal discomfort, more than half of the patients experience withdrawal effects similar to Fran’s.

Psychiatrists knew antidepressants could not be stopped “cold turkey”. We just didn’t know how to stop them. If patients were really miserable, we simply restarted the medication, misinterpreting symptoms as a sign of relapse. Patients hated it so much they wanted the medication back, thinking this was a sign of true need. Discontinuation horror stories are all over the Internet.

Guidelines state that withdrawal reactions are self-limited and last one to two weeks. Simply untrue. Recent studies show that withdrawal reactions can be longer and more severe than initially thought. Restarting medications has lead to a dramatic increase in the length of time patients are on these drugs. How much do we know about long-term risks?

This is not unique to antidepressants. How many of you have tried to stop proton-pump inhibitors (PPIs) for acid reflux? After a few days of heartburn you reach desperately for that omeprazole without giving the body time to adjust. Furthermore, long term use of both PPIs and antidepressants are associated with neurologic diseases like dementia.

Finally doctors are paying attention. There has been a new focus on withdrawal from antidepressants which will hopefully be generalized to other drugs. Research is surfacing about how to manage a safe discontinuation.

When I prescribe antidepressants we discuss withdrawal risks from the beginning. The taper must be super slow – it can take months or years. Dr. Mark Horowitz at University College London says many people “have to pull apart their capsules and reduce the dosage bead by bead”.

I was involved in the first clinical trials for SSRIs. Those were exciting times! Finally we had safer and better tolerated weapons to beat depression. These medications have saved lives. Now we need to be just as skilled at de-prescribing as we are at prescribing them.

CELEBRATE INDEPENDENCE

On the 4th of July Milwaukee is like Pleasantville, USA. This becomes a place where people are “swell and perky.” American flags fly proudly. Kids decorate their bikes in festive red, white and blue. There is a parade with floats, clowns, animals and classic cars. You can win a stuffed animal at the carnival. Roasted sweet corn, snow cones and cotton candy are standard fare, along with plenty of beer.

I love a holiday with no religion.

Family travels in and the walls of our house expand to fit whoever can stand the chaos. My famous American flag cake is expected. I don’t formally invite friends; it’s an open annual event by now. The barbecue grill is fired up for hours. We skip the carnival and the parade and spend the day in the water.

When darkness sets in, we move to the deck, leaning on the railing in anticipation. Local fireworks are launched from a nearby park and we can see them from our backyard. The colors light up the night sky and reflect off the lake. The deep booms and short pops are magnified and echoed in the bowl of the lake. Only after our dog Marley lost her hearing in her later years could she finally relax during the show.

Who can resist the glory of fireworks? Those brilliant, loud, flashes of light mesmerize even the cynics. Scientists say we like them because they scare us. I say they are a part of our collective unconscious. They bring us back to a time we believed in magic. Even when experienced in a group, the experience is paradoxically internal and personal: fireworks stir up a sense of nostalgia, wonder, and possibility.

The Secret Killer in Your DNA

Who’s afraid of genetic testing? Pretty much everyone.

Just like there are people who unpack their suitcase at a hotel and others who don’t, there are people who want to know their genetic risks and people who don’t. I get that. Particularly when it comes to diseases which have no cure, like Dementia.

BRCA is different. 

WHAT IS THE BRCA GENE?

BRCA genes are tumor-suppressor genes that help repair damaged DNA. Both men and women carry it. A damaged BRCA gene can lead to an increased risk of certain cancers, particularly breast or ovarian in women. It can increase the risk of breast and prostate cancers in men also. One in 400 people in the general population carry a BRCA mutation. The number is one in 40 in the Jewish population.

WHO DISCOVERED IT?

The BRCA gene was discovered by Dr. Mary-Claire King. She is an American Cancer Society Professor of Genome Sciences and Medical Genetics. Her discovery of the BRCA gene has dramatically changed the field of genetics.

HOW DO I KNOW I HAVE IT?

You can talk to your physician who will collect blood or saliva for testing. 23andMe does include BRCA but at his time, it only tests for three BRCA variants, while there are over 1000. 23andMe also does not include genetic counseling, an important part of the process. Invitae, a company that provides genetic information and support as well, would be a good place to start.

WHAT IF I DON’T KNOW MY FAMILY HISTORY?

This would be a good time to ask relatives if you are unsure. Take the time to find out the cause of death of close relatives, if you can. I am missing some valuable genetic family history on my father’s side because of the Holocaust.

ISN’T THIS SOMETHING MY DOCTOR WILL TALK ABOUT?

Like sex, doctors don’t discuss genetic testing. According to Dr. King, only 19% of U.S. primary care physicians take a decent family history to assess for BRCA testing. In Israel the number is only 35%, even with the common knowledge of the increased risk of BRCA related breast and ovarian cancer in the Ashkenazi (Eastern European origin) Jewish population. Don’t wait for your doctor to bring it up, particularly if you have family history of breast or ovarian cancer. Too often testing is done only after a woman develops cancer.

WHEN SHOULD I GET TESTED?

Dr. King advocates for testing of all women around age 30. If you haven’t been tested, now is a good time. If you have been diagnosed with cancer, the results may change the course of action in the treatment.

WHAT IF I AM POSITIVE?

Breathe deep and know you have options. This is life-altering news but you are blessed with knowing and you have options. Choosing preventative surgery, like Angelina Jolie decreases your risk to nearly zero. Genetic counselors are expertly trained to support and guide.

FINAL THOUGHTS

If you know your BRCA status, you can be proactive and take steps to prevent deadly cancers. As Dr. King states, women do not benefit by practices that “protect” them from information regarding their own health.

None of this changes the fact that a healthy lifestyle and diet remain central to the enjoyment of life on earth. Illness can be random and beyond our control. But when it comes to BRCA, you may have an opportunity to dramatically reduce your risk before it is too late.

Special thanks to Laurie Nemzer, Genetic Counselor extraordinaire, and her colleagues at Kaiser Permanente for their oversight on this article. 

The Weekend

What are you up to this weekend? I’m laying low; I got no deeds to do, no promises to keep. Here are a few suggestions for reading and watching…have a good one!

If only I had the problem of big hair! This is a fun read about hair and identity.

How One Woman Refused to Let Anxiety And Anti-Semitism Define Her

I’ve been enjoying The Time of Our Lives on Amazon Prime Video. This very watchable Australian series tackles marriage, divorce, parenting, infidelity and adoption with sensitivity and keen insight.

I can easily recommend this book, before I have even finished it – Catch and Kill: Lies, Spies, and a Conspiracy to Protect Predators, Ronan Farrow’s new book. He recounts the Harvey Weinstein story and the Hollywood cover-ups with chilling detail. The mistreatment of women and the extent men are willing to go to silence them reaches far beyond the man and the victim – it is a team effort, in this case by NBC.

Ronan Farrow

Apples 🍎! After an afternoon of apple picking, I made applesauce mixing Macintosh, Gala, Fuji and Honeycrisp. I threw peeled and cored apples in the crock pot with juice from one lemon, a cinnamon stick and about a tablespoon of brown sugar and cooked 3-4 hours on high. That’s it! A few seconds of hand immersion blending created a smooth, bronze, creamy applesauce that tasted nothing like store-bought. Food porn at its finest.

My friend sent me this New Yorker article and I’d like to hear your thoughts . A long life is a gift. But will we really be grateful for it?

This past weekend the Kincaid fire couldn’t keep us away from a family wedding in The Sea Ranch, California. Quite the nauseating three hour drive from San Francisco but the place is special. A haunting, sparse, quiet place for celebrating love and healing along the craggy coast of the the pacific. Check it out.

Sunset at The Sea Ranch

Hula Hoops

Hula Hoops by Chuck Rogers

Why in the world would anyone posting their first post on their first blog write about Hula Hoops?

Because hula hoops are a metaphor. They represent what I write about in this blog.

Continue Reading

7 FOOLPROOF TIPS FOR FALL 2019

The days are shorter, the temperatures are dropping. This is a time of transition both mentally and physically. Some love it, others are less enthusiastic. Here are some tips to help all of us stay present in the moment and accept the changes in this astounding universe. Let’s start with the one everyone loves to hate…

1.Get a flu shot. Get a flu shot. Get a flu shot. I know, you’ve heard me say this before but I need to repeat. The flu makes you feel totally miserable. It can also kill you. Millennials, are you listening? If you want to hang out with the most interesting people on the planet like older adults, babies, sick people and pregnant women you better get the shot. There are no medically proven dangers. Don’t listen to the pseudoscience fear-mongers.

2. Start a Vitamin D supplement. Even if you are outside a lot, you are too covered up to absorb the rays of the sun. Low vitamin D is linked to seasonal affective disorder, muscle and bone loss and Type 2 diabetes. Starting in October, I take 5000 IU’s of D3 based on my doctor’s recommendation after a blood test.

3. Invest in cold weather gear. This does not have to be expensive – I got a packable down jackets from Costco- but go for quality. And they should look good. You want to be able to hike and then meet a friend for dinner and look as classy as ever without going home to change. Remember there is no such thing as bad weather, only bad gear!

4. Work on your mindset. Your body is highly adaptable, it’s your mind that is less flexible. The obsession with the weather here in Wisconsin is absolutely insane. If you expect five miserable cold months, that is exactly what you will get. Get psyched for cozy clothing, hot fires, and winter sports. Embrace the lovely quiet and stillness of the winter. Read and write more.

5. Work out at home. There are times when you just won’t be up for getting dressed and driving to the gym. That’s ok! This is an opportunity to get out of your exercise rut and try something different. Believe it or not, I’ve started hula hooping again. Hula hooped through halftime of last nights football game! Many of my readers are fans of Adriene. She has easy to follow yoga videos for all levels. The enviable Michelle Obama reveals her workout secrets in this article. Then there is RBG’s workout for the rest of us.

6. Ignore the carbohydrate cravings. They can be overwhelming. Start with a protein rich breakfast – avocado, cottage cheese, eggs, nuts. Winter vegetables are particularly rich in antioxidants and color. Squash, leeks, garlic, brussels sprouts, cauliflower, pumpkin and kale are filling when simply prepared and delicately seasoned. My homegrown cauliflower plants are just starting to bloom. Salmon and other fatty fish remain essential for the gut and skin. Hydration is harder to maintain but should be a habit by now.

7. Laughter, friends and healthy sex are the most festive ways to raise those serotonin and dopamine levels. This is a Love and Medicine four- season recommendation 💜.

Ask Dr. Annie K.: Pain

I’m 22 years old and haven’t had sex yet. I’ve had close encounters, but every time I try I experience a lot of pain. Actually any sort of penetration brings severe pain and discomfort (tampons, fingers etc). i’ve had a basic exam from my gynecologist who reports everything is healthy and normal down there. What can I do to finally have an enjoyable sex life?

Over 75% of women experience pain from vaginal penetration at some point in their lives. You are not alone. 12% have severe pain the first time having intercourse. Many women will benefit from you asking about this very important (and painful) topic. Thank you for not being afraid to ask – Dr. Annie K is here for you.

What you are describing is called primary dyspareunia, a.k.a. painful penetration. From your gynecologic exam (which I bet was painful) it sounds like there was nothing visible externally that would indicate an infection or some kind of skin problem.

So what could it be and what to do? When it comes to painful sex, it is never “all in your head.” There is always a cause.

When I hear women talk about pain from inserting a tampon or finger as you describe, my first thought is vaginismus. Vaginismus is is considered a vagina in panic. There is an involuntary tightening of the muscles around the vagina, usually in response to penetration, or even from expecting penetration. Some women describe it as a ripping feeling or a sharp burning pressure that can last for hours or days. Anxiety is common along with frustration.

Although it may sound unusual, the first treatment recommendation is physical therapy. There are therapists specifically trained in pelvic floor anatomy. The entrance to the vagina is through pelvic floor muscles – there is no way around them! The treatment has a very high success rate in women like you who are highly motivated.

When talking sex let’s not forget the basics.

When the time comes, be sure you are with a partner you feel close to. Communication with your partner can be a game changer when a women has pain. This is a medical problem – you are working on it and sex is a priority. This may even bring you closer as a couple.

Technique is important. Allow for adequate foreplay – that part is fun! Most women achieve orgasm by stimulation of the clitoris, not penetration. No medical therapy can make up for a sexual partner who doesn’t like to play.

Lubrication can help many women who have pain with sex. Inadequate lubrication happens. It is ok to use K-Y jelly or go natural and use organic coconut oil or saliva.

Women who have experienced trauma may have painful sex as it may trigger PTSD. Work with a therapist is crucial in solving those issues and being able to move on to have a fulfilling sex life.

Whatever your age, when you have sexual pain, it can affect your self-esteem. Know that it is treatable but may take time. Start with finding the right physical therapist.

Unfortunately the first time is rarely like it looks in the movies. But it gets better! You are on your way to a healthy sex life.

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