deeply rooted pain.

Most gynecologists will tell you that one of the most difficult patient encounters they will have in their clinic is someone with pelvic pain.   Pain comes in many forms and is different for every individual.  Sometimes pain is straightforward.  If I were to give you a generous throat punch (a hollow threat I often use) you will be able to precisely locate your pain and know its cause.  Some painful events are less straightforward.  Let’s say your img_4091appendix has decided to become inflamed, infected and will try to  rupture in an attempt to ruin your life.  That pain will usually start around your belly button before it moves to the lower right side of your belly which is home to the offending organ.  Pelvic pain is often like the latter.  It is difficult to find the cause and can present in a variety of different ways.

About 15% of women will experience chronic pelvic pain at least once in their lifetime.  Chronic pelvic pain is pain that lasts 6 months or more in duration.  It could be daily or constant pain or it could come and go inconsistently.  About 5 to 8% of women will struggle with chronic pelvic pain for a large portion of their life.  When I see patients who have pain in my clinic I remind them that I can list probably a dozen things that might be causing their pain.  Usually we can narrow down what we call the differential diagnosis (list of potential causes) to a few most likely causes or maybe even the exact reason for the pain.  In other circumstances we have no answer.  Nothing.  A list of maybes, a list of treatments, but no name, no diagnosis for the face that sits in front of us.

Most women with pelvic pain have endometriosis.  Endometriosis occurs in less than 10% of women but is the diagnosis for at least 70% of patients who present with pelvic pain. The American College of Obstetricians and Gynecologists state in their practice bulletin on the topic that “the clinical manifestations of endometriosis are variable and unpredictable in both presentation and course.”  No sentence could be more true.  Endometriosis is, to put it too simply, when the lining of the uterus is implanted inside the body, usually in the pelvis.  When visualized during surgery it can appear red, black, white, clear or even be difficult to see.  Harder than finding it is getting rid of it.  Many women with endometriosis have infertility from their disease.  We have few medications and surgery is often not curative.

Some other women with chronic pelvic pain have muscle spasms that are often long-standing and difficult to reverse. These women often have a difficult time being diagnosed and once they are, the road back to health is quite long.  Still others have gastrointestinal disease, inflammation of their bladder, scarring from previous surgery or pain caused by previous trauma or abuse.  Even depression and anxiety are known to cause pelvic pain. Can you have pain without a cause?  Sure.  Just like you can be sad and not know why or be upset and not exactly know what you are upset about.

If you know someone with pelvic pain, know their pain is real.  If you are someone who has been diagnosed with chronic pelvic pain, please know that your doctor wants to help you get better.  My best advice for you is to find a provider you trust; to know the road will be long and will require patience and strength; and to find someone who will support you on the journey back to health.

 

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the measure of success.

How do we measure success?

The Pastor and I were discussing the events of the last few months and upcoming events. Elections, the national title game, the end of the church year, the end of the calendar year, the NFL playoffs, the Super Bowl, the upcoming year.  Each of these events has many ways in which those involved can measure success.  For some, success is equal to winning.  For others, success is equal to just being present in something greater than yourself. Success can be measured on a personal level, a team level, a national level.  And not all those measurements will come up with the same answer in the same situation.  Let’s take employment, for example.  If the unemployment rate goes down then, on the national level, it will be counted as a success.  But, if you lost your job in that same timeframe and are yet to find new employment I am guessing you would not agree that there was major success in reducing unemployment.

 

In medicine we measure success in many ways. One of the most common ways is morbidity and mortality.  Morbidity refers to disease or worsening health and mortality refers to death.  We view morbidity as complications or poor outcomes related to disease or surgical or medical interventions. Mortality is easy to measure.  Did the patient live or die?

How does our own nation do?  When we look at comparable countries (those with total and per capital GDP rates above average in the last 10 years) we find that we have worse mortality rates for almost all diseases than in those other countries.  The US spends more on healthcare than any of these nations.  Why the difference? Some of it falls on the healthcare system itself.  We have issues that lead to difficulty in accessing healthcare; we have a complex system that contributes to cost, and for many Americans a significant portion of that cost will be spent in their last year of life.  But there are also social determinants that impact our health.  We have more obesity, a more sedentary lifestyle, and more disease caused by environmental factors.  When we evaluate morbidity, or disease burden, we see that despite having a lower rate of smoking and alcohol consumption, we have higher rates of lung cancer, alcoholic abuse and alcohol related liver disease than comparable countries.

Now those are all national statistics.  Measuring outcomes in a large scale view.  It is not the only way to measure success.  A patient might measure the success of their surgery based on when they are able to get back to their yoga class or weekly run and their surgeon might be measuring success based on the time it took to complete the surgery, or by minimizing blood loss or the patient’s hospital stay. Your primary care doctor may img_5778measure success by looking at vaccination rates, patient satisfaction, personal job satisfaction or seeing that long time patient achieve their weight loss goals or quit smoking.  Your OB might measure success by lowering their c-section rate, improving quality of life in the women they care for or when that patient who has long-suffered with infertility or pregnancy loss finally gives birth.

How will you measure success in 2017? Maybe you will set a personal goal for your health, your business, your family.  Maybe you will look at national data like the unemployment rate or what the Dow Jones does.  Maybe you will measure success by what your own state does for its own citizens.  Hopefully many of us will measure success in ways that are much less “measurable” but in ways that have much more meaning.  May we measure success by how we treat our neighbors, how much our children know that they are loved, by how the widow and orphan are cared for and by how we have given away from ourselves in 2017.

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but that’s my seat.

It was supposed to be a giant ice storm.  That’s what the ladies and gents on TV told us.  A large amount of ice and freezing rain was heading to the metro and we’d better prepare. So schools were closed, patients were moved up, generators were readied, salt and sand was placed on the roadways. Grocery stores were emptied of bread and milk and lots of other things this week in preparation for the ice.  If you actually needed bread and milk, because you were out at home, you were out of luck.  It was being gobbled up by anxious citizens bracing for the ice apocalypse. And then we waited…and waited…and waited.

We did eventually get some ice on the trees and a bit on the roads but it came about 24 hours after everyone predicted and wasn’t nearly as bad as anticipated.  Overall a good thing.  But times like these always make me realize how much we buy into the myth of scarcity.  There will be a disaster and not enough to go around.

So what are the other myths in our lives?  I’ll try to tackle some that I see on a not so infrequent basis.

  • “I did such and such method, (cry it out, shushing baby, swaddle, feed on demand, screen-shot-2016-10-03-at-8-39-30-ametc etc) and my baby was such a good such and such (sleeper, breastfeeder, transitioner).”  Reality check:  Babies do what they want.  We can try all the tricks in the book but some kids sleep well and some don’t.  Some are good eaters and some, who shall remain nameless, just jump up and down on their chair instead of eating during dinner time.
  • That spot in that public place you’ve claimed?  Well it doesn’t actually belong to you.  This happens at all sorts of places.  Someone takes “your seat” at church.  You are “saving” that piece of gym equipment while you use something else.  This is where you “always” park.  Reality check: None of those things are yours.  The church pew doesn’t belong to you no matter how many weeks in a row you’ve sat there.  That leg lift machine you’re saving is going to be used by me now, well, because you’re not actually using it. I get it.  We find security in routine. But I’ve only got so much time at the gym in the morning and you’re wasting it leg press saving guy.
  • “Someone else will do it.”  Giving the money, cleaning up the trash, standing up for injustice, speaking out when someone is doing harm.  Reality check: If you aren’t willing to do it, then why do you think someone else will?  None of us are really braver than you.  Either do stuff or don’t do stuff but don’t let yourself off the hook by assuming someone else will do it.  That someone else thinks you are already taking care of whatever it is.
  • Just because you can post something doesn’t mean you should.  Reality check: As first conceptualized by one of the church girls and then paraphrased by yours truly…”If you won’t say it to someone’s FACE then don’t post it on FACEBOOK.” img_3945 Seriously.  You don’t like someone’s opinions or beliefs?  That’s ok.  But it doesn’t mean you need to attempt to harm or discredit them.  I am almost 100 percent certain that no one’s mind or heart has ever been radically transformed by a hastily penned angry Facebook comment.  Trust me, it’s not easy.  I have about a thousand deleted comments that I thought were not only on point but witty and sharp.  They never made it to publication.  Why?  Because it just doesn’t help.
  • And finally “that’s just the way I am.”  The Pastor knows this is my least favorite myth that people live by.  Reality check:  You are never too old to change.  The person you were in 2016 does not define who you are in 2017.  The person you are today does not control the person you can be tomorrow.  And if you change something about yourself and you don’t like it?  Guess what?  Change again.  My favorite people in life are those who have lived enough and learned enough about themselves to know what to hold on to from each phase of life and what to let go.  That bad attitude you had all last year?  Don’t drag it along to 2017, let’s try something new.  Those hateful things you said?  Do better in the coming days and months.  Living your life as “that’s just the way I am” seems utterly disappointing and fairly sad to me.

There was no massive ice storm.  So maybe take that extra bread and milk and those extra hours at home and see if you can debunk any myths in your own life!  Here’s to living in reality and realizing you can make change in your own life in 2017!

 

women on lockdown.

In 2013 the Center for American Progress rated Oklahoma as one of the worst places to live for women. Why?  Well, in addition to our above average gender pay gap, ranking near the bottom for women in poverty, and the huge number of uninsured women, Oklahoma has more women in prison than any other state in America.

As a background, the United States imprisons more of its population than any other nation in the world.  In the last 20 years, the percent growth of female inmates was twice as much as male inmates.  So, as a country we have a trend.  When you look at my own state, Oklahoma, we have experienced exponential growth in female incarceration not screen-shot-2016-12-26-at-9-09-16-pmseen in any other state.  As of 2015, Oklahoma puts 127 of every 100,000 women behind bars.  Compare that to 63 of 100,000 as the national average.  From 2015 to 2016, the number of incarcerated women in Oklahoma increased by 9.5% while the number of incarcerated men decreased by 1%. This begs two questions from me: Why do we have so many women in prison? And then, are we any safer or better off with all these women behind bars?

First, at least 2/3 of the women in Oklahoma who are in prison have committed non-violent crimes. Many are incarcerated due to drug offenses, which up until recently carried serious jail or prison time due to Oklahoma laws.  There is no compelling evidence that we are any safer with a high female incarceration rate.  According to the our state Bureau of Investigation, violent crime in Oklahoma was up about 3.5% from 2013 to 2015, and non-violent crime was down by about 4.5% in that same time frame.  The overall violent crime rate in Oklahoma has decreased 7.3% in the last 10 years, while the rate of female incarceration doubled in the same time frame.

For the last couple of years I have given a lecture to our second year medical students on the state of women’s health in Oklahoma.  The good, the bad, the ugly.  I always touch on our incarceration rate.   Why?  Because our other state health indicators are major reasons why we incarcerate so many women.  1 in 25 women enters prison pregnant.  Over 2/3 of incarcerated women have a minor child. The consequences for these children are devastating.  Also, more than half of incarcerated women in our state have experienced domestic violence in adulthood and/or abuse in the home as a child. About 70% have been diagnosed with a mental health disorder.  Why does this matter? Because in 2013, our state ranked 46th (where 1st is best) in mental health expenditures per capita that were state funded.  picture1Most women in our state who enter prison live in poverty and have a lack of education. Again, we rate 40th out of 50 for number of women in poverty.  When women in Oklahoma are marginalized in health and economics, they are disproportionately more likely to end up in prison.  But is the news all bad? Fortunately, no.  In 2015, our state passed 2 bills that allowed reduced sentences for drug offenses and judges to deviate from mandatory minimum sentences.  Then, in 2016, the people of Oklahoma passed a state question that made certain drug and theft related offenses misdemeanors instead of felonies.  The money saved from the reclassification of these crimes will be used for rehabilitation programs, thanks to another state question supported by the voters in my state.  Tulsa County, along with the George Kaiser Family Foundation, have established a Women in Recovery program.  Since 2009, they have helped 475 women and over 1,000 children.  But we still have a long way to go.

Why should you care?  What can you do?  I think, no matter what state you live in, the rate and growth of female incarceration in our country should alarm you.  As a gynecologist I’m probably biased but I think we can measure the success of our nation by the success of its women.  If we can keep women out of prison their children are more likely to succeed in school and avoid drug abuse and addiction.  We should be advocating for increased mental health services in our states and in our nation; for reduction in the gender pay gap and other measures to reduce the number of women and families in poverty.  We should find ways to reduce domestic violence in our nation.  We should support efforts like the Women in Recovery program, and drug and mental health courts that focus on rehabilitation services.  No one knows this better than my sister-in-law, who also happens to be editor-in-chief of this blog.  She works in the drug court system.  She sees women as offenders every day in her home state of Missouri.  She knows it takes, sometimes, half a dozen times or more for offenders to find recovery.  She will be the first to tell you there are no easy fixes and no simple answers.  But I believe if we begin to change the idea that prison is the solution, then we can begin to create a culture where we focus on restoration and rehabilitation for our women.  I think we will all benefit. We have a shared brokenness.  We should share in the efforts of recovery.

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thanks a lot, 2016.

The Pastor has a funny way of having tempered expectations about things.  Let’s say we are going to see a movie.  (I mean, it might happen once a year or so.)  Even if everyone is RAVING about the movie, the Pastor will have his bar set for it to be about 3 *stars*.  That way, if a supposed 5 star movies is a technical disappointment, the Pastor only expected 3 stars.  In essence, he got what he expected.  No disappointment for him.  He expected 3 starts and got 3 stars.  Too bad the rest of us were looking for 5 stars.

It’s a pretty good strategy.  Lower those expectations and don’t be disappointed when the only funny parts are the ones they showed in the previews.  I feel like we should have done this for 2016.  We had big expectations for this year.  It was going to be great.  Interesting for sure. Lots of excitement.  And then we got, well, what we got.  A year of ups and downs. Surprises and disappointments.  There were unexpected events all around us.  Zika virus ruined vacations for lots of people I know and care for. In our house screen-shot-2016-09-26-at-12-17-45-pmwe mourned the announcement that Kevin Durant was breaking up with us and moving to California.  Famous and important figures died.  Lots of them.  Lots. The news was filled with violence in our own nation and violence, destruction and famine abroad. A gorilla got shot. I found out how government works and that most of us don’t really understand how government works. I had 5 star expectations of you  2016.

It’s easy to look back on a crazy unpredictable year like 2016 and only remember the chaos. To give it 2.5 stars and say “see ya!” To focus on the bad news, the mean tweets, the negative experiences.  Or, like some of my peeps on social media, to make sure everyone knows that your life had no interruptions, no disappointments in 2016.  To sugarcoat the year and move on with a “nothing to see here” attitude. Well friends, I don’t think we should subscribe to either practice.  As we move through life we will have ups and downs. Wonderful memories made and other times we’d rather forget about. My hope is that we look back on our year with a lens that allows us to learn from both our wins and our losses.  In that spirit, I give you my best lessons from life in 2016.

  • Life is better with people who care about you.  If 2016 has done anything for me, it has brought me some incredible friends.  Some are not new, I just spent enough time with them this year to really call them friend.  Most of them are quite different from me in career path, future goals, hobbies and interests.  But they are faithful and fierce.  I had someone comment to me upon seeing me out with friends for my birthday: “you have friends now?!”  In 2016 I made SPACE for other women in my life.  And I’m better for it.  They tolerate my crazy emotional loud self and they should be commended.
  • Busier is not better.  I have spent a lot of time filling my life with places to be and work to do.  The catch is that being busy doesn’t fill you up; it empties you out.  Here’s to a 2017 where I make time at home to sit and rest.  To say no to even some good things; to say yes to better things.
  • Why did the pig cross the road?  To get to the other lipstick.  This is a joke my 4 year old told me.  Like a hundred times.  And I laughed my face off every time.  It taught me two things.  To wear more lipstick, which I did in 2016 and it was good. And to cherish my kids more.  I swear they act crazy on Sunday mornings on purpose but they will only be small once and instead of looking for the days ahead, maybe it’s ok to enjoy today.  Even the math homework, the messy hands, the outfit choices.
  • You need more voices than your own.  This year I was thankful for Fr. Richard Rohr, Brené Brown, Tim Keller, Chimamanda Ngozi Adichie and many other writers who shared their knowledge and experiences with me.  And to audible for making my ‘reading’ happen on the way to and from the hospital.  I am thankful for my favorite podcasts like Hidden Brain, This American Life, and the Pastor’s friends who put out their sermons each week.  It is easy to listen to myself and believe that I am right.  If you know me, you are laughing right now because the only person who thinks they are more right than me is the 4 year old.  #amiright?  But seriously, we should never stop learning.  I hope in 2017 to read more and listen more to voices that will leave me for the better.
  • Use your voice for something more than complaining. I excel at complaining. If the strengths finder included snarky-ness I am pretty sure it would be in my Top 5. But as much as misery loves company, at some point having a dinner party with miserable people is, well, miserable.  My prayer in 2017 is to give more space and voice to the things that need them.  To shed light in the dark places that need attention from the world.  I am so grateful to all of you who have journeyed with me in this thing we call blogging.
  • And finally, 2017 will be what we make it. More celebrities will die. Hate and crime and violence will continue to be prevalent.  The economy will get better, or it will get worse.  Either more or less jobs will be created.  Our nation will get healthier, or it might not. People will continue to say things on social media they wouldn’t dare say to your face.  People will use filters and tell you their life is grand and great when it’s not.  You can spend 2017 being angry and bitter and anxious about the future or you can spend 2017 living in the reality that there is grace and mercy for all of us.  It won’t be easy to remember when 2017 hands you lemons. I’m sure I will have many moments of judgment, criticism, complaining and anxiety. But we have the power to extend grace and mercy to your friends, your family and even your enemy and your opposite.  And more than that, we can be gracious and merciful to ourselves. May 2017 bring more of God’s grace, peace, mercy and love into your lives friends!

 

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