You all have them, you can’t avoid them. Many factors contribute to a challenging patient including those that refuse your recommendations, have coexisting conditions/multitude of symptoms, have unreasonable expectations, and may even want to take over the role of healthcare provider.

Top 15 “Frustrating things patients say”

1. “Dr. Oz says”…
2. “Dr. Phil says…”
3. “I read on the internet that…”
4. HCP: “How’s your support system? Patient: I don’t know why, but no one wants to be around me”
5. “I don’t have an addictive personality”
6. “I have a high tolerance for pain medications”
7. “The pain clinic discharged me for no reason”
8. “Hold on, I have to answer my cell phone.”
9. “I’ve done a lot of research, plus my family and friends said they think I …”
10. “Is there a natural medicine for this?”
11. “Can you put me to sleep?”
12. “I’ve tried everything, and nothing works”
13. “I don’t eat anything, but I still gain weight…”
14. “Why am I always tired?”
15. “I just hurt… Where? All over.”

If you’ve experienced these patients… join the live conversation in one of our five fantastic locations for three days of education in the mornings, and relaxation in the afternoons. You will interact with and learn from top thought leaders in Women’s Health, Pain, and Diabetes and the difficult patients that accompany these diseases. These programs are not commercially supported, and there is a small tuition for the education.

If you are able (or unable) to attend, please leave a reply to this post and tell us the most frustrating thing your patients say and we will discuss these issues at our live events.

Note: Do not include any identifying information…
just generalized frustrating comments that impact your practice.

Here are some more frustrating things your patients say…

1. “Do you practice/believe in alternative medicine?”.  To which I reply, when you come to me office having traveled by alternative transportation and wearing alternative clothing….
2. ” I felt better so I stopped taking my (fill in the blank) medicine.”
3. ” I took my husband’s antibiotics for 2 days but I don’t think it was enough.”
4. “I know I need antibiotics because this phlegm is green and thick.”
5. “I need a refill on the heart medicine my other doctor gave me but I don’t know the name of it.”
6. “I stopped taking my medicine 2 months ago because they said on TV it can cause…”
7. “Can you write my wife a prescription for antibiotics too in case she gets sick?”
8. I left my other doctor……
9. I left my other doctor because he/she wouldn’t listen to me.
10. I am allergic to everything (presents a long list)
11. Can’t I just order it off of the internet?
12. I need a weight loss drug.
13. My other Doctor gave it to me, so…..
14. I went out of town and left my medication behind.
15. I dropped my medication into the toilet.
16. Which weight loss supplement is the best?
17. I only eat one meal a day.
18. I want to lose weight and I can’t, I can’t exercise because of (fill in the blank).
19. I have another appointment at 10 (pts appt with me was at 9:30)
20. I needed to see you, but YOU were on vacation.
21. I am tired, no I won’t stop my klonipin TID.
22. I need my Adderral in order to function at my job.
23. You should see my house when I don’t take my Adderral.
24. I tried my friend’s Adderral and it works for me.
25. My friend is on Adderral and does great, why can’t I have it too?
26. I am tired…….(I only sleep 4 hours at night).
27. I am tired……(I have 2 jobs, a husband and 2 kids)
28. I am tired……(I take klonipin, ambien, and lyrica)
29. I am sick, I couldn’t go to work today, but I have to work out tonight.
30. My child (with leg/arm pain) has soccer games this weekend and must play.
31. I need an antibiotic, I have to get back to work.I need an antibiotic, I am leaving on vacation tomorrow.
32. I need an antibiotic called in, I am leaving town in 2 hours.
33. I need an antibiotic, I need to nip this thing in the bud.
34. I need an antibiotic, I don’t want to pass this thing to anyone else.
35. “You just don’t understand my pain”
36. “I was having a lot more pain last month since I had (a fall/MVA/picked up something heavy…) so I ran out early, I need an early refill.” Even after being told and documented no early refills for any reason at prior visits.
37. Patient that is disabled and does not work “I don’t have time to do all that” (check blood sugar, walk or other exercise)
38. Patient doesn’t keep appointments then has a conniption fit at the front desk when I refuse to give refills.

Please post more! And join us at one of the five fantastic locations to continue the conversation!

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Updated Guidelines for Diagnosis and Management of Acute Otitis Media in Infants and Children

Acute otitis media (AOM) was the third most frequent diagnosis in ambulatory care for patients under age 15 in the most recent National Ambulatory Medical Care Survey  and is the most common cause of antibiotic prescriptions for infants and children.[1] The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have updated evidence-based guidelines for the diagnosis and management of uncomplicated AOM in children ages 6 months to 12 years.[2,3] I will attempt herein to summarize both the initial guideline published in 2004 and the current update. This summary will include the guideline’s assessment of quality of evidence and strength of conclusion, but will omit the supporting evidence reviewed by the guideline developers. Free full text of both is available online from the AAP containing summaries of the supporting evidence for each recommendation.

(http://pediatrics.aappublications.org/content/113/5/1451.full for the initial and http://pediatrics.aappublications.org/content/131/3/e964.full for the current update).

Here are the stated 2004 Recommendations:
1. To diagnose AOM the clinician should confirm a history of acute onset, identify signs of middle-ear effusion (MEE), and evaluate for the presence of signs and symptoms of middle-ear inflammation.
2. The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.
3A. Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.
3B. If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.
4. If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent.
5. Clinicians should encourage the prevention of AOM through reduction of risk factors.
6. No recommendations for complementary and alternative medicine (CAM) for treatment of AOM are made based on limited and controversial data.
The current update to the guidelines contain the following “key action statements” which correlate to the previous recommendations:

I think it is noteworthy to mention some of the recommendations of the initial guideline, notably an option of “watchful waiting” while withholding antibiotics, has not been embraced by the practitioner community and remains unchanged. [4] I believe it is not that we do not appreciate the risks of prescribing unnecessary antibacterials or that we are unwilling to share informed decision-making with the parents and caretakers of our pediatric patients, but rather the burden of additional time and visits for the patients, families, as well as the healthcare system is substantial for a condition in which precise diagnosis by identification of bacterial antigens in the middle ear fluid is impractical in a primary care setting. The option of “observation with close follow-up” increases the possibility of error of omission of necessary observations and actions by a complex triad involving patients, caregivers, and clinicians. The existing healthcare system challenges coordinated communication even in the best of circumstances. If a toddler is holding his ear in day care, but is afebrile because he was prescribed acetaminophen or ibuprofen for otalgia the night before, will that information get processed into a decision process to trigger a re-evaluation?
Applying the revised guideline which requires proof of middle ear effusion (MEE) for diagnosis increases the necessity for additional diagnostic testing with associated time and expense.  Pneumatic otoscopy is a clinical procedure challenging to perform even in a cooperative patient. Tympanometry, even when available, is not reliable as an independent assessment of middle ear disease and must be combined with the clinical assessment. [5] Tympanometric systems cost over $2000, testing is often not reimbursed by third party payers, and importing the data into electronic records systems is not easy.

The recommendation to initiate antimicrobial therapy with amoxicillin (80–90 mg/ kg per day in 2 divided doses) unless contraindicated, remains in the revised guidelines.  Although I hear complaints from parents who claim “it never works in my child” and presentations from pharmaceutical manufacturers encouraging me to prescribe their branded products, I am comfortable with this practice. I believe this recommendation is based on evidence derived from sufficient microbiological studies including studies of the effect of the recent adoption of infant immunization with polyvalent pneumococcal conjugate vaccine (PCV). I find flavored amoxicillin chewable tablets are appreciated by those children who can use them and avert substantial inconvenience in transporting refrigerated suspensions in our highly mobile society.

The updated guidelines also have specific recommendations for initial treatment failure and a recommendation against antimicrobial prophylaxis to prevent episodes of recurrent otitis media.

Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA

Published on May 7, 2013

Biosketch
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975. He completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. He was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences. He maintains certification by the American Board of Family Medicine and has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.

References

1. National Ambulatory Medical Care Survey. Top 5 diagnoses at visits to office-based physicians and hospital outpatient departments by patient age and sex: United States, 2008.  http://www.cdc.gov/nchs/ahcd/web_tables.htm
2. Lieberthal AS, Carroll AE, Chonmaitree T, et al.  The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964-999.
3. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004 May;113(5):1451-1465.
4. Coco A, Vernacchio L, Horst M, Anderson A.. Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics. 2010 Feb;125(2):214–220.
5. Onusko E. Tympanometry. Am Fam Physician. 2004 Nov 1;70(9):1713-1720.

I think it is noteworthy to mention some of the recommendations of the initial guideline, notably an option of “watchful waiting” while withholding antibiotics, has not been embraced by the practitioner community and remains unchanged. [4] I believe it is not that we do not appreciate the risks of prescribing unnecessary antibacterials or that we are unwilling to share informed decision-making with the parents and caretakers of our pediatric patients, but rather the burden of additional time and visits for the patients, families, as well as the healthcare system is substantial for a condition in which precise diagnosis by identification of bacterial antigens in the middle ear fluid is impractical in a primary care setting. The option of “observation with close follow-up” increases the possibility of error of omission of necessary observations and actions by a complex triad involving patients, caregivers, and clinicians. The existing healthcare system challenges coordinated communication even in the best of circumstances. If a toddler is holding his ear in day care, but is afebrile because he was prescribed acetaminophen or ibuprofen for otalgia the night before, will that information get processed into a decision process to trigger a re-evaluation?
Applying the revised guideline which requires proof of middle ear effusion (MEE) for diagnosis increases the necessity for additional diagnostic testing with associated time and expense.  Pneumatic otoscopy is a clinical procedure challenging to perform even in a cooperative patient. Tympanometry, even when available, is not reliable as an independent assessment of middle ear disease and must be combined with the clinical assessment. [5] Tympanometric systems cost over $2000, testing is often not reimbursed by third party payers, and importing the data into electronic records systems is not easy.

The recommendation to initiate antimicrobial therapy with amoxicillin (80–90 mg/ kg per day in 2 divided doses) unless contraindicated, remains in the revised guidelines.  Although I hear complaints from parents who claim “it never works in my child” and presentations from pharmaceutical manufacturers encouraging me to prescribe their branded products, I am comfortable with this practice. I believe this recommendation is based on evidence derived from sufficient microbiological studies including studies of the effect of the recent adoption of infant immunization with polyvalent pneumococcal conjugate vaccine (PCV). I find flavored amoxicillin chewable tablets are appreciated by those children who can use them and avert substantial inconvenience in transporting refrigerated suspensions in our highly mobile society.

The updated guidelines also have specific recommendations for initial treatment failure and a recommendation against antimicrobial prophylaxis to prevent episodes of recurrent otitis media.

You are What You Eat

“You are what you eat” is an adage that is supported by research. Eating healthy foods can lead to a healthier body, while not having such foods can lead to problems such as nutrient and vitamin deficiencies, unintended weight loss, or obesity. In the elderly population, nutritional issues are of particular importance, as the aging body becomes more susceptible to chronic and acute disease states.

The Aging Body: As people age, the sphincter tension and contraction strength of the esophagus is diminished and the stomach mucosa can become more prone to damage (particularly as certain diseases that lower gastric acid secretion are more likely to occur). With the decrease in the elasticity of the stomach, there is a reduction in storage capacity and a delay in gastric emptying. This may result in a prolonged sensation of satiety. Changes in the small intestine can include a reduction of nutrient absorption, due to bacterial overgrowth, as well as intolerance of lactose, related to a decrease in lactase enzymes. Changes within the large intestine include a slight decrease in peristaltic movement and a slight enlargement of the rectal vault with a diminished ability for it to contract when filled with fecal matter.[1]  Additionally, the liver loses some metabolic capacity, while the ability to produce bile and its flow is reduced, as well. [2]  Although all of these changes can occur as the body ages, in an otherwise healthy body, the gastrointestinal system’s reserves will still function at near normal capacity. [1]

Pathophysiology: Pathophysiology has a profound impact on the nutritional status of a geriatric person. There are multiple disease states, common among the elderly, which can affect their ability to properly utilize the nutrients they consume. Some of these diseases are a result of genetics or changes in body physiology, whereas others are consequence of other disease. For example, changes in mucosal cells of the stomach and large intestine can lead to disease states such as colorectal and stomach cancer. [3] In diverticulosis, intestinal wall weakness creates pouches that can become sources of inflammation and infection. [4] Crohn’s disease and ulcerative colitis are both related to genetic predisposition and autoimmune compromise. In these disease states, inflammation occurs, creating pain, ulceration, and diarrhea, which often lead to complications of malabsorption and dehydration. [5,6] On the other hand, dyspnea, as experienced in chronic obstructive pulmonary disease, can lead to fatigue and loss of appetite, which in turn can lead to malnutrition. [7] Additionally, diseases such as severe arthritis, Parkinson’s, stroke, dementia, and depression can predispose older people to malnutrition as these problems can affect their ability to obtain and/or prepare food. [8]

Medication side effects: Diuretics, antacids, statins, antihypertensives, antibiotics, antidepressants, steroids, anti-glucose, and non-steroidal anti-inflammatory meds are just a sampling of drug categories that induce gastrointestinal upset, reduce saliva production, diminish the sensations of taste or smell [9] or decrease the body’s ability to adequately absorb nutrients. [10]

Limited resources: Seniors living with mobility, physical, or mental disabilities often are unable to shop for and prepare healthy foods independently. They may not have people available to assist in performing these tasks for them. Lack of access to the store and limited budgets to purchase healthier food also create other impediments to eating healthily. Those with dentition problems, who cannot afford dental services or appliances, may have trouble in chewing and swallowing their food adequately. Risk of choking can be a fear for them. Elderly who live by themselves may skip meals due to feelings of loneliness or not wanting the bother of cooking just for themselves. Additionally, those who are institutionalized oftentimes do not have control over the meal choices or the environment in which they must eat. For instance, lack of time to eat or lack of feeding assistance, unpalatable food presentation, and foods that do not address their cultural or dietary needs present such obstacles to nutritious eating. [11]

Lack of knowledge: Food falls within three nutritional categories: carbohydrates (complex, simple, and starches), proteins, and fats (monounsaturated, polyunsaturated, saturated, and trans fats). Foods within these categories can be further subdivided into five foods groups. [12]

Complex carbohydrates, that include starches and fiber, take longer for the body to digest thereby prolonging satiation. These are found in breads, cereal, grains and pasta. Whole grain, B-12 (at least 2.4 mcg/d) fortified, and folic acid (400 mcg/d) enriched products are the best choices, as these help nerves cells to function well, help produce red blood cells, reduce inflammatory homocysteine levels, and provide fiber to combat constipation. Six or more servings of these are recommended for people aged seventy and older and at least 20 grams of fiber, everyday. Fruit and vegetables are also complex carbohydrates and starches. The best choices within this group include those with the most vivid colorings of green, yellow, red, and orange, as they contain higher amounts of vitamins such as  C and A, as well as antioxidants. Fruit juices should be consumed in limited quantities due to their high sugar content. Canned vegetables are fine to eat, but those with lower sodium are most preferable. Three or more servings of vegetables and two or more servings of fruit each day are recommended for people over age seventy. Simple or refined carbohydrates, on the other hand, should be avoided or eaten minimally, as they have low nutritional value. Foods within this group include sweets, white rice and white flour. [13]

Proteins consist of a variety of food groups. Wise dairy product choices include low fat milk, cheeses, and yogurt which are rich sources of calcium (1200-1400 mg/d recommended) and Vitamin D (600 mg/d recommended). Elderly people should have three servings of these foods daily. Also, poultry, lean meats such as pork or T-bone steak, fish such as salmon or mackerel, and eggs are excellent protein sources. Legumes such as kidney beans, soy, and lima beans, and nuts such as almonds and walnuts are as well. [14] Those 70 or older are encouraged to have at least two or more servings of these foods every day. [13]

Fats can be further divided into saturated and unsaturated. The mono and poly unsaturated fats help the body by reducing blood cholesterol levels, cardiovascular disease risk, and increasing brain cell function.  These foods include avocados; olive, vegetable, and canola oils; and fish and fish oils (omega-3 fatty acids). These oils remain in liquid form whether in the refrigerator or at room temperature. Trans and saturated fats, on the other hand, are bad for body’s health since they lower good HDL cholesterol, increase bad LDL cholesterol, and increase cardiovascular disease risk. These foods include butter, animal fats, peanut oil, and coconut oil, which solidifies when, cool. [15]  The elderly, however, should eat all fats, sparingly. [13]

By following these serving size and food suggestions, the elderly who consume at least 1200 to 1600 kilocalories daily, will receive 100% of their daily recommended nutrient and protein allowances. Daily fluid intake of at least eight glasses of water (two quarts) is recommended to prevent dehydration and constipation. [13] Additionally, in healthier older people, consuming 30 kilocalories for each kilogram of body weight (consisting of 30% or less of fat calories and 0.8 to 1.0 gram of protein per kilogram each day), their daily recommended kilocalories can be achieved.  Of course, calorie and fluid requirements will differ in those who are ill, already fluid overloaded, or malnourished, and should be adjusted and monitored accordingly. [16]

In my practice, a female patient came to see me with her sister, who was concerned with the patient’s weight loss.  The patient had been widowed two years prior and had problems with depression and insomnia. The patient used to enjoy cooking for her family, but after her husband’s passing, she did not enjoy cooking and would even skip meals stating she “just wasn’t hungry.” The patient was also on a fixed income and did not drive, so she did not often venture out to the grocery store.  The patient had atrophic gastritis for which she was on an H2-blocker, as well as hypertension for which she was on a diuretic and an ACE inhibitor.  After a history and physical with bloodwork was completed, it was determined that the patient was also B-12 deficient for which Cobalamin supplementation was added. Also, mirtazapine (Remeron) was added to help to combat both the depression and insomnia, which would enhance her ability to take better care of herself. I spoke with the sister about healthy food choices and hydration for this patient. She agreed to purchase these foods for her sister each week when she did her own grocery shopping. She even agreed to the idea of cooking several dishes her sister would enjoy and place them into small one-serving containers that her sister could microwave and eat. She purchased healthy snacks such as cheese sticks, baby carrots, and fruit. Additionally, she kept a pitcher of lemonade and bottled water in the fridge to remind her sister to drink her fluids. With the help of a social worker, Meals on Wheels provided meals whenever her sister was unavailable.

Within one year, and with med dose adjustments, the patient’s mood improved and she felt that she had more energy. She had almost returned to her normal weight and began going to the grocery store with her sister. She also developed a friendship with a woman at church who transported her to a senior center for socialization, outings, and even daily lunch!  She participated regularly and slowly began to enjoy life again.

Nutrition in the elderly can be a challenge, as their needs can vary according to their state of health. With careful evaluation of their situations and assistance from resources such as area agencies on aging and social work, geriatric people have a better chance of receiving the help they may need to eat more nutritiously. Also, having a better understanding of the types of food available for consumption and how they can affect the body, older people can make wiser food selections and enjoy what they eat. Bon appétit!

Karen Digby, GNP-BC
Chair of Family Medicine, Northside Hospital
Atlanta, GA
Published on April 23, 2013

Biosketch
Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, assist living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

1.    Shaheen NJ. Affects of aging on the digestive system. The Merck Manual Home Health Handbook.  August 2006.
2.    Cohen S. Effects of aging on the liver. The Merck Manual Home Health Handbook. July 2006.
3.    Salles N. Basic mechanisms of the aging gastrointestinal tract. Dig Dis. 2007; 25: 112-117.
4.    Mayo Clinic. Diverticulitis. http://www.mayoclinic.com/health/diverticulitis/
5.    Mayo Clinic. Crohn’s disease. http://www.mayoclinic.com/health/crohns-disease/DS00104
6.    Mayo Clinic. Ulcerative colitits. http://www.mayoclinic.com/health/ulcerative-colitis/DS00598
7.    American Dietetic Association, Dietitians of Canada. Manual of Clinical Dietetics, 6th edition. Chicago: American Dietetic Association; 2000.
8.    Hickson M. Malnutrition and aging. Postgrad Med J. 2006; January; 82(963): 2-8.
9.    Bromley SM. Smell and taste disorders: a primary care approach. Am Fam Physician. 2000; Jan 15;61(2):427-436.
10.   Dunn J. Pharmaceutical malnutrition: the downside of drugs. Dr. Dunn’s Natural Health News. July 2007. http://www.drjondunn.com/Newsletters/2007-07DownsideofDrugs.html
11.    Hickson M. Malnutrition and aging. Postgrad Med J. 2006; January; 82(963): 2–8.
12.    CDC. Nutrition for everyone: Food groups. http://www.cdc.gov/nutrition/everyone/basics/foodgroups.html
13.    Russell RM, Rasmussen H, Lichenstein AH. Modified food guide pyramid for people over seventy years of age. J Nutr. March 1, 1999; Vol. 129; 3: 751-753.
14.    CDC. Nutrition for everyone: Nutrition basics. http://www.cdc.gov/nutrition/everyone/basics/protein.html
15.    American Hearth Association. Fats and Oils: AHA Recommendation. http://www.heart.org/HEARTORG/GettingHealthy/Fats and Oils/Fats101
16.    DiMaria-Ghalili RA. Nutrition in the elderly. July 2012. http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more

Interview with Susan Hutchinson, MD, author of “The Woman’s Guide to Managing Migraine: Understanding the Hormone Connection to find Hope and Wellness”.

Dr. Able Interview

Dr. Able: “This is Dr. Able introducing and talking to Dr. Susan Hutchinson, who is a board certified family physician with a sub-specialty in headache. She just wrote a very good book called “The Woman’s Guide to Managing Migraine: Understanding the Hormone Connection to find Hope and Wellness”. Susan, thank you so much for agreeing to this interview.”

Dr. Susan Hutchinson: “You’re welcome, it’s a pleasure to be with you.”

Dr. Able: “Tell me, what motivated you to write this book?”

Susan: “Well, what I was finding is over the years and focusing on headache patients in my practice, there seemed to be, on the one hand neurologists who these headache patients were being referred to and often the women would point out to the neurologist if there was a hormonal connection to their migraines and the neurologist would say, “ Well, I don’t do anything with hormones, go back to the gynecologist or your primary care physician.” The patient would then go back to the gynecologist who said “I don’t know anything about migraine.” And so there seemed to be a need to bridge that gap in that for many women, in fact about 60% of women migraineurs there is a hormonal connection to their migraines and specifically there appears to be a worsening of the migraines around their menstrual period and in some cases ovulation and this was a need that I think needed to be addressed. And so part of the reason for the book was to empower women with the information that they could then use and take to either the neurologist  or their primary care physician or their gynecologist and say “Look, I was reading about these things. Could we try some of these things?” Because I think, medical practices today often there is such a scarcity of time and often patients are being booked every 15 minutes. So the idea was to give women migraine sufferers the information they need and then hopefully that can open up dialogue with their physicians and help ultimately create in better care for them and less burden of the migraines in their lives.”

Dr. Able: “Well Susan, how is it that you know this connection and these neurologists and obstetricians and gynecologists do not?”

Susan: “Well, I think it is my background and training which is why I felt it was important to bring this book to market and specifically I am board certified in Family Medicine, starting practice in 1985, but very quickly for me and I think this is true for many women primary care physicians, we very quickly do a lot of gynecology and women’s health in our practice. For example, there are many women and I’m sure that this is true all across the country, if they are a woman family physician and then they are in a practice with male family physicians, women naturally gravitate towards the women providers for their gynecological care. And I think for their care in general, you know things like birth control and talking about your periods, I think women also are more comfortable opening up to women when it has to do with thinks like depression,  complaints about fibromyalgia, I think they feel their complaints are less likely to be dismissed. So, I already had a lot of women’s health background and I was actually recruited to join a large women’s OBGYN group in Irvine in Orange County and so for eight years I became part of a large women’s healthcare group and our goal was complete, comprehensive care for female patients.  So that a woman could come to see us for all of their needs and within that practice I was allowed to start a headache and mood focus to my practice, but in a sense, I had a practice within a practice. And I felt there was a real need there in that not just neurologists were referring to me since they didn’t want to do anything with hormones, but also even within the group I was in, the OBGYN’s were referring to me, the internal medicine. So I began very passionate to try to take care this group of women, if you will, that had migraines that often, these migraines were complicated by hormonal issues and other comorbid conditions such as depression.”

Dr. Able: “What’s the take-away message for a woman reader?”

Susan: “Oh, yes, no, I try to be extremely practical and for example, my approach to menstrual migraine is carefully outlined in the book and I’ve already had feedback from the book as I do put my email on the book and I would like for your feedback and already women are telling me “Based on your book, I’m going to the store and getting this herbal supplement or I’m doing this.” And in a nutshell, there’s a lot more detail in the book, but I look at specific hormonal regimens that I think can be helpful and this is not just based on my experience, this is actually based on clinical studies. And then I also talk about the role of herbal prevention including magnesium for prevention of menstrual migraine, I talk about where nonsteroidals such as Aleve or Motrin might fit in. I talk about traditional preventives, so I think there is extremely specific information that that woman patient can then put into practice. Some of the things she can do don’t require a prescription or even a visit to her doctor. But some of them then at least can open up at least specific dialogue and hopefully lead toward better more effective medical management. “

Dr. Able: “Well, I can see how that would empower a woman, that she could do something on her own and see how it works and then go back to her doctor and discuss it”.

Susan: “Yes, and I think that’s again, that’s why I wrote the book because many women, they might be in small rural communities all across the country where there isn’t even such a thing such as a headache specialist. And so, this can give them the information hopefully to work with their gynecologist and or their primary care physician and perhaps not even need to see a neurologist for management of their menstrual migraines.”

Dr. Able: “So now, even if you’re not a woman who suffers from menstrual migraine would this be a benefit to other people?”

Susan: “Yes, I think it can be a benefit in several ways. One is that there is a lot of specific information about treatment of migraine in general, what causes migraine, because we know from studies patients don’t just want medications for their migraines. They want to know what causes them, “What can I do to avoid them? Why do I have them?” So even for a woman headache sufferer who either doesn’t know if her headaches are migraine or she doesn’t really think there is a hormonal connection, I think it still could be very helpful. An in addition, I tried to include information that  I think would be helpful for the non-migraine family member, the co-worker because certainly migraine cuts across the effect of not just the patient, but it could affect the dynamics of the family, the work situation and I think often co-workers or family members. They’re perplexed because they don’t quite understand the disability that’s associated with migraine and for example they often say “it’s just a headache, get over it.” So I think this can also empower and give information to people that are affected by those that have migraines.”

Dr. Able: “So many times headache is considered part of PMS and it’s just dismissed. Do you have a section on that?”

Susan: ”Yes, I do, and I think I made it clear in my book that headache is not just part of PMS and I was certainly affected by that thinking years ago and I can remember countless times women would come in to see me and I would be doing their annual PAPS smear also known as the Well Women Exam and they would start telling me about these bad headaches with their periods. And I would look back at the original history forms and they never even marked the box that said “headache” and I said why did you never even tell me about these before? And they said” Well I thought there was nothing I could do for them. I thought it was a burden I just had to accept.” And I’ve actually had patients tell me that their male gynecologist said “You know, Honey, it’s just a headache, get over it.” So I think for years women have been taught that yes, headache is just part of the whole PMS set of symptoms. But now we know that migraine is completely separate from that and for most women if they get a predictable headache with their period, almost 100% of the time, that would be menstrual migraine and that needs to be looked at and treated separately than PMS.

Dr. Able: “I understand too, that you’re going to do some programs called Destination CME with Primary Care Network. Could you explain what your role in that is?”

Susan: “I’ve actually been a speaker for Primary Care Network for a number of years and they’re known for putting on very high quality, interactive engaging programs for Primary Care. But, this is going to be different because it is going to be much more focused on those difficult, challenging, complicated patients in our practice and these are going to be located in destination areas. I know one of the locations is Hilton Head, for example, another one is Captiva Island, Florida and this is designed for providers that really want to go beneath the surface and try to get very practical information on how to treat these challenging patients in our practice and it’s not pharmaceutically sponsored. And what’s really  unique about this is there is only going to be three of us that are speakers or presenters and we really want to encourage participants to come with case studies, come with questions. We’ll be breaking into workshops and I know for me when I look at my schedule, there’s a small percentage of my patients that creates most of the problems for myself and my staff. And a typical patient comes to mind that perhaps comes in and yes, they have migraines, but they have fibromyalgia, they have depression, they may have issues going on in their home and sometimes they come in and they just have that depressed look and you feel nothing you can do helps them. And it’s those kind of patients that really, I don’t know the exact statistics, but I would say that probably for many of us, probably 3-5% of our practice, you know,  brings us 95% of our problems. And so, I think that’s what we want to do in this, is really focus on those difficult, challenging, complicated patients in this on a very interactive format.

Dr. Able: “So you do have answers so that people like that can be helped?”

Susan: “Oh, I think so, I think that those of us that are presenters, the three of us, we have a lot of experience with this type of patient and yes, we may not have a miracle cure, but I think that we can work with the participants and engage together and say “You know, what’s the best way to approach these patients? “ Particularly when you’ve got all these different conditions and we’ve got a lot of psychological issues going on along with the more straightforward medical issues and some of the topics we’re going to cover would be Migraine Headaches, Diabetes, Drug Addiction, patients that are narcotic seeking, how do you deal with them? And again, many of these patients having comorbid conditions, so they don’t just come in with one condition and how do we work with these kind of patients in an effective way, particularly in a busy primary care setting?”

Medical Ethics: Is the Price Right?

Over the years as a practicing primary care physician, I have witnessed ethical dilemmas that remind me of the long-running, popular TV show, THE PRICE IS RIGHT. But unlike the show, the price one pays for medical care encompasses not only money, but issues of quality of life, unintended consequences, and possibly life itself. Options and decisions are not always black or white and the person or group tasked to render best practices advice does so from a complex of diverse educational and cultural backgrounds.
The following are real cases that highlight questionable medical practices with respect to ethics, proper oversight, credentialing and licensing. Even though the majority of clinicians deliver health care ethically, deeply caring for their patients, there are some who do not. In these cases, the lay public too has responsibilities. As Jay Leno once said, “If you trust Google more than your doctor, it’s time to get a new doctor.”

CASE ONE:
An 83-year old married, Caucasian male with no children has noticed problems with intellectual processes (thinking, reasoning, remembering). He and his slightly younger wife of over fifty years attribute the changes to “getting older.” He still drives short distances, eats without help, and takes care of his personal hygiene and grooming. He usually takes a morning walk around his neighborhood retirement community, with or without his wife. One morning he was walking alone, passed out, and hit the side of his face and head. Golfers in the area called 911 and an ambulance arrived within minutes to transport him to the emergency room of the nearest hospital. Luckily, he had his wallet with identification. His wife was notified and she immediately went to the hospital ER.
The emergency room evaluation revealed an elderly man with a badly bruised face, no recollection of his name, date, transport or location. He recognized his wife when she arrived. His injury was diagnosed as a concussion and he was admitted to the hospital. Because the couple did not have a family physician, the hospital assigned several physicians: an internist, a general surgeon, a neurosurgeon, and a cardiologist. They ordered multiple laboratory tests, a total body CT looking for trauma, and two MRI’s. The cardiologist ordered daily EKGs. He submitted bills to Medicare and their secondary insurance but never talked to the wife. The internist told the wife that he placed her husband on an ACE inhibitor and diuretic for blood pressure control. He also left an order for sleep medication if needed. The general surgeon exited from the case after concluding that his services were no longer needed.
The wife called me, as a family friend, on the third hospital day. She told me what had happened to her husband and was particularly upset about two things: 1) Her husband was still confused about his surroundings and had no recollection of his fall or the transport to the hospital; and 2) The neurosurgeon had made a diagnosis of “normal pressure hydrocephalus” and recommended an immediate shunt operation. I told the wife that a diagnosis of “normal pressure hydrocephalus” was, to me, an oxymoronic conclusion; i.e. if the pressure is normal, why put a tube in to relieve excess pressure that doesn’t exist? I also checked with various specialty colleagues and came away with the same conclusion; a shunt was not needed. The most likely diagnosis was a concussion that would most likely improve over time. Once the wife refused permission for neurosurgery, the social worker suggested that her husband be transferred to the “acute rehabilitation service.” She was told that Medicare covered him for two weeks, after which he would be eligible for possibly 180 days of “chronic rehabilitation care,” depending on his progress. After further discussion with the social workers, the wife found out that she could sign her husband out of the hospital and have Medicare cover home rehabilitation and nursing care for several weeks. Even though I advised that her husband extend his stay in the hospital for a few days, she opted to take him home right away. She was very disappointed with her assigned physicians’ lack of attention to her husband and communications with her.

After the third day at home, the therapist arrived for the usual morning workout. She took the patient’s pulse and told the wife she would have to skip that morning’s therapy because his pulse was down to 40 beats per minute. The wife called me and I made an immediate appointment for him with a cardiologist friend of mine. He needed a pacemaker. The cardiologist explained to the wife that an irregular heart rate probably caused him to blackout during his walk. His blood medication was discontinued because of unpleasant side effects.

It has been three years and he is doing well; not perfect, but well. He needs assistance with bathing and help in getting his clothes on. He feeds himself. He discarded his walker after the first 4 months post pacemaker and he accompanies his wife on errands about town.

What is your evaluation of this scenario?

1. Did the medical attention given to this patient and communication with the wife meet acceptable standards?

Yes        No

1. What about the neurosurgeon’s diagnosis and recommendation for a shunt?

• An error in judgment?    Yes        No
• Outright medical malpractice?    Yes        No
• Too busy, tired, or preoccupied?     Yes        No
  Should the wife have asked about the average number of shunts he had implanted compared to local and/or national data bases?    Yes        No

3. Why didn’t the hospital cardiologist or the internist diagnose the need for a pacemaker?

• An honest medical error?    Yes        No
• Inadequate attention to test results?    Yes        No

4. As this woman’s primary care physician, would you have reported this incident to the hospital’s ethics board?

Yes        No

Please explain your answers.

CASE TWO:
An 80-year-old Caucasian lady living alone with a black German Shepherd in a small retirement community developed generalized abdominal discomfort with mild nausea on a Monday. Her personal and family history contained no significant disease condition. She belonged to a medical plan that required that she see a physician in their directory.
When this woman called the physician ‘s office on that Monday, the office staff listened to her complaint and advised her over the phone about drinking fluids, using Tylenol for pain, and resting. She called every day saying it was getting worse. She never spoke with the physician. By Friday she was throwing up, had severe diffuse abdominal pain, a temperature of 102, and could barely get out of bed. The staff advised to come in for an appointment that afternoon. The physician (according to the patient) did a very cursory examination and told her that she had diverticulitis. He prescribed an antibiotic and sent her home. She passed out at home. When she regained consciousness, she called 911. The ambulance took her to the nearest hospital where she was diagnosed as having diverticulitis with a perforated bowel. The surgeon did an emergency laparotomy with bowel resection, temporary colostomy, drainage, antibiotics and intravenous fluids. She did survive. After approximately six months, her surgeon admitted her to the hospital to reconnect the remaining bowel and do away with the colostomy. She developed a staphylococcus methicillin resistant infection, which led to increased morbidity, need for mesh reinforcement of the abdominal wall, and expenses not covered for outpatient perfusionists and very expensive antibiotics.
This patient had been an executive secretary in earlier life. She was computer savvy and very meticulous with keeping records. She had hospital records, ambulance records, doctor’s office records, prescription records and outpatient consult records. I looked at her copies of office records from her visits to an infectious disease expert. His records clearly stated, in his words, “hospital acquired staph resistant infection.” The preponderance of evidence leaves no other choice as to the origin of the infection; you go into the hospital fine and come out with an infection. The hospital, of course came up with other scenarios.
I became aware of this case through a series of award winning articles about hospital mishaps and I offered to look into the details to see if I could help this woman get monetary justice. The damage had already been done. She had written to the State Board of Medical Examiners. Their decision was, ”there was no evidence of malpractice.” She tried to find an attorney with no success. By the time I got  involved, the statute of limitations had expired. Of eight attorneys I called, one advised, “If the patient has sufficient money and longevity, she could find an attorney to take her case. Her chances of setting a precedent relative to the statute of limitations, based on mitigating circumstances, were next to none, but she could try.”
What do you think of this case?

1. Why didn’t the primary care physician diagnose the perforated bowel?
   • An honest medical error?    Yes        No
   • Inadequate attention to the physical exam?    Yes        No
   • Failure to order lab or other tests?    Yes        No
2. Should the surgeon or the hospital we held accountable for the infection and subsequent complications?
   • Surgeon
   • Hospital
   • Neither
3. If she were your patient, would you advise her to report this problem to her medical insurance company?    Yes        No
4. The infection that this woman developed following the surgery, was this due to:
   • An error in judgment?    Yes        No
   • Medical malpractice?     Yes        No
   • Being too busy, tired, preoccupied?    Yes        No
   • Lack of sterile technique in the surgical room?    Yes         No
5. As this woman’s primary care physician, would you have reported this incident to the hospital’s ethics board?

Yes        No

Please explain your answers.

CASE THREE:

Recommended guidelines for colonoscopy are relatively clear with respect to when and how often the procedure should be done:

1. There are high risk patients and low risk patients
2. There are abnormal intestinal discharges or other chief complaints involving the large bowel

Yet unfortunately monetary incentives drive a minority of physicians to order certain tests. Some of the tests carry the risk of serious mishaps and the patient needs to know the risks. One such physician arrived in my hometown with very little material possessions but huge expectations coupled with an obsession to succeed in terms of money and power. Over the years, he became a leader in gastroenterology.
In 2007, the County Health Department was notified and investigated three closely-timed cases of Hepatitis C each following a colonoscopy at the hospital where the unnamed doctor was the chair of the GI department. The City Mayor first stepped in to curtail activities by revoking the business license of the Endoscopy Center. No health regulatory body came forward in an appropriate and timely manner.
In 2008, the Board of Medical Examiners restricted the doctor’s license and allowed it to expire in 2010. If he were to make application for licensing in another state, he could truthfully say that his medical license was never revoked. Although the unnamed doctor is up for trial, the date has been repeatedly rescheduled. The charges are serious. He and his two nurse anesthetists were charged with 28 felonies for allegedly exposing patients to hepatitis C. He was also charged with racketeering, patient neglect, and insurance fraud. One of the hepatitis C patients died in April, 2012. The doctor and company are now charged with second-degree murder. Not only are these undesirable events preventable, they should never have happened. But just as important, appropriate penalties and accountability should have been applied so as to minimize a recurrence. Effective oversight was glaringly lacking.

What do you think of this case?

1. In your opinion, is there effective oversight in the hospital where you practice?    Yes        No
2. Should the nurse anesthetists have reported the physician to the hospital ethics board?    Yes        No
3. If one of the three individuals who contracted Hepatitis C after a colonoscopy was you patient, what would you have advised?

• I will report the incident to the hospital ethics board
• Contact your insurance company
• Focus on managing the disease

4.  Would you refer a patient for a colonoscopy to the Endoscopy Center after its business license was reinstated?

Yes         No

For your patients’ Bill of Rights, go to Families USA. The Affordable Care Act: Patients’ Bill of Rights and Other Protections. April 2011.

http://familiesusa2.org/assets/pdfs/health-reform/Patients-Bill-of-Rights.pdf

Leonard Kreisler, MD

Published on April 2, 2013

Biosketch

Dr. Leonard Kreisler, MD received his Board Certification in Occupational and Environmental Medicine as well as Family Practice. He has fifty years in health care delivery (forty in Las Vegas). Dr. Kreisler’s medical practice started in 1960 with 13 years as an old-fashioned Marcus Welby-type family doctor in Peekskill, NY. He currently enjoys writing and lecturing on healthcare issues.

Mental Status Examination: Brainteaser for Primary Care

Why perform a mental status exam?

I suspect the answer to this question lies not in recalling the number of lives we may have saved, but those we have lost instead.

In my first year in practice, a man in his 30’s consulted me for treatment of hypertension. Married, a non-smoker and employed, he seemed not unlike other patients I had known in my young career. I examined him, ordered some blood tests and prescribed medication – all routine. Two weeks later, he shot himself.

Could I have uncovered his emotional strife? Would 10 seconds inquiring about his moods have made a difference? Although I will never know the answer, I understand now the importance of stepping back from the routine of the history and physical to read some non-verbal cues, note gaps in fluent speech and pick up on my emotional reaction to the patient. I can only hope that I will hear an unspoken warning.

My patient anticipates the opening of the exam room door, I look for clues in the chart before I enter, then our eyes meet and we instinctively form impressions of each other. We find ourselves observing posture, dress, movement, eye contact, apparent age. We introduce ourselves and observe still more: speech pattern, thought process, level of consciousness, and the disarmament of a smile.

We have performed a healthy chunk of a mental status exam on each other within the first 30 seconds of our encounter – not too much different than what we might do on a blind date.

If you are like me, trying to remember all the components of the mental status exam is daunting, and seems to test our own cognitive abilities. And there you have it: the mnemonic to help us incorporate this assessment into our daily interactions with our patients.

After reviewing much literature on how to perform a mental status exam, I created a mnemonic to help my brain get though it without any notes or checklists (can be done on a desert island without an EMR template). Try this mnemonic:

Alas, Someone Must Always Think About The Examiner’s Cognitive Abilities.

Translation (use first letter of each word in the above sentence):

Appearance and alertness
Speech
Motor activity
Affect and mood
Thought and perception
Attitude and insight
Threat of harm to self or others
Examiner reaction to patient
Cognitive abilities

Remember that others assess us as we do them. That’s it.

Now that you have an outline, here are some details to record during the mental status exam:

1. Appearance
Note grooming, dress, posture, eye contact

2. Speech
Note if speech is fluent, pressured, halting.

3. Motor activity
Note presence of tics, slowness, akathesia (can’t sit still?)

4. Affect and Mood
Mood is a patient’s sense of emotional state. Normal? Happy? Sad? Angry? (euthymic, euphoric, dysphoric?)
Affect is the observable expression of a patient’s subjective feelings. Appropriate? Flat? Blunted?

5.Thought and perception

Thought process
Is thought process logical?  (ideas flow in sequence)
Is there flight of ideas? (topics change abruptly without direction)
Racing thoughts?
Does patient answer questions directly, or are answers vague (circumstantial), irrelevant (tangential) or drift away from the subject (derailed)?

Thought content
Poverty? (limited information, vague answers, repeated phrases)
Delusions? (fixed beliefs)
Hallucinations?
Phobias?
Obsession? (recurrent thought)
Compulsion? (repetitive, ritualistic  behavior)

6. Attitude and Insight
Note if the patient is cooperative, hostile, seductive, indifferent, or evasive
Does the patient seem to understand the problem or illness or deny it?
Assess judgement and impulse control (“what would you do if…”)

7. Threat of Harm to Self or Others
Suicidal, homicidal, or violent fantasies
Planning
Access to weapons
History of violence or attempted harm
Poor impulse control

8. Examiner’s Reaction to Patient
Note your own feelings toward the patient. These may offer clues to the underlying diagnosis – for example, do you feel dysphoric (depressed patient), off balance and unable to follow the conversation (schizophrenia), or frustrated (personality disorder)?

9. Cognitive Abilities
Attention during the interview: focused or easily distracted?

Language: Note fluency, word selection, ability to express ideas clearly
Memory: Assess recent and remote memory; general or selective amnesia
Reasoning: can the patient formulate a plan to solve a problem?

If you can remember the mnemonic, you are on your way to a succinct yet thorough mental status exam.

Need a checklist style mental status exam to incorporate into your EMR? One created by Jeff Patrick, the Mental Status Examination Rapid Record Form, (see Chart 1) is available at www.nevdgp.org.au

Chart 1

Mental Health Exam

Andrea L. Brand, MD
Published on March 26, 2013

Biosketch
Andrea Brand has produced numerous articles, has presented, and has written a personal memoir. Since 2008, she has been a clinical assistant professor of Family Medicine at the Florida State University School of Medicine.

References

1. Dennis Jerry L, MD; Medical Director, Arizona Department of Health, www.azdhs.gov
2. Snyderman D, Rovner B. Mental status exam in primary care: a review. Am Fam Physician. 2009 Oct 15;80(8):809-814.
3. Patrick, Jeff, Mental Status Rapid Record Form, www.nevdgp.org.au
4. Martin, DC. The Mental Status Examination. In: Walker HK, Hall WD, Hurst JW. Clinical Methods:The History, Physical, and Laboratory Examinations, 3rd ed  Boston, MA: Butterworth Publishers; 1990.

Optimizing Screening and Management of the Patient with Hereditary Angioedema: A Primer for Primary Care Practice

Note: There is a print link embedded within this post, please visit this post to print it.

Learning Objectives

After participating in this educational activity, participants should be better able to:

1. Apply available screening and diagnostic tools to promptly differentiate between clinical presentations and symptoms of HAE to accurately identify patients with HAE
2. Customize treatment utilizing consensus algorithms, published clinical evidence, and new therapeutic options for acute attacks of HAE
3. Implement strategies to ensure “attack vigilance” by treating HAE symptoms early and employ prophylactic strategies in patients with recognizable prodromal symptoms

Introduction

Hereditary angioedema (HAE) affects approximately 6,000 to 10,000 individuals in the United States of all races and ethnicities. The disease exacts a considerable toll in terms of human pain and suffering, impaired quality of life, and cost to patients and the healthcare system. Reported rates of mortality range from 30% to 50% with asphyxiation from laryngeal edema being a major contributing factor. Patients suffer episodic attacks of painful edema of the face, tongue, extremities, genitals, larynx, and bowels as well as nausea, vomiting, and diarrhea, which can last for 2 to 5 days before resolving. Acute attacks of HAE can result in disfiguring edema, disruptions to daily living, significantly decreased quality of life, unnecessary gastrointestinal surgery, and potential loss of life from a severe attack of laryngeal edema.

Published on March 19, 2013

Postmenopausal Hormone Replacement Therapy

Hormone replacement therapy (HRT) in postmenopausal women has been more controversial since the publication of the Women’s Health Initiative (WHI) (see http://www.nhlbi.nih.gov/whi/) findings in 2003. Many women have stopped taking estrogen on their own, or have been told to do so by their healthcare provider, and now those women are having hot flashes or other sequelae of menopause. This has caused a lot of discomfort for patients and in many, if not most cases is an over-reaction to the findings of the WHI.
In looking at the actual numbers from the study, the risk to patients taking estrogen plus progestin (HRT) is really low in comparison to placebo. For every 10,000 women taking estrogen plus progestin pills:

38 developed breast cancer each year compared to 30 breast cancers for every 10,000 women taking placebo pills each year.
37 had a heart attack compared to 30 out of every 10,000 women taking placebo pills.
29 had a stroke each year, compared to 21 out of every 10,000 women taking placebo pills.
34 had blood clots in the lungs or legs, compared to 16 women out of every 10,000 women taking placebo pills.

For patients who are having significant hot flashes, trouble sleeping, mood changes and loss of sex drive, the benefits of HRT in terms of quality of life are substantial and most patients will opt for HRT after an objective discussion of risk. The FDA and most other medical groups recommend using the lowest effective HRT dose for the shortest possible time, but how can that be done in practice?

When starting a patient on HRT, I usually choose a dose in the range of 1mg estradiol or 0.625mg of conjugated estrogen. I like using Activella (1mg estradiol + 0.5mg norethindrone) or Prempro (0.625mg conjugated estrogen + 2.5mg medroxyprogesterone). Activella is available as a generic and comes in a lower dose (0.5mg estradiol + 0.1mg norethindrone); Prempro is available in several doses but not as a generic.

For patients without a uterus, estrogen alone (ERT) can be used for menopausal symptoms. For ERT, the WHI showed an increase in thromboembolic disease and stroke, but not for breast cancer or heart disease. We are of course, still concerned about long-term use of these drugs and so the same principle applies, that is, to use the smallest effective dose for the shortest possible time. Estradiol is easy to use and available as a generic in several different doses; 1 mg is a good starting dose.

I see my patients on HRT or ERT yearly, and I ask if they have had any hot flashes or night sweats. Usually they have missed a few doses of meds here and there throughout the year. If they don’t seem to have any problems when they miss a dose or two, then that is a good time to consider decreasing the dose. Once a patient is on the lowest oral dose (0.5mg estradiol or 0.3mg conjugated estrogen), then consideration can be given to stopping the medication once no (or very few) hot flashes are reported. Once a patient is off her ERT or HRT, she may experience more vaginal dryness and estrogen cream or vaginal estrogen tablets can be considered.

I don’t recommend phytoestrogen (plant estrogens like black cohosh or red clover), progesterone cream or evening primrose oil. There is little scientific evidence behind these agents and they may confer some risk. Why choose these agents, with essentially unknown or uncertain benefit and risk, when we have pharmaceutical grade products that work, and about which the benefit and risk is better quantified?

There are some special situations that should be mentioned.

If a patient has significant vaginal dryness symptoms, along with hot flashes or other systemic symptoms, Femring can be considered.  This is a very convenient vaginal ring that is flexible. The patient generally cannot even feel it and it can be left in all the time. Femring comes in two doses, 0.05mg and 0.1mg estradiol, and lasts for 3 months.

For breast cancer survivors, who have no clinical evidence of disease, the Estring is a consideration. This is a vaginal ring with extremely low dose, effective for vaginal dryness in these patients. Most oncologists feel that this is a safe product for breast cancer patients because of the low dose with minimal or no absorption (vaginal estrogen cream would not be a safe choice in such patients).

If a patient does not tolerate oral HRT or ERT well, then a transdermal patch can be used. There is a once a week ERT patch called Climara that is available in several doses, and available as a generic. The 0.05mg/24hr dose is a good place to start. This patch is changed weekly. Vivelle dot is a small, easily applied patch that is changed twice a week.
There are HRT patches as well. Combipatch is available in 2 doses (changed twice a week), and Climara Pro is available in 1 dose, changed weekly.

Finally, some patients have vaginal spotting or bleeding on HRT. If the bleeding is so light that protection is not even needed, I just watch to see if it increases. Bleeding that requires protection demands investigation, usually in the form of an endometrial biopsy. Once a “pattern” of bleeding is established, then it does not have to be investigated again unless or until that pattern changes.

We should not be afraid to give estrogen to patients who need it. It is good to review the risks of ERT and HRT with each patient being given these medications. If the patient then hears something about the risks of estrogen, she will be better informed. We need to decide in each case if the risks of estrogen use are outweighed by the benefits, which may include better sleep, better quality of life, better sexual and bone health.

Casey Younkin, MD
Southern Illinois University School of Medicine
Springfield, Illinois

Published on March 19, 2013

Biosketch
Dr. Casey Younkin is an associate professor on the faculty at Southern Illinois University School of Medicine in Springfield, IL. He has been interested in bone health for many years and is a member of ISCD (International Society of Clinical Densitometry) and ASBMR (American Society for Bone and Mineral Research). His goal is to see every patient with a fragility fracture evaluated and potentially treated, to prevent the next fracture from occurring.

References:

1. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3): 321–333.
2. Grady D, Herrington D, Bittner V, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA. 2002;288:49-57.

Not so long ago, migraine was considered a neurotic woman’s problem, stemming from the ups and downs of hormones. Today, women are fighting back. Susan Hutchinson, MD, board certified in family medicine with a subspecialty in headache, has written a book for women about migraine, self-management, and how to respond to a neurologist who admits knowing nothing about hormones and an obstetrician who does not feel competent to treat migraine. That is the medical abyss in which many women with migraine find themselves floundering.

Dr. Hutchinson writes as if she is speaking directly to you. You can almost smell the carnations in a vase on her desk and want to take a bit out of one of the pears in a bowl on the coffee table in her office. She describes real-life patients, their history, what she has recommended, and how well they responded. She also recounts when and how she had to change her approach and treatment plan.

She admits that what she writes is an anecdotal report with the findings of scientific studies interspersed. What works for her patients is her ultimate goal rather than following an algorithm. She personalizes her treatment of patients because she too has migraine and has experienced the frustration of not being listened to, being advised to “live with it,” and to have to find effective treatment through trial and error.

She shares that one of the most insightful suggestions that she received was to “write 10 activities that make you happy and do each one at least once during the next 14 days.” Through this exercise, she found that, “Stress was one of the biggest barriers to overcoming my migraine problem…It is empowering to carve time out for yourself and consider it as important as an appointment or a date with a friend.”

She provides useful information to women with migraine who are planning a pregnancy and want to breastfeed their newborn. She suggests books about the effects of drugs on the growing fetus and on the breastfed infant. She also discusses her favorite medications for specific problems. It is a refreshing book to read with guidance that makes a difference.

To order the book on Amazon, go to http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=The+Women%27s+Guide+to+Managing+Migraine+by+Susan+Hutchinson