BODY SYSTEMS & DIS-EASE: Recent Episodes
The Original Guide To Mens Health
Episode Summary: What are those aches and pains in your fingers, hand, elbow, toes, foot, ankle, and knee? What causes them? What do you do when they seem more severe and interfere with your activities? What are the various types of arthritis? Not all Rheumatological disease is arthritis; what else does this area of medical...
Episode Summary: Learn all you need to know about Kidney Stones, who is at risk, the various types of stones, and presentations.
Guests: Robert M. Sweet, MD, FACS, MAMSE Professor of Urology, Surgery, and Bioengineering (adj) Medical Director UW Medicine Kidney Stone Center Chief, Division of Healthcare Simulation Sciences Executive Director of WISH and CREST University of Washington
Dr. Sweet is a Joint Professor of Urology and Surgery and Adjunct Professor in Bioengineering at the University of Washington. He is the Inaugural Chief of the Division for Healthcare Simulation Science and the Founding Medical Director of the UW Medicine Kidney Stone Center.
Dr. Sweet founded and led the University of Minnesota’s SimPORTAL and cofounded the University of Washington’s ISIS, renamed the Washington, Wyoming, Alaska, Montana, and Idaho Institute for Simulation Technologies (WISH) when he assumed the Executive Director position. He is the PI for all Center for Research in Education and Simulation Technologies (CREST) programs, including the “Advanced Modular Manikin.”
During This Episode, We Discuss: We review the diagnosis and various presentations of stones- Why are some painful and others not?
How are Kidney Stones diagnosed? What constitutes a Kidney Stone emergency?
Who has stones that might pass versus stones that require therapy? How are Kidney Stones managed and treated?
How can we prevent Kidney Stones
The Role of the Kidney Stone Center
Quotes: "Kidney Stones are Increasing in incidence in the United States and around the world. 2.5% of persons will experience a stone event each year."
Dr. Sweet
"The increase seems to be associated with our diet and diseases like Obesity, Diabetes, Metabolic Syndrome, and Hypertension."
Dr. Sweet
"The most common type of stone is Calcium Oxalate."
Dr. Pelman
"When a person hears that they have a calcium-based stone, the first thing they usually do is to stop ingesting calcium…and it’s the opposite... We encourage a normal calcium diet."
Dr. Sweet
Recommended Resources: Pelvicrehab.com: Use this as a resource to find a Pelvic Health Physical Therapist
Episode Transcript: Coming soon!
Episode Summary:This episode follows two Kidney Cancer expert Urologists in understanding Kidney tumors from diagnosis to treatment options.
Guests:John L. Gore, M.D. Professor of Urology, Surgery, Health Services Researcher, University of Washington. Urologist, surgeon, clinician, researcher, educator, and expert in clinical care guidelines and outcomes. Dr. Gore is the PI of a large pragmatic trial in bladder cancer and a quality of care expert.
He previously served as the American Urological Association (AUA) representative to the National Quality Forum, which endorses national healthcare performance measures. He has been on guidelines panels for the National Comprehensive Cancer Network (NCCN) for kidney cancer and the AUA for bladder cancer.
Brian Shuch, M.D., is the Director of the Kidney Cancer Program and the Alvin & Carrie Meinhardt Endowed Chair in Kidney Cancer Research. He completed his urology training at UCLA and a Urologic Oncology Fellowship at the National Cancer Institute. He is an accomplished surgeon (open/laparoscopic/robotic surgery and percutaneous ablations) and clinical/translational researcher.
He serves in leadership positions within various kidney cancer research organizations such as SWOG and the Society of Urologic Oncology. He is recognized as an expert in the genetics of kidney cancer. He runs a translational research program with over 140 peers reviewed publications, including primary research published in prestigious journals such as Nature, Nature Genetics, Proceedings of the National Academy of Sciences, Journal of Clinical Oncology, and Clinical Cancer Research. He is one of the few clinicians to bring bench science to the bedside in an upcoming therapeutic clinical trial for metastatic kidney cancer.
During This Episode, We Discuss:The types of Kidney Cancer
Non-cancerous kidney cysts (benign) versus cancerous kidney cysts
Solid kidney tumors, benign and malignant
Diagnosis of kidney cancers: Imaging and Biopsy
Risk factors for kidney cancers
Genomics of kidney cancer
Treatment of kidney cancer: Localized and Metastatic
Quotes (Tweetables):Back in the olden days, we used to talk about the triad of three symptoms people associated with kidney cancer. Those three symptoms were hematuria or blood in the urine, palpable mass, and flank pain. Realistically in 2023, this triad happens less than 1% of the time. What has changed is that there is a much higher frequency of use of imaging to diagnose problems in our bodies. Kidney cancer is one of the fastest-growing cancer types in incidence because of incidental detection.
Dr. Gore
Regarding tumor size, it all depends on the scenario. The larger the lesion, the more concerning it is for cancer, but even a 1 cm tumor can have some aggressive elements. There is no absolute size where you say a tumor below this threshold cannot be cancer.
Dr. Shuch
Most kidney cancers are what we would call sporadic in that it occurs in the absence of known risk factors. The two biggest risk factors that are more behavioral are smoking and obesity.
Dr. Gore
Recommended Resources:KCA: Kidney Cancer Association
Kidney Can
KC Cure
American Cancer Society
Fred Hutchinson
UCLA
Episode Transcript: Coming soon!
Episode Summary:Learn what we know about these often undetected conditions: cardiac disease, prostate cancer, high blood pressure, and diabetes (metabolic syndrome). We look back to relevant episodes and some important comments from our experts.
We also asked our producer Sean Fox for some of his favorite episodes from the past year.
Guests: Episode 36. Quick Virtual Workouts for Anywhere
Lauren Updyke, MS, American College of Sports Medicine Certified Trainer, Director of the University of Washington Whole U program.
Episode 6. Cardiovascular Health—How to Keep Beat with your Heart
Eugene Yang, MD: Cardiologist, Clinical Associate Professor, Cardiology, UW School of Medicine; Medical Director for UW Physicians Eastside Specialty Center, Governor of the Washington Chapter of the American College of Cardiology; Director of the Cardiovascular Wellness & Prevention Program at University of Washington
Episode 15. What Everyone Should Know about Tobacco, Smoking, and Vaping
Sarah Ross Viles, MPH: Director of the Tobacco Studies Program University of Washington, former Chronic Disease Program Manager Public Health, King County, Washington.
Tim McAfee, M.D. Affiliate Assistant Professor, Health Sciences University of Washington, Former Director, Office on Smoking and Health, Center for Disease Control and Prevention. Consultant with the CDC Anti-Smoking Media Campaign
Episode 4. Diet - Eat, Drink and Be Healthy
Marian L. Neuhouser, Ph.D., RD Fred Hutchinson Cancer Research, Program Head, Cancer Prevention Program Public Health Sciences Division, Affiliate Professor University of Washington, School of Public Health, Department of Epidemiology
ALSO:
Episode 27: Metabolic Syndrome, Diabetes, and Other Common Endocrine Health Issues
Arthi Thirumalai, MD. Assistant Professor, Endocrinology Division, University of Washington
Episode 16. Mental Health: Part 1—General Depression; Part 2—Deeper Depression, Suicide, and Suicide Prevention.
Daniel J. Singer Ph.D. Washington State Licensed Mental Health Therapist specializes in Counseling and Treatment of Mental Health Diagnoses.
Dr. Jeffrey Sung, M.D. University of Washington Instructor of Psychiatry and Behavioral Sciences, Board certified psychiatrist at the University of Washington, the Pioneer Square Clinic, and in private practice.
Episode 10. Prostate Cancer: A) Detection, Diagnosis, and PSA, B) Surveillance and Treatments
Daniel W. Lin, MD, Professor Department of Urology, University of Washington School of Medicine, Chief of UW Urologic Oncology, and The Pritt Family Endowed Chair for Prostate Cancer Research.
Episode 52: Hiking, Backpacking, and Staying Safe in the Wilderness
Lee Jacobsen, JD. Lee is a Seattle attorney and avid hiker and backpacker. He is a founder of the Washington Hikers and Climbers Facebook group, an 8-year running FB hiking community of over 200,000 people in WA.
Tim Durkin MD. Tim is a physician with board certification in emergency and sports medicine based in Colorado. Dr. Durkin is the chief medical officer for Base Medical, a wilderness medicine education company, medical director for the San Juan National Forest, SAR program coordinator for Colorado Highland Helicopters, and a responder with La Plata County SAR in Colorado. He is a former paramedic and Eagle Scout with over 25 years of technical wilderness SAR experience. Dr. Durkin practices emergency medicine at a rural hospital serving Native Americans and occupational medicine for public safety agencies. Opinions expressed today by Dr. Durkin are his own and not official positions of any of his employers or affiliates.
Episode 47: Dental Health and Care
Gary Burt, DDS. Private practitioner for more than 35 years in Seattle, Washington, USA. Specializing in General and Family Dentistry, Esthetic Dentistry, and Complex Restorative & Cosmetic Dentistry.
Episode 44: Grief, Grieving, and the End of Life
Jennifer R. Levin, Ph.D., MPH, MFT. Trauma and grief therapist, marriage and family counselor with extensive experience in counseling and education on trauma, death and dying, bereavement, and loss.
During This Episode, We Discuss:Please visit each individual episode page to review the discussion points.
Quotes (Tweetables):Please visit each individual episode page to review the quotes.
Episode Transcript: Please visit each individual episode page to review the episode transcript.
Episode Summary:Please join and listen to this wonderful review of common conditions affecting the lungs. Dr. Schwartz provides us with information regarding how today's air quality affects the developing lungs in children and how it affects those of us who are adults and may or may not have underlying pulmonary issues.We review the most common pulmonary concerns, advances in therapy, and how to maintain good pulmonary health.
Dr. Schwartz shares some very recent information on the genetics associated with one of the more common pulmonary diseases, Pulmonary Fibrosis.
Guest:Dr. David Schwartz, MD, Distinguished Professor of Medicine and Immunology in the Division of Pulmonary Sciences & Critical Care at the University of Colorado
Immediate Past Chair of Medicine at The University of Colorado School of Medicine, Director of Center for Genes, Environment & Health, National Jewish Health, and previous National Institute of Environmental Health Sciences Director at the National Institutes of Health.
During This Episode, We Discuss:* A review of how the lungs function * The role of the Pulmonary specialist * How the lungs interact with the environment * A review of common lung conditions and diseases * What is COPD * Asthma * Bronchitis * Emphysema * Sarcoidosis * Pulmonary Fibrosis * Pulmonary Cancers and Detection * Pulmonary Infections * Smoking and Smoking related pulmonary diseases * Chronic Cough * When should you be seen by a Pulmonary specialist (Pulmonologist) * Current research and understanding of the role of the environment and the above conditions, diseases * Genetic determinants of pulmonary disease * How to maintain good pulmonary health
Quotes (Tweetables):‘The Environment that we are faced with really is interesting because it forces the lungs to adapt and re-adapt to a changing and dynamic environment.’
Dr. Schwartz
If you smoke less than ten cigarettes daily, you're not addicted to Nicotine.
Dr. Schwartz
Recommended Resources:Pulmonary Fibrosis:
National Heart, Lung, and Blood Institute (NHLBI)
Pulmonary Fibrosis
https://rarediseases.info.nih.gov/diseases/8609/idiopathic-pulmonary-fibrosis
The Pulmonary Fibrosis Foundation
www.pulmonaryfibrosis.org
Dr. David Schwartz
University of Colorado School of Medicine, Division of Pulmonary Sciences
Pulmonary Disease:
Your Primary Care Physician (Family Medicine or Internal Medicine Physician)
Select Health Information: Pulmonary Disease
WW.NIH.GOV
Episode Transcript: Coming soon!
Episode Summary: Ophthalmology is a medical-surgical specialty concerned with studying and treating disorders and diseases of the eye. This episode reviews common conditions affecting the eye and our vision. Find out what you need to know to take appropriate care of your eyes. Learn how different eye diseases are diagnosed and treated. Listen to Dr. Alder speak about innovations in disease management. Learn how to preserve and optimize your vision.
Guest: Brian Alder, M.D. is a fellowship-trained cornea, external disease, and refractive eye surgeon. He received his medical degree from Duke University in Durham, North Carolina, where he interned and then advanced to Chief Resident during his residency. Dr. Alder published numerous articles and abstracts related to eye conditions and collaborated on cutting-edge corneal surgery research at Duke. Dr. Alder did his corneal fellowship training at Bascom Palmer Eye Institute at the University of Miami, recognized by U.S. News and World Report as the country's number one hospital for ophthalmology.
Dr. Alder worked side-by-side with the most prominent cornea specialists in the world to learn the most up-to-date treatment of corneal disease. Shepherd Eye Center proudly presents Dr. Alder’s unique corneal expertise to Las Vegas.
Dr. Alder is Board Certified by the American Board of Ophthalmology and is a member of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. Dr. Alder loves spending time with his wife and five children outside the office. His favorite pastimes include board games around the dinner table, playing sports, traveling, and watching movies with a family-sized bowl of caramel popcorn.
During This Episode, We Discuss: During This Episode, We Discuss:
Ophthalmologist vs. Optometrist, what is the difference, who should you see for eye care?
What to expect from a general eye exam
When should you begin to get eye exams, what changes in eyesight should lead to an exam?
Common Eye Conditions:
- Cataracts
- Macular Degeneration
- Glaucoma
- Floaters (what is a floater and what’s not)
- Retinitis Pigmentosa
- Dry Eye and Excessive Tearing
- Cancers of the Eyes
- Viagra and the Eye
Quotes (Tweetables):
As you approach age 60, start thinking about more regular eye exams, maybe 50s, if you are having eye problems, certainly start at that time.
Dr. Alder
Cataracts are probably the most common disease that causes blurry vision and the most common surgery in the United States.
*Dr. Alder*
The outside of the eye is the Cornea, the window through which light passes on its way to the back of the eye, the Retina….. The light must bend at different places to focus properly and bends at the Cornea but also through a lens…… the lens can develop some opacity, that’s a Cataract.
*Dr. Alder*
In the minority of cases, especially if a floater comes on suddenly, often associated with not just a floater but a flash of light certainly if associated with any blurry vision, that floater is not caused by the simple vitreous issue but by retinal damage and needs to be immediately evaluated.
*Dr. Alder*
Recommended Resources:
The American Academy of Ophthalmology
EyeWiki.org
Episode Transcript: Coming soon!
Episode Summary: This episode reviews the progress in developing biomaterials that allow for external and internal non-invasive interfaces with our various organs. A leading researcher examines the requirements for such materials and shares some recent device developments.
Guest: Dr. Chris J Bettinger, Ph.D.:
Christopher Bettinger is a Professor at Carnegie Mellon University in the Departments of Materials Science and Engineering and Biomedical Engineering. He directs the Laboratory for Biomaterials-based Microsystems and Electronics at CMU, which designs materials and interfaces that integrate medical devices with the human body. Dr. Bettinger has published over 90 articles and issued over ten patents. He has received numerous honors, including the MIT Tech Review TR35 Top Young Innovator under 35 and the DARPA Young Investigator Award.
During This Episode, We Discuss: * The challenges of interfacing device technology with humans. Think of fitting a device to curved tissue that's flexible, miniature, and allows for continuous monitoring. * Materials Science: Bio-Inspired Materials * Embedded Electronics * Noninvasive monitoring of the human Gastrointestinal tract
Quotes (Tweetables):
“In your gut, there are also 100 million neurons, organized into complex networks, localized computational functions, sensory feedback, mechanosensation, the gut is the third brain.”
Dr. Bettinger
“We could be interfacing with the neurons in the gut, and we are developing technologies that enable that interface.”
*Dr. Bettinger*
“Gut health is interesting and is underappreciated…. What is a leaky Gut? What about devices that could measure physical properties of the gut, where you could get a quantitative lens on what is now a semi-qualitative descriptor.”
*Dr. Bettinger*
Recommended Resources:
Carnegie Mellon University, Faculty, Dr. Chrisopher J Bettinger.
Episode Transcript: Coming soon!
Episode Summary:
A smart speaker and your Heart. “Alexa, is my heart rhythm normal”? An Electro Cardiologist interfaces a clinical problem with a smart speaker to identify cardiac arrhythmias.
Learn how innovation in biotechnology had led a cardiologist and his team to train Alexa to determine abnormal from normal heart rhythms. Still, in development, this fascinating interface highlights how leading innovators take technology and smart devices forward to enhance clinical care.
Listen as we review common cardiac arrhythmias, causes, treatments, and diagnoses current and future directions for innovation with devices and additional developments in Telehealth.
Guest:
Arun Mahankali Sridhar, M.D., M.P.H., is a cardiac electrophysiologist and a specialist in heart rhythm disorders. He is an Assistant Professor in the Division of Cardiology at the University of Washington.
Dr. Sridhar sees patients with both rapid and slow heart rhythm disorders and patients with a risk of sudden cardiac death. He has comprehensive expertise in the management of both common and complicated arrhythmias. He is an expert in catheter ablations for atrial fibrillation; atrial flutters (both typical and complex), supraventricular tachycardia, WPW, ventricular tachycardia (VT), and premature ventricular complexes (PVCs); stroke prevention in atrial fibrillation, including left atrial appendage closure. In addition, he is an experienced implanter of all types of cardiac device therapy, including cardiac pacemakers, implantable cardiac defibrillators (ICDs), and cardiac resynchronization therapy (CRT).
Dr. Sridhar’s research focuses on improving ablation techniques and patient outcomes in atrial arrhythmias. He collaborates with the UW computer science and bio-engineering department on various innovation projects to improve the care of heart rhythm patients utilizing advanced computing and novel low-cost patient-accessible technologies.
During This Episode, We Discuss:
- Cardiac (Heart) Arrhythmias: causes, detection and treatment options.
- Innovations in the diagnosis of arrhythmias.
- The benefits of a multi-disciplinary team in researching a very innovative solution to a common clinical problem.
- The role of adaptive, machine learning, signal processing, and clinical experience in moving technology forward.
- Future potential enhancements in current technology to diagnose other metabolic, cardiac, and respiratory conditions.
Quotes (Tweetables):
“At some point, patients can sit in front of a smart speaker and get a good, quick diagnostic test to see if their heart rhythm is normal without having to go to a hospital and get an EKG. Caution that this is still research and not yet ready for patient use.”
Dr. Sridhar
“Sometimes, even some dietary agents can cause an arrhythmia, one of the most common culprits is coffee, and excess alcohol can lead to arrhythmias. Alcohol-induced Atrial Fibrillation is very well described; people, especially college students who go on a binge drinking weekend, end up with a Monday morning arrhythmia, usually Atrial Fibrillation.”
Dr. Sridhar
“We converted a smart speaker into a short-range sonar device.”
Dr. Sridhar
Recommended Resources:
UW Cardiology website: Stopafib.org
Article: Using smart speakers to contactlessly monitor heart rhythms
Episode Transcript:
Coming soon!
Episode Summary:
Males & females have similar anatomy + physiology when it comes to libido, arousal, and orgasm—but they can differ in likes and experiences. To improve sexual health, couples should communicate about these. Learn also how hormonal, medication, education, and technological methods can help both younger and older people.
Guests:
Rachel Rubin, M.D. Practicing Clinical Urologist and Sexual Medicine Specialist in the Washington DC area; Assistant Clinical Professor of Urology at Georgetown University. Clinician, researcher, and educator.
During This Episode We Discuss:
- Information on female sexual health that is useful for both males found in the episode description and females to know.
- Conversation and communication about sex in couples, of any gender or orientation, helps each partner to have rewarding sex.
- We don’t learn much about how to talk about or have sex in our educational system, despite sex being a key part of our anatomy, physiology and adult lives.
- Libido, arousal, orgasm and pain are the main sexual health issues for males, females & all genders. There are many causes (including antidepressants or other medications for example), but the good news is that there are ways to help each of these issues.
- The orgasm gender gap: Heterosexual men are orgasming at higher frequencies than heterosexual females. The average time for a male orgasm is five and a half minutes. The average time for a female orgasm is 13 minutes with a partner, or 5.5 minutes solo.
- Solutions to improve sexual function and experience for individuals and couples include biological (hormone), medication, educational, therapy and technological methods, with many new and some game changing (e.g.vaginal creams).
- Loss of estrogen with menopause can change the sexual experience for females, but “There is no age at which sexual health stops being important,” says Dr. Rubin. There are approved meds for boosting libido in women (dopamine based), and safe vaginal creams that restore estrogen and other hormones to reduce dryness and pain. The creams also reduce urinary tract issues such as urgency, frequency, infections.
- The focus in this episode is on heterosexual sexual health. Many issues will be the same for LGBTQIA sexual health.
Quotes (Tweetables):
— “We’re talking about what happens when two people are not meeting at the same level of sexual desire, or health or accomplishment, and what can we do.”
Dr. Pelman
— “Sexual health is just health. Genitals are just anatomy and physiology.”
Dr. Rubin
— “There is no age at which sexual health stops being important.”
Dr. Rubin
Recommended Resources:
-
To find sexual health information or a sexual medicine doctor:
-
International Society for the Study of Women’s Sexual Health (ISSWSH)
-
The North American Menopause Society (NAMS)
- Sexual health: https://www.menopause.org/for-women/sexual-health-menopause-online
-
Listen to other podcast episodes on sexual health:
-
The Original Guide to Men’s Health— see podcast episodes on sexual health:
- Episode 20 Sexual Health: Erectile and Ejaculation Problems
- Episode 38 Dating, Sex and Relationships in Young Adults (Human Sexuality Part 1)
- Episode 39 Sexual Desire and Function (Human Sexuality Part 2)
-
Health by Heather Hirsch — see podcast episodes on sexual health
Episode Transcript:
Dr. Pelman (00:00):
Good news. “ The Original Guide to Men’s Health” has just finished a brand new website. And you can find it online at theoriginalguidetomenshealth.com, also theoriginalguidetomenshealth.org. Our website has podcast episodes, resources links to our brand new social media accounts, which can also be found in the episode description. Whatever you do, whatever you enjoy, you need your health. Welcome to The Original Guide to Men’s Health,” a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy; maintenance and prevention strategies; along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Pelman (01:18):
On this episode of “The Original Guide to Men’s Health,” we will be exploring female sexual health, what men should know, with Dr. Rachel Rubin. Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist. She's an assistant clinical professor of urology at Georgetown University and works in private practice in the Washington DC region. She is one of only a handful of physicians fellowship-trained in male and female sexual medicine. Dr. Rubin is a clinician, researcher, and vocal educator in the field of sexual medicine. She completed her medical and undergraduate training at Tufts University; her urology training at Georgetown University, and her fellowship training under Dr. Irwin Goldstein in San Diego. In addition to being education chair for the International Society for the Study of Women's Sexual Health, ISSWSH*, she also serves as an associate editor for the Journal of Sexual Medicine Reviews. Dr. Rachel Rubin. Welcome, Dr. Rubin.
*ISSWSH: https://www.isswsh.org/
** Journal of Sexual Medicine Reviews: https://www.journals.elsevier.com/sexual-medicine-reviews
Dr. Rubin (02:27):
Thank you so much for having me. It is just how fun and my absolute honor to be here.
Dr. Pelman (02:33):
We're so happy that you have a moment. I understand you've just opened a new practice and you're busy, but thank you for joining us. So to initiate, we've done some prior episodes on sexual health. We have episode 20*, which is on sexual health, particularly about erectile and ejaculatory problems. And then we do a couple of more explorations of sexual health, particularly with episodes 39 and 38. We have a website at www.theoriginalguidetomenshealth.com, where you can find all episodes to date. And in particular, you can find the episodes related to sexual health that we're referring to. In episode 38, we covered dating, sex, and relationships in young adults. And in episode 39, we covered sexual desire and function in human sexuality part two, with Irwin and Sue Goldstein. So why are we covering this particular subject now? I really wanted to be more specific about female sexual health in particular.
Speaker 1 (03:50):
Dr. Rubin, I had listened to you present in a recent University of California-Irvine review on sexual medicine, and I really found it fascinating. I was wondering why we were exploring female sexual health in a male sexual health course. And of course, it fits perfectly. So I think I'm going to just add one more comment, and then we'll delve into this subject. The comment was from a PBS interview on fresh air with Ari Shapiro and Dan Savage. And one of the things I was struck with, he says a lot of readers get, and what a lot of straight people sort of intuitively get is that your gay friends know a little bit more about sex than you do, and maybe are a little better at it than you are. And that's not because we're magic. Although we are magic, it's something else. Gay people have to communicate about sex; straight people get to consent and stop talking about what happens next or what they want.
Dr. Pelman (04:48):
And when two people of the same sex go to bed, they get to, yes, they get to consent. And then they have to have a whole conversation about what's going to happen. So, I think a lot of what we're gonna be talking about here is how to have a conversation with your partner. And the last thing I'll say is, there are many people who are very comfortable being asexual or in relationships that are asexual. And that's perfectly fine, but we're going to be exploring what happens when two people are not meeting at the same level of sexual desire or health or accomplishment and what we can do. So, Dr. Rubin, I've talked a lot. I’m going to let you start with perhaps a review of female sexual health and some data for what men should know about female sexual response and sexual health. Dr. Rubin.
Dr. Rubin (05:38):
Well, what a wonderful introduction. And it is my absolute honor to be talking with you today as such an expert, and as someone who is sort of newer in this field, right? I've only been out of my training for about four years, how exciting and wide-open of a field it is, sexual medicine. We have so much research that needs to be done that is not yet perfect. And how exciting that we get to watch it evolve in front of us. So I do feel like I'm a part of something much bigger than myself. And my big thing is that sexual health is just health. Sexual medicine is no different than any other type of medicine. Genitals are just anatomy and physiology. And it's really how they drive, and how do we get them to drive with more pleasure or with more consistency. And sometimes they need an oil change every now and then, and how do we get plumbing to work together?
Dr. Rubin (06:31):
How do we get genitals to match up in a way that is satisfactory and pleasurable to all people who are engaging in these activities? And it's not always so simple. And so I don't know about you, but a 10 to 15-minute doctor's visit is not really a great space to have these conversations. And sometimes it can get really lost and you are left believing that your sexual health does not matter to a medical doctor. And I really, really try to fight against that. And so these issues do take time and they do take some expertise, but there are a handful of us out there who do love talking about these types of issues. So I am very blessed in my practice. And you had Irwin and Sue Goldstein on your podcast, who are my mentors and have taught me so very much. And in my practice, I take care of all genders.
Dr. Rubin (07:16):
And it's really an incredible opportunity to be able to help everyone, as well as to maximize everyone's quality of life. And so when I talk about sexual health problems, they're no different in either gender. We deal with libido issues, arousal issues, orgasm issues, and pain issues. It's really those four buckets, and they all overlap. And they're super messy because all sorts of medical conditions and medications and surgeries and cancer can all affect each one of those buckets. And so whether you are a man or a woman or any gender that you identify with, those are issues that can come up. And so, my job as a sexual medicine doctor is to really talk to you and listen to your story because I'll tell you, your story is not like anybody else's. And how can I take your story and really figure out what are the biological solutions? What are the psychosocial interventions? What is the education that I can give you that will get you to just have as much fun as humanly possible when you are alone, or with a partner or partners?
Dr. Pelman (08:20):
So let's explore that a little bit. We've explored some of the male sexual responses in episode 20 on erections and ejaculatory dysfunction and erectile dysfunction*. But I think for a lot of listeners, they're sort of not that educated about female sexual arousal and sexual response. So, go a little bit through that area so we can then move into what happens when couples and heterosexual couples get together, or same-sex couples that aren't satisfying each other.
*Ejaculatory dysfunction: https://denverurology.com/male-urology/sexual-health/ejaculatory-dysfunction/
https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/symptoms-causes
Dr. Rubin (08:52):
Yes. We love to talk about how men and women are so different, right? Men love and need sex and think about it all the time, and women never do. And it's just not true. We all live on a spectrum, and I can't tell you how many male patients I have in heterosexual relationships who come to me because their libidos are not as high as their female partner’s, and just the opposite, right? I see it all. And so I think sexual response, in my opinion, is probably pretty similar. Again, the libido, there's a lot of discussion about libido in women and how some women have responsive desire, where a partner initiates and then they get interested in sex, as opposed to innate desire, where they just come up with it on their own. And what the data really shows is that some women have an innate desire, and some women have responsive desire.
Dr. Rubin (09:40):
And most women have both at different times and even, you know, within different relationships. And that's all sort of a spectrum of normal. And so if you're bothered by it, is it a medical problem? And my answer is if I'm bothered by the wrinkles in my forehead, I can go get lots of Botox treatments to fix that. So, if you are bothered by your sexual functioning, yes, it's a medical problem. And yes, there are medical solutions. So, libido is definitely something we see, and sometimes you have an innate desire and sometimes you have responsive desire. And arousal for a female is really essentially erectile function. So as a penis relaxes, it grows big and gets hard, and can penetrate. And as a clitoris*, which is exactly the same as a penis, is made up of all the same tissue and embryologically comes from the same place, when it relaxes it fills with blood and it expands and engorges
*Botox: https://www.mayoclinic.org/tests-procedures/botox/about/
**Clitoris: https://www.plannedparenthood.org/learn/teens/ask-experts/
Dr. Rubin (10:31):
And so the clitoris is mostly an internal organ that lives underneath the vulvar*, the labia major. And so as that tissue swells, when a woman has arousal, they feel engorgement. They feel swelling; they feel an increase in blood flow and sometimes good sensations, and that arousal can come with a good brain sensation. And so, when women experience orgasm, it is overwhelmingly due to clitoral stimulation, either from manual stimulation, oral stimulation, or vibratory, vibration, stimulation of the clitoris, which as I said, lives in the labia majora sort of area. So, it's not typically vaginal penetration that allows the majority of women to orgasm. And I think that is a big societal misnomer out there in that most people think, “Oh, my partner should be able to orgasm from penetration.” Or, I see women coming to see me and say, “Dr. Rubin, I'm broken. I can't orgasm from penetration.”
*Vulva and female anatomy: https://www.plannedparenthood.org/learn/health-and-wellness/sexual-and-reproductive-anatomy/what-are-parts-female-sexual-anatomy
Dr. Rubin (11:31):
You're not broken, more than 80% of women cannot orgasm from penetration. You are normal. And I sort of explain it to my male patients like this, “If you rub the inside of your thigh over and over again, are you gonna have an orgasm?” Probably not, right? If you really rub the inside of your thigh really hard for like 10 minutes, are you gonna orgasm? Probably not. And I say why? And they say, “Well, Dr. Rubin, it's not my penis.” I said, “But it's close to your penis.” And they say, “Yeah, but it's not my actual penis.” And that's my exact point when it comes to women. The vagina is close to the clitoris, but it is not the actual clitoris. And so most women cannot orgasm from vaginal penetration. That doesn't mean that women don't enjoy it and like it and want it, and it certainly helps with reproduction. But it's really important just to understand how the plumbing works. Because when we understand how it works, we can navigate it a little bit better and make it work better.
Dr. Pelman (12:24):
So I'll go back to my lead-in from Dan Savage. We have couples that meet each other. They’re a younger spectrum; they may not have much sexual experience. How does the female partner in that scenario tell a male partner that's not doing it for her?
Dr. Rubin (12:42):
It's so challenging. And I will tell you, you know, I show a slide often when I give lectures. And I think I showed it at the lecture that you saw me speak at of a male gym teacher from a movie called Mean Girls that says you, it's basically, he's teaching sex ed and says, “Don't get pregnant cuz you will die,” or “Don't have sex because you will die and get pregnant.” And again, that's where most people get their sex education from. If they're lucky enough to get sex education, it's from like a male gym teacher or something. And so we don't get the lesson of how to talk to our partners, and no one teaches us how to say, “Honey, that move you've been doing for 30 years, it's not working anymore,” or, “It doesn't feel as good,” or, “I've been saying I like it, but I actually don't like that move you've been doing.” How do you have those conversations? And I find couples can talk about almost anything. They can talk about children's diarrhea and constipation, and all sorts of bodily fluids. But when it comes to genitals and masturbation and orgasm, it's not so easy. I couldn't agree with you more that communication is really, really important, but actually one of these great universal things that most people are terrible at.
Dr. Pelman (13:48):
Yeah. I think his quote was so right that a lot of people can engage if they're heterosexual. Whereas the same-sex couple has to have a conversation. And so the heterosexual couple just initiates intercourse. There may never be a conversation. And that's so important for people to talk about, you know? What's good? What do you like?
Dr. Rubin (14:09):
And it's hard because a lot of people start having the conversation when things go wrong, right? A man's erection starts to get weaker, or a woman starts to have pain. And they've never talked about it when it was going well. And so now that things are not going well, or somebody comes up with a medical condition, it becomes that much harder to talk about. And so, we don't do a very good job of leading people through those conversations.
Dr. Pulman (14:32):
So, what do you do when say a female patient comes into you and says is anorgasmic or is delayed and it's really disturbing the relationship. What things are looked into and what? We heard a little background that it's not so different. Men and women, you know, we have the peripheral nerves* and stimulation and hormones involved in the central nervous system. But go through that a little bit.
Central and peripheral nerves: https://courses.lumenlearning.com/wm-biology2/chapter/the-central-and-peripheral-nervous-systems/
Dr. Rubin (14:55):
So orgasm is just a reflex, right? It's a very good feeling reflex. Almost like a seizure, even when you have it, you know, your brain kind of stops working a little bit in a good pleasurable way, not for everybody. And there is a subset of humans who can't orgasm or have delayed orgasm, muted orgasm, or too many orgasms. It can, all sorts of things can go haywire and go wrong. And so, my job as a urologist and sexual medicine specialist is a little bit like a sex detective, right? I put on my detective hat, and I really have to listen to the story and listen, listen, listen. Did you have an orgasm, and you lost it? Have you never had an orgasm? How do you try having orgasms? Is it just through penetration? Are there other devices at play? Is there other visual stimulation, right?
Dr. Rubin (15:41):
Really asking detailed questions and then understanding, well, what is your education around orgasm? And then really, again, a medical history. Have you had back surgery? Have you had pelvic surgery? Are you on medications that can affect your hormones? A physical exam is so important. We do not train doctors how to examine clitorises. It's a nightmare. And so, a lot of my work is in clitoral anatomy and getting other doctors to examine the vulva systematically so that we can pick up pathology. We have a whole, Dr. Pelman, you and I have spent our entire careers in the field of male sexual organs. We are penis doctors, right? And yet the penis and the clitoris are exactly the same things. And we have no understanding of anything that can go wrong with the clitoris. Whereas we have a whole medical specialty devoted to the male penis. It's so interesting, the barriers that we have. And so many things can go wrong with the clitoris. And so we're doing some research on that right now because we are finding that there are some anatomical things that can happen that can delay, mute, or impair the ability to orgasm. But since nobody's looking or asking, nobody's finding it.
Dr. Pelman (16:55):
In our episode with the Goldsteins, we did touch on the fact that blunted sexual responses for females and males can change because of medications. And one of the common issues is antidepressants. And there are females who were probably orgasmic and didn't have difficulties who, when they go on antidepressants, find things change. And there are some other medications as well. You wanna just touch on that?
Dr. Rubin (17:16):
Many medications can affect sexual function, whether its blood pressure medications, antidepressants, anything that affects hormones like birth control pills or acne medications, or even sometimes hair loss medications. All of them can have sexual consequences. And sometimes they’re worth the risk, and sometimes they're not worth the risk. And that's a big problem because if doctors who are prescribing these things don't know the risk, they don't even know to warn you about the risk. They're not talking about sexual function. They're not gonna warn you about the risk. And so, we often see people after the fact, unfortunately. And so yes, those are very common things that can happen.
Dr. Pelman (17:53):
And then we do have some newer medications on the market that can help. So, if somebody needs the antidepressant, just a little enlightenment, as far as what they should be going to the doctor about.
Dr. Rubin (18:03):
Yeah. There are some great things that are out there right now. I have really a lot of hope for the future, but I'm usually a very pessimistic person. So, we all know that antidepressants can cause sexual problems. And so can there be medications that can boost sexual function and kind of promote dopamine in your brain and get you more interested? And there are two FDA-approved medications that do just that. These are two medications that are approved for low libido in premenopausal women. Though we do have data that they work great in postmenopausal women, and even there's some research being done that they work in men. And the way these medicines work, they work on your brain similar to how medicine for depression might work on the brain, but it works in that opposite way to boost dopamine* and to get it to improve sexual response.
*Premenopausal: https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666#:~:text=Perimenopause%20means%20%22around%20menopause%22%20and,also%20called%20the%20menopausal%20transition.
**Dopamine and sex drive: https://sanescohealth.com/blog/male-libido-testosterone-nervous-system/#:~:text=Dopamine%20contributes%20to%20the%20desire,cases%2C%20it%20enhances%20sexual%20activity.
Dr. Rubin (18:47):
And like any medicine on your brain, you know, not everyone responds to Prozac the same way. They work in about 50 to 60% of people who take them. And when they work, what's so cool about it is that it boosts libido, but it also shows improvements in orgasm, arousal, lubrication, and satisfaction. And so, the first one to the market was called Addyi, A-D-D-Y-I, Addyi. And it's a pill you take every night at bedtime. And the cool side effect of this drug is it's a nice sleep aid. And so my patients get a really good night's sleep and wake up well-rested. So I can often get patients off melatonin or Ambien,** or, you know, whatever they're taking for sleep. And when it works, again in that 50 to 60%, it is really, really beneficial. It's called Addyi, A-D-D-Y-I, the doctor's name is flibanserin. And so, it can be a really great medication to sort of counteracting some of those side effects of antidepressants.
*Prozac (Fluoxetine): https://medlineplus.gov/druginfo/meds/a689006.html
**Addyi (Flibanserin): https://addyi.com/
***Ambien (Zolpidem): https://medlineplus.gov/druginfo/meds/a693025.html
Dr. Rubin (19:42):
The other FDA-approved option is called Vyleesi, or bremelanotide, and that is a subcu* auto-injector. So it's a little injection that you give yourself sort of an hour before you wanna hit dopamine. An hour before you want to want and get excited about sex. And so, it's a little more on-demand, as opposed to the Addyi, which is kind of always in your system and kind of more brings you back to that baseline of sexual thoughts. And so both are great options. Not each one works for every person. So, it's very cool that I have more tools in my toolbox now as a sexual medicine specialist for all genders.
*Vyleesi: https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-hypoactive-sexual-desire-disorder-premenopausal-women
**Subcu (Subcutaneous): https://medlineplus.gov/ency/article/002297.htm
Dr. Pelman (20:18):
And the second medicine again is?
Dr. Rubin (20:22):
Vyleesi. The other name is bremelanotide.
Dr. Pelman (20:24):
So it's a V, as in victory?
Dr. Rubin (20:26):
V. V as in victory.
Dr. Pelman (20:28):
Great. So these options occur. What happens when, you know, there's a differential. The average time for male orgasm is?
Dr. Rubin (20:37):
Five and a half minutes.
Dr. Pelman (20:39):
And the average time for female orgasm?
Dr. Rubin (20:42):
Well, remember I said most don't orgasm from penetration ever. Ever. But most with a partner, the data seems to show that it's around 13 minutes. This is interesting data. I've seen data to show that a woman by herself, also five and a half minutes, just like a man. She can do it pretty quickly. Soon as you get a partner in there, it bumps up to like 13 minutes because you got, you're all distracting. And it's hard to concentrate on your orgasm when there's a partner around. And so we do have an orgasm gap in the country that heterosexual men are orgasming with a much higher frequency than heterosexual women.
Dr. Pelman (21:14):
So, one of the most important things in a visit would be to bring the partner?
Dr. Rubin (21:19):
It can be incredibly helpful. I mean, education on just the basics of how your body functions is so important. I had a patient recently; this was so magical. I had a patient recently who I see for sexual pain. And her partner, I've been working with her for several years. And finally, her partner came in and watched me do an exam. And he saw how it wasn't painful everywhere. That there was just one piece of her body that had pain, and why it has pain. And we talked about it, and he looked at, he sat, sort of stood behind me as was doing the exam. And I was talking through the exam and he said, “Holy shit Dr. Ruben. Why didn't I come three years ago? I mean, I just learned so much.” You know, it's not about me and our relationship. The tissue, it hurt, it hurts to the touch. And I can see with my eyeballs where this problem is, and it was so transformative for their relationship to be able to talk about the issues.
Dr. Pelman (22:09):
So, flashing on a one-man show that I saw years ago called Defending the Caveman*. It was, I think, Becker was the author and initial actor. I remember him talking about the fact that women have multiple erogenous zones and pleasure zones, and that his wife was approaching by rubbing his back and saying, “Isn't that great?” And he was thinking, “Well, yeah, but you're still two feet away.” So there are different approaches here, and it was very comical. But there's some truth. And so both people in the relationship really do need to communicate about what is good, what's useful. What other options do you give besides medication for males who may be climatic in a more rapid sense than the female partner? Besides trying to extend orgasm for the male, there are some solutions. So, you can talk a little about that.
*Defending the Caveman: https://en.wikipedia.org/wiki/Defending_the_Caveman
Dr. Rubin (23:03):
We do have solutions to try to make men “last longer.” Nothing wrong with wanting to prolong sexual pleasure, right? There's nothing wrong with that. I think it's really understanding what gives each of you pleasure and is their pleasure. I think the word foreplay should be stricken from vernacular. We should no longer use the word foreplay. It should all be sex, right? This idea that you can have great sex without penetration should be talked about. If you can both orgasm and roll around in the sheets and you know, and have a good time, you should see that as a positive sexual experience, as opposed to, oh my gosh, I didn't penetrate my partner. I'm an absolute failure. So some of it is just getting our minds around what is sex, right? Why is sex solely based on a man's penetrative experience? It shouldn't be.
Dr. Rubin (23:49):
And so, I think the idea that a female partner might orgasm before her male partner, and I know we're speaking very heterosexually. And so the answer is it can look so many kinds of ways. Sex can be long. It can be short. It can be multiple times. It can be one time. It can be once a month. It could be once a year. But if it is pleasurable to you and it's enough for you, then it's a success. It's a win. And I think this idea that it has to look a certain way for society to be okay with it makes no sense because nobody's in the bedroom with you, except your partner. Your clergy is not in the bedroom with you, God willing, unless you are clergy, and then it's your own bedroom. Your middle school gym teacher who taught you sex ed isn't in the bedroom with you. The porn stars are not in the bedroom with you unless you're choosing to watch them, right? Like this idea that we think we're supposed to behave a certain way. Nobody's watching. Just enjoy yourself.
Dr. Pelman (24:41):
You know, introducing toys and simulators. I mean, how do you make suggestions sometimes that that's useful?
Dr. Rubin (24:48):
I love that question because I love devices and sex technology. All of our lives are so much better because of tech, and worse because of technology. But how cool you are on the west coast right now, and I'm on the east coast right now. And we're able to provide education to people because of technology. I can order my groceries with a click of a button on my phone if I want to. There are so many things that make our lives better due to technology. Sex is no different. And so, if you need a prosthetic leg, you're gonna, or a motorized wheelchair to get around to improve your quality of life, you're gonna do those things. And it's wonderful, right? Similar, if you have delayed orgasm, and if we add vibration to make your orgasm happen more powerfully and more enjoyably, let's use some vibration. And the technology out there, and even what's coming out in the future, is so exciting. And there are so many wonderful devices out there for couples; for men who have sex with men who; for women who have sex with women; for women alone; for men alone; prostate stimulation; vaginal stimulation; clitoral stimulation; nipple stimulation. I think why not add more fun tools to your sexual toolbox.
Dr. Pelman (25:59):
As you say, technology is improving. So, for males who have some difficulty maintaining erections, there are congestion rings. But some of the congestion rings actually come with some vibratory sense that buts the clitoris that can help satisfy both partners’ needs. And I also looked at the consumer electronics show. I think it was 2019 when they gave an award to a female stimulation device, and then realized what it was, took it back, and then gave it back when they finally awoke to the fact that we're modern and that this is part of life. And I think that company was Osé, O-S-E, and there's a newer group out there, satisfyer.com. I think that's where now incorporating smartphone technology into female stimulation. So you can dial up what you need. So there are all kinds of solutions. People shouldn't just give up.
Dr. Rubin (26:50):
People should not give up. And most importantly, your sexual health matters. Whether you have extra weight on you; whether you don't like the way you look; whether you're in a wheelchair; whether you have had cancer; your sexual health matters. And if it is important to you, let's figure out how to maximize the pleasure and the quality.
Dr. Pelman (27:12):
So, you know, we spoke about a younger couple. How does the young guy who visions that, you know, everything he does is all she needs and she approaches him with, “Well, actually.”? How do you advise them to go about that discussion?
Dr. Rubin (27:28):
Very interestingly, I have an anecdote. I went back to my old high school last week and I got to teach, give a booster sex-ed class to the seniors who were about to graduate. They graduate early where I used to go to high school. And I gave them all my cell phone numbers at the beginning of the talk. And I said, text me questions. A girl texted me anonymously and said, “Can you please teach the boys where the clitoris is, but like, actually teach them. Why are they so bad at giving oral sex?” And I read this out loud to the whole group. And I said, “Well, that's a very good question. Did you get that class in middle school about how to do oral sex and how to properly give oral sex?” No, none of us got that class, right? How is this senior in high school boy supposed to know how to properly give oral sex to his senior girl partner when no one ever taught him how? Good for him for attempting to give her pleasure, but we have to learn and find ways, you know, to be able to navigate and talk to each other and find out. If you don't know your own buttons, how are they supposed to know what buttons to push?
Dr. Rubin (28:27):
And so it really becomes education and self-exploration and the ability to use words, use real adult words, and talk about it.
Dr. Pelman (28:35):
Yeah, especially when your high school did have a class. Many high schools don't anymore, and resources seem to be disappearing from certain library shelves so.
Dr. Rubin (28:45):
So where do people learn? They learn from pornography, which is it's like learning how to exercise watching the WWF, right? Like it's all fake.
Dr. Pelman (28:54):
Yeah. You know, we did cover a bit about pornography with episode 39 from a professor at the U who teaches sexual education class. It's been going on for years. And she's the third generation of a professor who has a wonderful episode. And, you know, she feels porn is okay as long as people realize that they're well-paid actors. So, if we go back to kind of looking at than a couple, you kind of mentioned that they've been together, everything was okay, and now things change. So we moved from the spectrum of youth to age, and things change in the female body with age. So, talk a little bit about the effects for listeners on menopause and its effect on sex.
*The U: University of Washington
Dr. Rubin (29:40):
Yeah. You know, as you age, you know, the day you stop looking is the day you die. But some people, there's their brains and their sexual interest does not wane, right? I saw a patient this week that I see both partners in the relationships. He's in his late eighties and his partner, and she's in her late seventies. And I see them every year or so, or every six months. And every time he is getting older, he keeps telling me, he says, “Geez, doc,” every time he says to me, “Dr. Rubin, I love my wife more than ever before. I am so attracted to her. I love being with her. I love caressing her. I love holding her. And I love having sex with her.” His erections are not perfect. They can't do penetration. And he is okay with that. And he thinks of the sex that they do have as phenomenal and wonderful.
Dr. Rubin (30:23):
And he loves his sex life. And for her, right, she has changed from menopause and may have some dryness and delayed orgasm and things like that. And so they've added some devices, and they've added some vaginal hormones to help with lubrication and orgasm. And so we tinker, and we kind of work with each of them to say, “What can we do to maximize, you know, the quality of your sexual health together?” And it's been really fun to watch because there's no age with which sexual health for some people stops being important. If you're not bothered, if you're not having sex and you're not bothered by it, you don't have a problem. It's okay. No one ever died because they didn't have an orgasm. But if it bothers you and then it's an important part of your life then yeah, come see someone who really cares about this stuff.
Dr. Pelman (31:06):
So, you know, part of menopause is the change in tissue is a loss of estrogen*. So that is a physical change. But there's also a change in libido as estrogen dissipates because some of that estrogen changes to some testosterone, and that's what drove libido. So, what happens when a guy's still interested, but his menopausal wife, who decides not to go on estrogen is not getting the systemic total body benefit of estrogen, libido starts going? What do you advise?
*Menopause: https://my.clevelandclinic.org/health/diseases/21837-postmenopause
**Estrogen: https://www.hopkinsmedicine.org/health/conditions-and-diseases/estrogens-effects-on-the-female-body#:~:text=Estrogens%20are%20a%20group%20of,small%20amounts%20of%20the%20hormones.
Dr. Rubin (31:39):
Yeah. We have lots of biopsychosocial options. So, sex therapy is always a good option. Nobody doesn't benefit from sex therapy, right? Everyone can get better talking about sex. And we do have medical options. So, they range from hormonal and non-hormonal. So, you can use testosterone in women. So maybe if she's not on estrogen therapy, you could use estrogen therapy. It works great. And is typically very safe to do. If you're before age 60, within 10 years of menopause on a case-by-case basis, we'll do it after that fact and would typically use more, not pills, but typically more like patches and transdermal* or through the skin products. So there are some patients who benefit from that. Testosterone is an option. You can use testosterone therapy for your whole body. And that has lots of data to show benefit in women’s sexual health, especially libido. But we don't have an FDA-approved testosterone option for women in the United States.
*Transdermal estrogen patch: https://medlineplus.gov/druginfo/meds/a605042.html
Dr. Rubin (32:31):
It's approved in Australia. So it's good enough for the Australians, but there's a lot of politics that do not allow us to have it in America. So we typically, at least in my practice, use male-approved testosterone in female doses, which is about 1/10th of the dose. And then there are non-hormonal options. Like the ones we talked about earlier that are typically approved for pre-menopausal women, but they work great in postmenopausal women. So, ways to that Addyi and Vyleesi to boost dopamine in people's brains. I don't know of a single antidepressant that is approved for premenopausal women, but not postmenopausal women. So there's really no reason that these medications don't work great, and they do clinically. They do work great.
Dr. Pelman (33:10):
And some of the changes also come, as I said, physically in females. Milu in the vagina, there is a change without estrogen. So if somebody elects not to go on systemic estrogen or is not safe for them, there's still local estrogen that can help revive the tissue.
Dr. Rubin (33:27):
Local hormones, either vaginal estrogen or vaginal DHEA*, which is also available in America, are universally beneficial for every human over 45 and should be used until death do they part. If you are 98 and not sexually active, vaginal hormones are so beneficial for urinary frequency, urinary urgency, and to prevent urinary tract infections, which can kill you right? And that's really important. And so, we actually, I spend a lot of time teaching and talking about the importance of local vaginal hormones for this condition not as a sexual medicine doctor, but as a urologist who wants to decrease urinary tract infections in this world.
*DHEA: https://www.mayoclinic.org/drugs-supplements-dhea/art-20364199
Dr. Pelman (34:06):
Yeah. There's a lot of benefit to maintaining that Milu that comes from local estrogen. And so of course, a lot of patients who have experienced breast cancer are concerned about any estrogen. Can you speak to that a little?
Dr. Rubin (34:21):
Yeah. Thank you for asking. There is no data. There is not a single piece of data to show any harm of vaginal estrogen. In fact, we have data that shows no breast cancer progression, no breast cancer recurrence, no increased risk of blood clots. There's no data to show harm or risk. It's just that the word estrogen scares people. And I can't make it not scare people other than to present them with the data that shows it's not scary. And that all hormones are not the same. So, an oral medication that you take by mouth, that's like a birth control pill, goes through your whole body is going to have very, very different side effects and risks than a very small tablet or cream that you put locally in your vagina that doesn't go your bloodstream. And so, I spend a lot of time and it really does take time, just counseling women on what is the true data? What do we know? What don't we know? Let's talk with your oncologist and let's look and show, you know. And we need more studies, which hopefully one day will be done, and some are being done. But again, it's really hard to undo the fear that media has built up over something that has no data to show harm.
Dr. Pelman (35:26):
You know, there is so much news out there. Say a woman has a BRCA gene,* and she's done some genetic testing and says, “Oh, I'm at risk for breast cancer. I don't wanna hear the word estrogen.” A local vaginal estrogen does not promote breast cancer. Correct?
BRCA gene: https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer
Dr. Rubin (35:41):
So the very interesting thing about this is how wrong they got the data in the first place. There's an amazing podcast called Women's Health by Heather Hirsch. And one of her most recent episodes has the physician who wrote the oncologist who wrote the book, Estrogen Matters.* It's a must-read book and his podcast with her, Avrum Bluming I believe his name is. And it was incredible, again, to show what a cancer doctor has to say about estrogen. The study that Women's Health Initiative that made all the headlines, that study that came out that said estrogen was dangerous, when women in that study were on estrogen alone, they had a decreased risk of getting breast cancer and a decreased risk of dying from breast cancer. Estrogen was always protective against breast cancer. And yet the media somehow made that data look to say estrogen causes cancer, which was never what the data said. And so we got it wrong. And I don't know about you, but look at what of the messes of getting the messaging wrong. You know, COVID has everyone doing every which way? Every which thing, because the messaging is not unified and is not correct. And we have a really hard time. Once people get it in their brain of yes or no good or bad to change their minds. And so it's a nightmare. It's such a mess right now and it's been decades and it is N mess.
- Women’s Health by Heather Hirsch podcast
Dr. Pelman (37:00):
So, what was the name of that podcast that you were just referred to?
Dr. Rubin (37:04):
It's called Women's Health by Heather Hirsch. It's a brilliant podcast all about menopause. She's Harvard's menopause doctor and a very good friend. And her recent episode with Avrum Bluming, he wrote the book, Estrogen Matters.
Dr. Pelman (37:19):
If you looked at actual estrogen, locally. We're not talking about taking it orally or injections or patches. We're talking about it just vaginally placed. That is very, very, very, very safe,
Dr. Rubin (37:33):
Very, very, very, very safe. I'll add an extra very.
Dr. Pelman (37:36):
And how do you compare that to some quasi estrogen or synthetic estrogen patches like Vagifem,* that other estrogen substitutes, I guess?
Vagifem: https://www.vagifem.com/
Dr. Rubin (37:48):
Vagifem is a bio-identical estradiol tablet. So Vagifem is fabulous. Estradiol creams are fabulous. DHEA inserts are wonderful. There is a synthetic form called Premarin*, which works great. It works fine. Again is safe, but has some, you know, the way they make it with horse urine and there's some politics behind if you agree with that or not. And creams are not always my favorite because patients don't always like them. But of all the FDA-approved options, the local options work. And we just have to find one that is affordable and that you will actually use because if it sits in your bathroom drawer, unopened, it will not work. It actually definitely won't work. And like wearing a seatbelt or brushing your teeth, you don't get to say, “Well, I've done this for a month. I can stop now.” Right? You have to keep doing it forever and ever because your body's never gonna make estrogen again. And that tissue and your bladder, your urethra, your vagina, your vulva need hormones in order to function well.
*Premarin: https://www.premarinvaginalcream.com/
Dr. Pelman (38:45):
You mentioned the economics of local vaginal replacement, and it can be costly. And do you have any solutions for patients?
Dr. Rubin (38:54):
Have a huge solution and it just happened about two weeks ago. This big entrepreneur down in Texas, Mark Cuban, you might have heard of him, started his own online pharmacy* and he's trying to take very expensive drugs and make them affordable. And you can have your doctor type in Mark Cuban into their pharmacy list, and it will pop up a vaginal androgen, estradiol, 10 microgram tablets. You use one every day for two weeks, and then twice a week till death do you part is about $10 a month. I'm talking game-changing. If you like vaginal creams, a tube is only $50, whereas before it was $450. And that tube will last you about two months or more. And so holy macro it's been the best two weeks of my life because it used to be that women could not always afford these products and that insurance would not always cover these products, which we got a lot of work to do. But now there has been a game-changing situation just in the last couple of weeks.
*Mark Cuban Cost Plus Drugs Company: https://costplusdrugs.com/
Dr. Pelman (39:53):
Well, we always like to ask, is there anything else you'd like to contribute and then look towards some resources that you would recommend for listeners? So any other things that we didn't cover that you would like to add in?
Dr. Rubin (40:05):
I think you did a really fabulous job, and it's been such a wonderful opportunity to get to speak with you. And I think even more important that partners talk to each other, and really listen to each other's type of medicine. Because you know, it used to be the girls in one room and the boys in another room, and girls got to hear about periods. Boys need to hear about periods, and boys need to hear about dry vaginas and menopause. And because it matters to them, their pleasure depends on it too sometimes. And so it's really important that we all know about each other and advocate for each other, which is really, really important. So in terms of resources, if you wanna find a doctor who understands women's sexual health, I strongly recommend for the menopause age group go to the North American Menopause Society, or NAMS*. They have a find a provider on their website. And for all ages, the Women's Sexual Health Society or ISSWSH.org, ISSWSH.org. That again is I-S-S-W-S-H, isswish.org, also has a wonderful find a provider resource where you can find a doctor who gives a crap about all this stuff because it's really, really, really important. And just thank you so much for having me on.
*NAMS: https://www.menopause.org/
Dr. Pelman (41:19):
This is terrific, and it's so enlightening and so important. And unfortunately, it's getting swept under the table in certain areas, and youth aren't getting exposed. And so I think there's still like you said, a lot of work to do. But it's nice to know that there are people that people can go to. Appreciate your time, thank you.
Dr. Pelman (41:38):
My pleasure. Thank you for having me.
Dr. Pelman (41:41):
This completes another episode of The Original Guide to Men’s Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show's recordings are engineered and edited by Sean Fox. Episode titles and descriptions as well as editing assistance, are provided by Dr. Kathleen O'Connor, Ph.D. Music for our show is San Juan Bells written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society. The Original Guide to Men’s Health is an original publication of the Washington State Urology Society. Reproduction and use without the expressed or written consent of the Society are prohibited. For more information about men's health and previous episodes, as well as additional recommended resources, visit us online at theoriginalguidetomenshealth.com. This is Dr. Richard Pelman, Thank you for listening and reminding me to take care of yourself.
Episode Summary:
Bladder cancer affects more males than females by 3:1. In this episode, two experts demystify this common cancer, in a detailed and accessible discussion. They cover risk factors, cancer types, symptoms, diagnostic tests, treatments & reconstructive options. Useful information for anyone with bladder cancer or at risk for it.
Guests:
Max Kates, M.D. Urologist at Johns Hopkins Hospital, Baltimore Maryland; Associate Professor and Director of the Bladder Cancer Program at Johns Hopkins’ Hospital Brady Urologic Institute.
Jonathan Wright, M.D. Urologist at The University of Washington, Seattle Washington; Professor of Urology, Medical Director of the UWMC Urology Clinic at the University of Washington School of Medicine; Associate Professor at the Fred Hutchinson Cancer Research Center.
During This Episode We Discuss:
- Background information on what a bladder is made up of, what bladder tumors are, types of bladder cancers.
- Risk factors for bladder cancer. The biggest risk factor is smoking. Other risk factors include environmental exposures, advancing age, and being male. Genetic risk factors or family history do not play a big role, like they do in some other cancer types (for example, prostate cancer).
- The main symptom to watch out for is blood in the urine. Visual or detected by a test. Not typically associated with pain.
- Diagnostic procedures to identify if there is a tumor, where it is and what type of tumor. Includes cystoscopy (not at all as bad as it might seem, as attested by many a patient!) and/or a CT or MRI scan.
- Various treatment options depending on cancer type: non-invasive or invasive. Some non-invasive types require continued monitoring and treatment, similar to periodic colonoscopies that monitor and remove polyps, or dermatology checks that find and remove problematic skin growths.
- In more aggressive cancer types, the bladder is removed and a new bladder created. Much progress has been made in this area and a high quality of life can be maintained.
- Patient networks, particularly patients of the doctor(s) treating you, are invaluable sources of information and support.
Quotes (Tweetables):
— “It seems like a mysterious disease because people don’t really visualize their bladders.”
Dr. Pelman
— Of risk factors, “smoking is number one, probably half of all bladder cancers are caused by it.”
Dr. Wright
— “The cystoscopy is something that people get a lot of anxiety about before it happens, and then I'll routinely hear ‘That was it?’, 98% of patients, that’s their experience.”
Dr. Kates
— “If you start with a noninvasive low-grade tumor the probability of it…. recurring is moderate to high…but it’s not like it's not curable, it’s kind of like when you go in and get your [regular] colonoscopy and they see a new polyp and they take that out…..”
Dr. Wright
Recommended Resources:
- bcan.org Bladder Cancer Advocacy Network; founded by spouses of bladder cancer patients, comprehensive resource for patient support, information, advocacy, and research.
- Make connections to local support groups and other patients.
Episode Transcript:
Coming Soon!
Episode Summary:
Biomarkers are windows into health, like a cholesterol or PSA test. Precision medicine biomarkers enable us to refine clinical targets and identify more precise cancer risks, diagnosis & treatments. This new health care trend translates into better cancer care & reduced collateral damage, especially for prostate cancer.
Guest:
Jeffrey J. Tosoian, MD, MPH Assistant Professor and Director of Translational Cancer Research, Department of Urology, Vanderbilt University Medical Center, Nashville TN. Dr. Tosoian’s research is focused on the development and clinical application of diagnostic and prognostic tools, including blood-, urine-, and tissue-based biomarkers, to guide detection and management of genitourinary cancers.
During This Episode We Discuss:
- Precision medicine addresses some of the limits of current diagnostic tools. For example, an elevated PSA (prostate specific antigen) level is not a very specific indicator of cancer—high PSA can be a result of several different things. A more specific test that follows up the PSA test can be a blood or urine test for specific cancer biomarkers, instead of an invasive biopsy.
- Using biomarkers to provide better and more targeted medical care is an example of translational research: taking new discoveries from the lab bench to the patient bedside. For example, identification of abnormal/cancerous genes in the lab gets ‘translated’ to the bedside as a reliable, effective, and less invasive(blood or urine) test for those faulty genes, which can be used by the medical system for diagnostic purposes.
- Biomarkers and precision medicine target several phases of cancer health care. There are biomarkers that can indicate and monitor: cancer susceptibility, specific cancer diagnosis, prognosis, and cancer growth or recession.
- Official Guidelines may recognize these diagnostic and monitoring tests as approved and providing an equal or higher standard of care, but there may be temporal and structural disconnects between use of these new tools and what health insurances may cover.
Quotes (Tweetables):
— “[Precision medicine is] a superior way of treating a cancer when you can target something specifically. Again, I've used the analogy before, [the old way is] dropping a bomb on a cancer versus a missile strike at a specific area.”
Dr. Pelman
—“Our National Institutes of Health define a biomarker as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic or abnormal processes, or our responses to a therapeutic intervention.”
Dr. Tosoian
—“Many men will have an elevated PSA that do not have a harmful or a significant prostate cancer. And so our current aim is to use newer noninvasive tools to look at that group of men with an elevated PSA and identify who among them really does need a biopsy…” Dr. Tosoian
—“Translational research ….. takes the discoveries made in the laboratory or at the bench and figures out how they can be applied to best helping our patients at the bedside. It really does lead to better outcomes for our patients. And so that term bench to bedside is often used.”
Dr. Tosoian
— “When we think about these things, most of us aren't reading about biomarkers at night, right before you go to bed. Most people aren't doing that. And so, I think it's finding that medium through which, you know, we are reaching everyone, or as many people as possible. That's why I mentioned this podcast as a way to reach a lot of people.”
Dr. Tosoian
— "You know, you don't want to be providing medical advice by Twitter, but pointing someone in the right direction [is needed], pointing them toward the resources that they can then take to their doctor and talk about in more detail…..finding those various avenues to connect with our larger population, our friends and families….”
Dr. Tosoian
Recommended Resources:
- The Original Guide to Men’s Health Podcast, Episode 10. Prostate Cancer: A) Detection, Diagnosis and PSA, B) Surveillance and Treatments.
- The Original Guide to Men’s Health Podcast Episode 43: Precision Oncology: Cancer Diagnosis and Treatment
- National Comprehensive Cancer Network— Patient Resources
- Prostate Cancer Foundation, Patient Resources
- BCAN—Bladder Cancer Advocacy Network.
Episode Transcript:
Dr. Pelman (00:00):
The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episodes the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.
Dr. Pelman (00:18):
Whatever you do, whatever you enjoy, you need your help. Welcome The Original Guide to Men’s Health, a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy, maintenance and prevention strategies, along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Pelman (01:07):
On this episode of The Original Guide to Men’s Health, we'll be exploring allergy and immunology. What does immunology or your immune system have to do with allergies*? Everything! Our guests on this episode are Dr. Lahari Rampur, physician allergy and immunology, Kaiser Permanente, Washington. Dr. Rampur treats allergic disorders and immunodeficiencies and practices at Capitol Hill, Seattle, and in Everett, Washington with Kaiser Permanente. Additionally, we have Dr. Andrew Ayars. Dr. Ayars is an associate professor, department of medicine, division of allergy and infectious diseases, University of Washington School of Medicine. He serves as director of allergy and immunology training program at the University of Washington School of Medicine. Dr. Ayars, Dr. Rampur, welcome and thank you for joining us. Many people have concepts about allergies, have allergies, but I'd like to go into a little background about why our immune systems are involved in the allergic response. Dr. Rampur, why don't you take this first? And then Dr. Harris, we'll ask you to fill in.
*Allergies and Immune System: https://www.hopkinsmedicine.org/health/conditions-and-diseases/allergies-and-the-immune-system
Dr. Rampur (02:24):
Thank you. Thank you, Dr. Pelman for having me here. And yeah, that's an important question. So allergies are typically genetically predisposed. There is nothing much that you can do. However, there is certainly an environmental influence on development of allergies. For example, kids who are exposed to dogs or cats at home, you know, they can develop allergies to cats or dogs. But basically they are genetically predisposed with family history of allergies with parents and history of eczema* can also predispose you to develop allergies as well.
*Eczema: https://www.mayoclinic.org/diseases-conditions/atopic-dermatitis-eczema/symptoms-causes/syc-20353273
Dr. Pelman (03:00):
So in looking at, you know, just going into some basics of the immune system, Dr. Ayars, just give us a little background. What is the immune system? How does it work as far as allergic response?
Dr. Ayars (03:11):
The immune system is actually amazing. If you think about how many bacteria, viruses, parasites we have to fight off, not as much parasites in the developed world. But we're constantly bombarded with, you know, organisms that we have to fight off and your body has to be able to see what's a friend and what's a foe. And that can be very difficult. And frankly, our body's really good at it. It's incredible. I'm actually amazed by the immune system all the time that we're able to pick out what's a threat, fight it off, you know, form the immune response, which is extremely complex. Now I kind of think the immune system, or the immune problems and the multiple categories, there's immunodeficiency*, meaning your body just can't fight off infection. We see people like that every day in our clinics, people without immune system can't fight off infection.
*Immunodeficiency: https://medlineplus.gov/ency/article/000818.htm
Dr. Ayars (03:51):
Now there's mistakes in the immune system and they can manifest in different ways, either rheumatologic or allergic. And rheumatologic, your body accidentally goes after yourself. You can go after a lot of different things and that can present in a lot of different ways. And that's more of a rheumatology talk. Whereas allergy is a body goes after something that's benign in the immune system like a food, a pollen, you know that's not a threat. But our body for whatever reason, and we I'm sure we'll go into that later, sees that as a threat and forms, you know, an immune response. So things like pollen or cat dander or things like that. Or foods, you know, we're constantly eating foods and it's amazing how our body can pick out what's a friend and what's a foe. But you know the immune system, if it's off sees that food as a threat and amounts an immediate immune response* to an or delayed immune response. It's our immune system almost working too well, meaning it's going after things that shouldn't in the allergic. And with allergy it's things external, with rheumatologic it's things internal. So that's kind of a simplistic way to think about it.
*Rheumatologic/Rheumatic: https://www.mayoclinichealthsystem.org/locations/mankato/services-and-treatments/rheumatology/rheumatic-diseases
**Allergic reactions: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/allergic-reactions
Dr. Pelman (04:48):
So Rampur, wet components are part of our immune system? I mean in our blood, what else? And what is in our blood that helps mount the immune response?
Dr. Rampur (04:59):
So the immune system consists of basically cells. So that are T-cells and B-cells, they're mainly white blood cells. I would look at them as sort of the leaders of the immune system, which drive all the other cells. So depending on what is being exposed, different categories of cells get activated. For example, if there is an infection, let's say there is an exposure to bacteria. So the bacteria has components that is recognized by specific types of immune cells, which then release other types of chemicals and molecules to attract specific component of the immune system. So if you are exposed to allergens that are different set of cells that are attracted. And if there are viruses, different type of cells are brought to the area of infection. And depending on the severity of infection, most of the time they are able to take care of the threat with some basic immune response that's called innate immunity*.
*T cells and B cells: https://www.genome.gov/genetics-glossary/Lymphocyte
**Cytokines: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/cytokines.html
***Innate immunity: https://medlineplus.gov/ency/article/000821.htm#:~:text=Innate%2C%20or%20nonspecific%2C%20immunity%20is,defense%20in%20the%20immune%20response.
Dr. Rampur (05:56):
However, if the innate immune response is not able to destroy the pathogen, or the threat, then the specialized forms of cells get activated. And they mount antibody response or long-term memory cells like memory T cells, B cells, which then come into picture. So the next time if you're exposed to a similar threat, the body can recognize easily. For example, in vaccination* so you're given an inactive virus and the body forms antibodies to these viruses. And there are also long-term memory cells. So the next time you are exposed to this specific virus, the body is able to recognize the threat immediately and form the antibodies in an effective manner and take care of it efficiently.
*Memory T cells: https://www.nature.com/articles/d41586-017-08280-8
**How vaccines work: https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html
Dr. Pelman (06:43):
And the antibodies are actually what type of cells?
Dr. Rampur (06:47):
So B cells are the cells which produce the antibodies. So antibodies are not cells. They are molecules or some sort of protein that are produced from the B-cells.
Dr. Pelman (06:58):
Okay. And Dr. Ayars, when we look at response and the immune response, we talked a moment ago about different types of cells from a bacteria or virus to an allergic response. What are those type of blood components that we see that respond?
Dr. Ayars (07:19):
I mean, there's a lot of different types of reactions. The classic allergy is something called IgE-mediated. That's, you know, seasonal allergies. That you watery eyes, runny nose, can cause asthma, can cause food allergies. And that's something called IgE. Dr. Rampur mentioned the antibodies, and they're basically little smart bombs. They have to see something. The body has to form the appropriate immune response. And then they have to be able to glom on and neutralize things like bacteria and viruses. And there's different types of antibodies. The most important is IgG**. That's the one we form that they can help fight off bacteria, viruses, very much essential to us to help fight off these organisms. There's different ones called IgA. There's one called IgE that historically helps us find out things like parasitic infections. Whereas historically, we were always bombarded by parasites and things like that.
*IgE-Mediated Reaction: https://www.rch.org.au/uploadedFiles/Main/Content/allergy/Non%20IgE%20Food%20Allergy.pdf
**Glom: https://www.merriam-webster.com/dictionary/glom
***Immunoglobulin G: https://www.uofmhealth.org/health-library/hw41342
Dr. Ayars (08:09):
We're not exposed to them as much anymore. And IgE, basically we in developed countries oftentimes we don't need IgE. But this type of antibody is what causes a lot of different allergies. It sits on these things called mass cells that we all have in the skin, GI tract, respiratory tract, and they're preloaded with all these different inflammatory mediators. And if they are preloaded with IgE, meaning they are predisposed to react to a pollen or a food, they will rapidly release their contents, release things like histamine, inflammatory mediators like prostaglandins**. I won't get too far into it, but someone walks into a room with a cat. If it's preloaded those mast cells, you know, if you get the cat in your nose that causes it to rapidly release their content. So things like histamine, and causes congestion, itchy, watery eyes, runny nose for those predisposed.
*Mass cells: https://www.aaaai.org/conditions-treatments/related-conditions/mcas
**Gastrointestinal (GI) tract: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract
***Histamine: https://medlineplus.gov/medlineplus-videos/histamine-the-stuff-allergies-are-made-of/
****Prostaglandins: https://www.yourhormones.info/hormones/prostaglandins/#:~:text=The%20prostaglandins%20are%20a%20group,All%20Hormones%20Resources%20for%20Hormones
Dr. Ayars (08:57):
If you breathe it in, you can have asthma: wheezing, chest tightness, mucus production. You know people have food allergies, you know, if they're predisposed and they have that IgE say to peanut. When they consume the peanut, it causes wheezing, chest tightness and the upper airway congestion, you know, things like that, nausea, vomiting. So if you're predisposed and have that allergic antibody, that’s what causes a lot of the allergies that we deal with. Things like allergic rhinitis* or like seasonal allergies, things like asthma and things like food allergies. So we'll talk about this later, I'm sure. But when we do like skin testing or blood testing, we test to look and see if patients have those antibodies and little smart bombs. The things that they shouldn't like, foods and medications or aeroallergens and things like that.
*Asthma: https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc-20369653
**Allergic rhinitis: https://medlineplus.gov/ency/article/000813.htm
Dr. Pelman (09:42):
So in looking at a allergic response, which is based in our immune system, it would be fair to say there is a cascade of events that take place with a recognition of an allergen, and then the response. And the response is trying to contain the allergen, but also a mediated response that involves cells that release certain things that cause our body to have reactions?
Dr. Ayars (10:15):
Yep. It's called the adaptive immune response* meaning say we're exposed to a virus or bacteria, our body has to see that and it has to process it, and know it's a threat and it forms different types of cells. Body has to see something first, react to it and then form the appropriate immune response. That's why if you see a cold for the first time, it takes a while to get over it because your body's giving mounting the appropriate immune response. But if you've seen that cold before, you can fight it off much easier. So same with foods and aeroallergens, your body has to see it. And it has to see it as a threat, and that's inappropriate threat but it sees it as a threat and makes that immune response and forms things like T cell response. But the big one, we were about an allergy, is B cells which make antibodies.
*Adaptive immune response: https://www.ncbi.nlm.nih.gov/books/NBK21070/
Dr. Ayars (11:00):
And again that IgE, sometimes we call it the allergic antibody, which classically fights off parasites and things like that. But now it's just kind of more of a nuisance cause it's one of the underlying causes or that one of the major ones for, you know, food allergies or seasonal or allergic asthma. So again, your body has to see it, mount an immune response, and then it becomes predisposed to, you know, in best case scenario, fight off a bacteria or virus, you know. The worst case scenario, it affects things that are benign like a pollen or a food, or like rheumatologic disease even like rheumatoid arthritis, goes after our joints and things like that. So again, when the immune system is functioning appropriate it's very efficient. It sees it, processes it and has a memory. So it can fight it off if it sees it again. But in the inappropriate response, it either goes after itself in the body, or it goes after something that's benign, again like a pollen or a food.
Dr. Pelman (11:51):
So going back, before we talk about various types of responses and where they're manifest in the body and how they're manifested, Dr. Rampur had said that a lot of this is genetically predetermined. That your immune system is going to turn itself on when it sees something based on sort of genetic code that you were born with. Dr. Rampur?
Dr. Rampur (12:12):
Yes, that is true. So if you're genetically predisposed, you are more likely to have allergic conditions like eczema, seasonal allergies, sort of environmental allergies, as well as food allergies. So here's an interesting thing about how kids with eczema may develop food allergies later on. So eczema is mainly a condition where the barrier, the skin barrier, is affected. So normal skin when it is exposed to food allergens or some other irritants, it has a good barrier. It doesn't react. However, kids with eczema has an issue with a barrier. So if the food is exposed through the skin, the skin can, the body gets sensitized to that allergen and can cause allergic reaction. So they may develop antibodies, which may recognize these allergens in the future as a threat. For example, a kid with horrible eczema is constantly exposed to peanut dust or peanuts at home. So their body processes that peanut as a threat. So normally when you eat peanuts, you may not become allergic. However, if there is an issue with the skin, if it's exposed through a different route, it can become allergic. The next time the body's exposed to the peanuts, these antibodies can attack the peanut molecules, and they go and tell the mast cells to release the histamine. And that's when you start having the reactions like itching or hives or anaphylactic type of reaction. So these are genetically predetermined, you know, parents with history of asthma, parents with history of eczema, or seasonal allergy type of history.
Dr. Pelman (13:48):
So let's look a little bit at some of the common type of allergic responses. We just talked about eczema. And again, a lot of this is based upon what you're being exposed to, what you're allergic to, and we'll go into some of those in a little bit. But generally, you might classify allergic responses in the skin and where else?
Dr. Ayars (14:12):
So itchy, watery eyes, runny nose, rash and post-nasal drip, sneezing are kind of the classic. And that can be, do a lot of different aeroallergens, things like dust, dust, mites, pets, grasses, aeroallergens, grasses, trees, molds, things like that. So classically upper airway. And the lower airway, you know, asthma causes, you know, wheezing, chest tightness, shortness of breath. You know, historically it's been called hay fever*. That's kind of a misnomer cause you don't get a fever with it. You felt sick. So that's why they got that name again. The fever is a misnomer, but you kind of feel like you have a cold basically when you're exposed to those aeroallergen, either a certain time of the year or if you're in an environment with dust mites or you have a pet allergy. That's kind of how the upper airway manifestations present.
*Hay fever: https://www.mayoclinic.org/diseases-conditions/hay-fever/smptoms-causes/syc-20373039
Dr. Pelman (14:57):
Yeah. You mentioned asthma. A lot of people think of asthma as a pulmonary disease, but asthma is really based in a allergic response?
Dr. Ayars (15:07):
Asthma is like arthritis. There's a lot of different types of asthma, and allergic asthma is certainly one of those types. Basically just like it causes inflammation in the upper airway and those that are genetically predisposed, it can cause lower airway inflammation. And classically, it seems like wheezing, chest tightness, shortness of breath. So we always ask patients, you know, you get asthma symptoms when you're in a room with a cat? You get at a certain time of the year? What are your certain triggers? So it's a broad question, and there's a lot of different types of asthma. But allergic asthma is what we see a lot of, especially in young kiddos. We see that a fair amount.
Dr. Pelman (15:41):
Okay. So let's take a look at some of the more common allergens in categories. So I'm going to throw out drugs. We have people who are allergic to medication, Dr. Rampur, what happens there?
Dr. Rampur (15:58):
So there are different types of allergic or hypersensitivity responses to medications as a broad category. It could be immediate or delayed type of responses. Immediate responses are, you know, as soon as you take a medication. For example, penicillin is one of the most common drug allergies. So the moment you take it, within like 15 minutes or half an hour, in most of the cases it happens within a few minutes of taking, you may feel itchy, flushed red, or hives all over your body or lip swelling or tongue swelling, throat closing type of sensation or wheezing or asthma type of response. Those are immediate type of allergic reactions. And this is where testing is most helpful. There's another type of reaction where when you take a medicine, initially nothing happens. But after seven days of taking, you may start to notice the rashes all over your body.
Dr. Rampur (16:48):
So most of the delayed rashes are benign. They just go away on their own after a few days after stopping the medicine. However, there are other types of delayed responses where it can be pretty severe. So where your internal organs may get affected, or you may have massive skin peeling type of response. Meanwhile, your internal organs or mucus membranes like mouth or gastrointestinal tract is called severe cutaneous drug responses. So like these, there are several different kinds, but you know, we often get asked about them. This patient had vomiting type of reaction to a medication. Can you test them? So vomiting by itself without any other symptoms is not an allergic response. It could be some kind of an intolerance and testing is not indicated. In studies have shown that more than 90% of the time, allergic response to any medication, you know, does involve a skin response like itching or hives. If somebody has a subjective breathing difficulty without any objective evidence of wheezing or anything, it's less likely to be a true allergic response.
Dr. Pelman (17:55):
And because we have people concerned currently about COVID vaccination and drug reactions. Dr. Ayars, I know that the reaction to the current vaccines as far as allergic response are rare, but can you go through a little bit about people who are concerned about that? What the risk? I know it's small and also how you might mitigate it. If say you've had allergic responses to other medications, does that necessarily make you more at risk for a COVID vaccine reaction?
Dr. Ayars (18:31):
The reactions are exceedingly rare. You can get, like Dr. Rampurl talked about, immediate type reactions: immediate wheezing, chest tightness, shortness of breath, lightheadedness. Those are very rare, but you can see them. So evaluate this all the time. And frankly, most of the time we're able to clear that to get the second vaccine or their booster. So, you know, even if there's a, you know, a fairly immediate reaction, oftentimes we can clear them and there's different components in the vaccine. But again, for the most part, it's very well-tolerated. Now there are delayed reactions that have been described, but again, those are exceedingly rare as well. You know, delayed rashes, a few other things that can happen after a few days. But for the most part they're really safe and really well-tolerated in almost anybody. You know, what we always ask people, “Have you had a reaction to a vaccine in the past?” And we try to characterize that. Drug allergy can be pretty tricky cause we don't have a lot of tools to diagnose it.
Dr. Ayars (19:24):
So it comes down to the history. What happened and what type of immune response do we think it was? So, you know, with the COVID vaccine, I always ask, “Have you reacted to any other vaccines? If so, was it immediate? Was there immediate wheezing, chest tightness, shortness of breath?” And if it was more mild, we've usually cleared them to get it. And we oftentimes will tell them to take a few anti-histamines. And instead of waiting around the average 15 minutes, we usually say, just stay about a half hour instead just to make sure nothing severe happens. But you know, I've seen, I'm sure Dr Rampur is the same, I've seen hundreds and hundreds of hundreds of these type of reactions. And most of them were able to clear. Most of them were able to tolerate the vaccine moving forward.
Dr. Pelman (20:01):
So when you say clear, do you mean you giving a medication to treat them or they just resolve spontaneously?
Dr. Ayars (20:07):
They clear them to get their second vaccination. They had a, you know, some chest tightness during the first vaccine. You know, we always ask about other symptoms. Did you feel like you're going to pass out? Did you have, you know, skin symptoms? And if they didn't usually we, again, clear them so that you can have that vaccine, but you might want to pretreat with some anti-histamines. I usually say Zyrtec, Allegra, or something like that. And then just wait a half hour instead of the standard 15 minutes that most facilities require. So there are people that have had a severe reaction to the first vaccine and that's where it can get tricky. But if there is a severe reaction to the first vaccine, that's when we always recommend see an allergist, an immunologist, and tease it out. And they can kind of have risk stratify if you will. So even if they've reacted to a different vaccine in the past, that's not a contraindication to getting COVID. And even if it's a mild reaction to the first COVID vaccine, oftentimes they're able to receive their back second vaccine or booster without an issue.
Dr. Pelman (21:01):
Dr. Rampur. So if you had a patient who is hesitant about receiving any COVID vaccination because of prior allergic reactions, would you pre-treat them? Or just monitor them and say, “We can treat you on the spot if something happens.”
Dr. Rampur (21:17):
So I have never recommended pre-treating any patients. I would ask them to take the vaccine and we monitor them, depending on the anxiety level, half an hour to 60 minutes. Yeah. I mean, it's out of abundance of caution. You know, of course people with history of severe anaphylaxis to, as you know, some of the medications and food, according to CDC guidelines, we monitor them for 30 minutes. But we don't necessarily know that they're actually at increased risk of having severe reactions to COVID vaccine. So there is a lot of anxiety. Of course, I do see a lot of patients with these concerns. So another aspect that I wanted to touch upon is that patients with previous history of severe reactions to another vaccine, we consider that a little bit more serious. We, first of all, true allergic reactions are extremely rare. However, if somebody said they had hives or low blood pressure, hypertension, chest tightness type symptoms with a, you know, let's say diptheria, tetanus vaccine. Some of the vaccines do contain similar components as COVID-19 vaccines. And that's when we also consider testing for, let's say polyethylene glycol, which is present in Pfizer and Moderna vaccines, and polysorbate*, which is presented in Johnson & Johnson vaccine. And polysorbate and polyethylene glycol, they cross-react with each other. And that's when we also consider testing to make sure.
*Polyethylene glycol: https://medlineplus.gov/druginfo/meds/a603032.html#:~:text=Polyethylene%20glycol%203350%20is%20used,it%20is%20easier%20to%20pass.
**Polysorbate (polysorbate-80): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015121/#:~:text=Polysorbate%2080%2C%20also%20known%20as,surfactants%20%5B1%2C%204%5D.
Dr. Pelman (22:43):
So as Dr. Ayres suggested, first of all reactions are extremely rare to the COVID vaccines. Two, If somebody does have a true allergic reaction to a different type of vaccination, they should see an allergist, immunologist, be tested and sort that out. And they still could potentially be a candidate to receive a vaccine, but they would go in having been evaluated. Dr. Ayars?
Dr. Ayars (23:09):
Certainly. We get a lot of referrals for people that have reacted to even a different vaccine. So with drug allergy, the biggest thing is the history. What happened? You know, what was the timing? What were the symptoms? And that really helps us risk stratify, you know, who is at risk for having a more severe reaction to the COVID vaccine, who isn't. So again, it comes down to the history. And if there's any question we always recommend seeing an allergist and immunologist for evaluation. Whether testing is necessary, that really depends on the history. But again, the biggest thing, we just need to sit down with them. What was the previous reaction? And that helps us risk stratify. You know, who is it likely to react to the COVID vaccine?
Dr. Pelman (23:46):
Well, let's go now to the common allergies. We talked about drugs. Let's talk about food. Now food is a very general term. We need food to sustain us. And it seems like, how can somebody be allergic food? But we know gluten. So let's review gluten for a sec., gluten allergy. What happens there?
Dr. Rampur (24:07):
Gluten allergy is a very broad term, and people kind of misuse gluten allergy, pretty much for all kinds of symptoms. You know, I do hear a lot of patients complain that they do have gluten sensitivity. So sensitivities, allergies there's is a huge difference, what can be tested and what cannot be tested. So gluten is a broad term for, you know, grains that contain gluten. But allergic response is typically to a specific allergen, not broadly to the gluten. For example, people can be allergic to wheat, contains gluten, but you are not allergic to the gluten component. When somebody say allergic response to an allergist, we think that the true allergic responses are itching, hives, slips, filling sort of immediate responses. And that happens because of preformed antibodies. Let's say you're allergic to wheat. You should have IgE antibodies, which can be tested. But when people say that I feel bloated and crampy after eating some gluten containing food, is this an allergic response? May not be. It could be some kind of an intolerance, or it could be gluten sensitivity, which is another immunological disorder. It's nothing to do with allergic response. It is because of antibodies to like they are called celiac antibodies, anti TTG antibodies, basically. And that's what we test them for. But this is not an allergic response.
*Food allergy vs food intolerance: https://www.mayoclinic.org/diseases-conditions/food-allergy/expert-answers/food-allergy/faq-20058538
**Anti Tissue Transglutaminase (TTG) antibodies: https://celiac.org/about-celiac-disease/screening-and-diagnosis/screening/
Dr. Pelman (25:33):
Dr. Ayars?
Dr. Ayars (25:34):
Yeah. I kind of categorized quote unquote, gluten or wheat allergy, or I say, quote, unquote allergy and the three categories. Ones, you can be allergic to wheat in form the classic immediate wheezing, chest tightness, lightheadedness, nausea like we talked about Dr. Rampur with the IgE. Actually that's pretty darn rare, especially in adults. I don't never see a true wheat allergy. Then there’s celiac disease* with Dr. Rampur also talked about. That's a different type of immune response to the gluten, which causes inflammation in the gut. And that usually presents with weight loss, you know, abdominal pain, diarrhea, things like that. And the way you test for that is actually do have to do a biopsy in the gut is the gold standard. And that's somewhat rare. Although a lot of people do have celiac disease. And then the most common is basically non-celiac gluten sensitivity, which is kind of a wastebasket term.
*Celiac disease: https://medlineplus.gov/celiacdisease.html#:~:text=Celiac%20disease%20is%20an%20immune,wheat%2C%20rye%2C%20and%20barley.
Dr. Ayars (26:24):
You haven't a reaction to it. It's not an immune one. And classically it's, abdominal pain, nausea, bloating, things like that. So again, there's the classic allergy, which IgE or the immediate reaction, which is very rare. Or celiac disease, which has the delayed reaction, which again in the gut causes diarrhea, abdominal pain, things like that. And then again, the most common is non-celiac gluten sensitivity. And I always tell you, say sensitivity is very real. It's just not an allergy. We don't have testing for it. So if you rule out the other two, the immediate reaction and celiac, basically it goes into this non-celiac gluten sensitivity. So people generally just don't feel well. And mainly GI symptoms with gluten.
Dr. Rampur (27:04):
I would also like to add that a lot of people have chronic abdominal bloating and gastrointestinal symptoms. They sort of think that they could be allergic to many different foods and they start avoiding these foods. You know, when somebody has symptoms chronically and they feel like they're reacting to everything, they're less likely to be allergic to the food. But there might be something wrong with their gut itself. So I would recommend gastroenterology evaluation rather than, you know, allergy evaluation at that point to see if that is some kind of an inflammatory bowel condition or an intestinal condition.
Dr. Pelman (27:38):
Thank you. Well, let's look at crustacean or shellfish. That's a common food allergy that some people have. Do you want to break that down a little bit? Dr. Ayars?
Dr. Ayars (27:48):
Yeah. So as kids, a lot of kids have developed food allergies. And the reason for that is very complex. And we can talk about that later if you want, but kids can be allergic to a lot of different things. You know, wheat, dairy, eggs, things like that. Most of the time they grow out of those allergies. There's a few that hang onto that into adulthood. But the more common ones that go into adulthood are about peanuts and shellfish allergy, you know, shrimp, lobster, crab, You can be allergic to finfish as well, salmon, cod, things like that. So yeah, that is, it's a very common and especially me seeing mainly adults. That's the most common allergy, that along with peanuts and other nuts that can cause that type of reaction. So it is one of the more common types of allergens. And so what we do see a lot of that, especially me seeing mainly adults, that's the most common that again and peanut or the most common ones that we see. Again, the other ones that a lot of kids can be allergic to like wheat, milk, you know, things like that, most of the time they grow out of that by the time they hit adulthood,
Dr. Pelman (28:46):
Dr. Rampur, when people have shellfish allergy, I've heard people say, “I can eat one type of shellfish, but not the other." If somebody has a reaction, should they stay away from all shellfish? Or how do you distinguish what kind of crustaceans they can consume?
Dr. Rampur (29:02):
So generally I would categorize shellfish allergy as shellfish, as crustacean and mollusks. Examples for crustaceans are shrimp lobster, crab, and mollusks are clam oysters and scallops. So crustaceans have, you know, they're more than 50% cross-reactive. So if you're allergic to shrimp, you could also be allergic to crab, but I've also seen patients who can just be allergic to shrimp, but not allergic to crab n' lobster. It kind of depends on the history, but if they are allergic to shrimp, I generally ask them to avoid all types of crustaceans. Because if you eat at a restaurant, that is a significant chance of cross-contamination. But the patients with crustacean allergy are not necessarily allergic to mollusks. Some people are, but that cross reactivity is lower compared to the cross-reactivity among the crustaceans. So when they are eating at a restaurant, I asked them to avoid all types of shellfish, but if they're pretty short at home and if they are re recently eaten clams, if they had an allergic reaction to shrimp, and if they're doing okay with the molluks, I would let them eat if they are a hundred percent sure. Yeah.
Dr. Pelman(30:10):
And you know, a common question is have people had this all their lives or can people develop these sort of shellfish allergies or mollusk reactions later in life?
Dr. Ayars (30:23):
You can develop an allergy at any time. Most commonly it occurs when they're younger, when they're a kid, when they are first introduced. The foods are seen in teens, twenties, it's very rare, but I see people develop it later in life. We don't know why that is. We're not entirely sure. So most commonly people develop allergies when they're fairly young and initially close to the foods, just kind of step back. I know it's a little off topic, but you know, say like peanut allergy, their old dogma used to be wait and don't administer it. Don't give the kid if you're predisposed to allergies until they're four or five. But there was a study a few years ago called the Leap Study where peanuts, where they randomized the groups into either early introductions, around six months versus three or four years. And the difference is totally different. The people that introduced early had a much lower incidence of allergies. So I remember sitting in a room as a fellow and people argue back and forth early versus late introduction. Now it's clear, introduce it as early as possible around six months. And that significantly decreases the risk of developing a reaction, specifically to peanuts. But you can associate that with other foods as well.
Dr. Pelman (31:26):
So An infant at six months, won't be able to chew a peanut, bu peanut butter?
Dr. Rampur (31:31):
Yeah. One of the reasons they realize this is in Israel, there's a food called Bamba that a lot of parents will give their kids. It's a peanut base, but it can really melt in the mouth. Actually, my kids loved it as well. And they introduced that earlier and they had a lower incidence of peanut allergy and that's one of the reasons they started this study. So there's a lot of different forms of peanuts that you can introduce. But the classic is Bamba, which is a very common, you can see it in most supermarkets. And that's what I gave my kids when they were around six months.
Dr. Pelman( (31:58):
And looking at the concern. I know that even if peanuts are in the air, the airlines have stopped circulating peanuts. If somebody has a definitive peanut allergy, what steps should they take to protect themselves?
Dr. Rampur (32:11):
So basically I advise no touching or eating. You know, if somebody next to you is eating, usually it's not a problem. It's not like inhaled in the air. And it's very less likely that they develop an allergic reaction without touching or eating. If you have a history of allergic reaction, make sure you read the labels of everything that you're eating or coming in contact with, and also carry an EpiPen. And never forget too, that's life saving. So everybody who has a food allergy should carry an EpiPen.
Dr. Pelman
Dr. Ayars?
Dr. Ayars (32:42):
I agree completely. The biggest thing is epinephrine and always having that available. Early epinephrine is life saving. You know, we do studies where again, to the studies and testings, you have to actually put, you know, kids or adults into reactions. We know the earlier we give epinephrin, they do much better. So there's a stigma about epinephrin and it's actually a very safe medication. So I tell patients if you're on the fence, you think you may be going into reaction, just take it and we'll tease it out later. So I agree with Dr. Rampur. The biggest thing is having an epinephrine. obviously reading labels and things like that is very important, but you know, having a strategy and things like Benadryl don't cut it. So, you know, epinephrine is by far and away the best treatment. So for those who have a severe allergy to anything, you know, shellfish peanuts, the biggest thing is having an epinephrine auto injector available at all times.
Dr. Rampur (33:29):
For when someone is in doubt, its always important to use epinephrin, rather than not using it. And one of the biggest causes of severe reactions, which turned out really bad, is that delay in using epinephrine. That's one. So when you're having a severe allergic reaction, people can have low blood pressure. And during this time, if you don't use epinephrine, but you stand up too quickly, or walk around, people can collapse and even die. So that's when severe reactions can happen. So when you're having a severe reaction take epinephrine, go call for help, call 9 1 1, because that's not the complete treatment, they still need to be monitored. EpiPen, lay down quickly, there where you are, and then call for help.
Dr. Pelman( (34:10):
Excellent. And we touched briefly on egg and milk. Do any of these travel together or do they distinctly separate the egg and milk allergies? Dr. Ayars?.
Dr. Ayars (34:19):
I mean, people that are predisposed to allergies, you're more likely to have multiple allergies, but there's no cross-reactivity between the two. It's just people who are predisposed to develop food allergies are more likely to develop it to multiple allergens like Dr. Rampur, you know, discussed, you know, crustaceans and things like that. That's much more likely to react to one versus the other, whereas like milk and peanuts, soy they're unrelated. Just those people are predisposed to develop that reaction.
Dr. Pelman (34:45):
And you said earlier that kids who have milk allergies can outgrow them.
Dr Ayars (34:50):
Yeah. It's very common in milk. So, things like that and egg. they're most likely able to grow out of those. It's the ones like peanuts, tree nuts and shellfish that people are much less likely to grow out as they get into adulthood. Now it's important to establish with an allergist and they test annually often, depending on the patient, just see whether they have the skin test positivity or the blood test positivity. So we just monitor that. Okay.
Dr. Pelman (35:15):
And before we leave, food's just one last. Sulfites? How do people present with sulfite? Where do they find those?
Dr. Rampur (35:21):
So sulfite in wines and certain types of food, like lettuce, can cause primarily asthma type of reaction. I haven't seen this commonly, but it's less likely to cause anaphylactic type of reactions. But there is no way to test this. You know, some people believe that they're allergic to sulfites in wine and alcohol, but there's no way to test them or prove.
Dr. Ayars (35:45):
Yeah, it's a distinct mechanism from the classic allergy. So it's much easier to diagnose, and usually the reactions much less severe with sulfides.
Dr. Pelman (35:54):
Well, let's look at moving off of foods to things that are common here in the Northwest. Mold. So I hear a lot about, you know, have your house suspect from mold. What happens? What's the manifestation of mold in your environment?
Dr. Rampur (36:10):
So, typically more allergies can cause now chronic sinus issues, inflammation inside your nose, and asthma, wheezing and chest tightness. And it can also cause a chronic hypersensitivity condition called ABP, called allergic bronchopulmonary aspergillosis. It's a condition where it presents like asthma, but the routine asthma treatment not work. So they present as difficult to treat asthma. And that's when we do the blood testing and also do a CT scan of their chest to diagnose. Apart from this, you know, I also hear people say, you know, toxic mold syndrome and some of weigh other symptoms, but there is no evidence that molds are actually causing the problems. And there are many types of molds in that environment. Not everything is harmful. Just because somebody is able to visualize it, easy to attribute their symptoms to the mold. But many of them do not even cause symptoms. There are a variety of toxins produced, but some are totally harmless. So there are some of them which can cause, in which can commonly cause respiratory issue, are aspergillus**, alternaria, penicillium, cladosporium. These are some of the common ones that we do test. And if they're positive, we can do allergy shots and things like that. But not every mold is harmful. I have to say.
*Allergic Bronchopulmonary Aspergillosis (ABP): https://www.aaaai.org/Conditions-Treatments/Related-Conditions/allergic-bronchopulmonary-aspergillosis
**CT scans: https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675
***Aspergillus: https://www.mayoclinic.org/diseases-conditions/aspergillosis/symptoms-causes/syc-20369619
Dr. Pelman (37:26):
Another source for allergies would be pet dander. So what happens there? What kind of reactions do we see?
Dr. Ayars (37:36):
Pet danders, you know, like I mentioned cat, you know, think over 50% of the country in the households have a dog now. And our mantra is, you know, even if you're allergic people get rid of their allergists before their animals, you know. You know, dogs and cats are family. So they do manifest, you know, upper airway, itchy, watery eyes, runny nose, congestion, asthma. Where people predispose, wheezing, chest tightness, shortness of breath, things like that. And classically it's when you're exposed, although specifically cat allergen is a very sticky allergen. So it's very difficult to get out of the house. You know, with dogs, there's some evidence to say, you know, if you're washing your dog or keeping it clean, that can help somewhat. But cats, it's very difficult. And I do want to step aside and say, there's actually no such thing as a hypoallergenic breed. I hear that all the time. They did a study a few years ago, it looked at this. What they found is actually the individual dogs themselves have vastly different amounts of allergic protein. So it's actually not the breed itself, it's the individual. Actually in that study, the lowest was labs, which is not quote unquote hypoallergenic. So yeah, there is no such thing as a hypoallergenic breed but some dogs seem to be more allergenic than others.
Dr. Pelman (38:44):
Interesting. So looking at somebody who, like you said, they'll get rid of their allergist before they get rid of their pet. I want to keep my dog. I want to keep my cat. What do we do?
Dr. Ayars (38:55):
Medical therapies are where we always start. You know, for upper airway, topical steroids, things like flonase, nasonex*, anti-histamines things like Zyrtec, Allegra, things like that. So there's medical therapies, you know. Like I talked about, there's some evidence that bathing them twice a week can decrease the allergenic protein but that's somewhat controversial. And the final thing that I'm sure we'll touch on this is allergy shots. That's the one thing that changes your body's underlying immune response to those. So a lot of my patients who say get a dog and obviously they don't want to get rid of their pet, they'll come to us. One for medical therapy, you know, obviously we diagnose that with skin testing or a blood test. And if the medical therapy isn't cutting it, that's when we often times go to allergy shots, which work fairly well for most people, but they’re a lot of work. So we kind of saved them for last line.
*Flonase: https://www.flonase.com/allergies/what-is-fluticasone-propionate/
**Nasonex: https://www.rxlist.com/nasonex-drug.htm
Dr. Pelman (39:42):
Dr. Rampur, any thoughts on pet allergies?
Dr. Rampur (39:45):
So there are also certain things that you can do at home to reduce the pet dander. HEPA air purifiers have shown to reduce dander exposure. And we also ask people not to expose or not to allow pets inside their bedrooms, especially when they have severe allergies or asthma. Yeah. These are some of the things that you do. And yes, allergy shots, as Dr. Ayars mentioned is a way to go if you still have persistent symptoms
Dr. Pelman (40:11):
And do people have carpeting versus a bare wood floors do better or linoleum floors without carpeting who have pets? Are there any tricks that way?
Dr. Ayars (40:21):
Yeah, no. The carpet is certainly a reservoir. The bedroom is as well. We have people that cover their sheets if they have dust mites, which is one of the most common allergens at least in this part of the country, the Pacific Northwest. Dust mites are basically our dominant year round allergen other than pets. So you can get dust mite covers, cover the sheets, mattress, things like that. Yeah. So there are strategies to limit it. A lot of patients, if they can, tell them to get rid of the carpet in the bedroom specifically. But that's not always an option for people, you know, other reservoirs for things like dust mites or stuffed animals or old, you know, old carpets in the bedroom or things like that. So I tell them to try and get rid of it, specifically with dust mites, to get rid of as many reservoirs as they can.
Dr. Pelman (41:02):
So deep cleaning HEPA filters; try to get rid of reservoirs; topical treatments that you can take; all will help mitigate responses to things like dust mites. Let's talk briefly about insect because that can be, I know people have certain bee allergies and reactions. Dr. Rampur, you want to take that?
Dr. Rampur (41:25):
Sure. You know, the common types of stinging insects are honeybee, yellow jackets, white faced hornets, yellow faced hornets, wasps, and fire ants. People can have pretty severe reactions to these. They can have anaphylaxis hypertension, people can collapse. Or they can also have local reactions like itching and swelling, localized swelling. So how we can do allergy shots or venom immunotherapy shots for these as well, especially for people who've had severe reactions. So studies have shown that people who have a severe reaction to a stinging insect are more likely to develop future severe reactions. And for these people, we recommend testing as well as allergy shots. So there are some people who get large local reactions, meaning they get stung and the entire limb gets swollen. So this is also some type of an allergic response. Generally, they may not be at a very high risk of developing severe reactions. However, if you are a beekeeper and you are constantly at risk of exposing yourself, we do recommend testing and they can consider allergy shots as well.
Dr. Pelman (42:35):
You mentioned fire ants. They have a friend who had never been subjected to a fire ant bites. It was out in the garden and did, and got severely systemically, really, almost an anaphylactic type of reaction. Would you advise that person then to have allergy shots or, you know, for a rare fire ant? Or could just carry an EpiPen? Or what sort of things should they do?
*EpiPen: https://www.epipen.com/en
Dr. Ayars (43:01):
Dr. Rampur brought up a nice distinction there. There's that large local rash, which I get. If I'm stung my upper arm might swell all the way down to my hand. Now I've never been tested. I don't need an EpiPen. I don't eat allergy shots cause I'm not much higher risk than the general population to react. We always distinguish that from immediate wheezing, chest tightness, whole body hives, lightheadedness. That's a different story. Those patients are at a much higher risk. If they're stung, they're at a 50% chance to react. Now if we get them an allergy shot, that gets down closer to around 5%. So it's an incredibly effective therapy for it. Obviously we always have them carry an epinephrine auto injector, but if your friend had a severe, immediate reaction, you know, we don't see fire ants around here, but down south, you know, when fire ants answer native, yes, we do recommend that they at least consider starting allergy shots. And certainly we recommend they carry an epinephrine auto injector.
Dr. Pelman (43:50):
Excellent. And I want to touch on latex allergies, which we see a bit. How would that manifest and how does somebody know if they had a latex allergy?
Dr. Ayars (44:00):
So latex allergy can be IgE mediated, meaning they can have antibodies to latex. So when they come in contact with latex, they can have immediate onset hives or swelling or anaphylactic type of reactions. Latex allergy, these days, is very rare and testing is also not greatly sensitive. We can do blood tests or we can do skin tests, but I've never seen a positive latex allergy. And there are also certain types of food like fruits, like banana and avocado, can cross-react with latex. You know, people with latex allergy can have reactions to these fruits, and people with reactions to these fruits may have maybe a higher risk of reacting to latex. But I've never seen a positive latex, truly positive latex study.
Dr. Ayars (44:46):
And latex was a big issue in the nineties, late eighties, mainly because people started wearing gloves more mainly because of the HIV epidemic. So they used to see it a lot. Or not a lot, but it used to be much more common. I agree with Dr. Rampur, I very, very rarely see a true allergic reaction you know, to latex. It can be an irritant, especially if you're breathing it in and it can cause irritation. But you know, most of the products we use, especially in the medical field, are not latex based. So it's a much less common problem than it was, you know, 20, 30 years ago.
Dr. Pelman (45:18):
And lastly, let's look at plants, you know, weeds, grasses, and hardwood, deciduous trees a far as seasonal allergies that a lot of people suffer from and the pollen counts are up. Let's talk a little bit about what would somebody do? Spring allergies, fall allergies, summer allergies. What do you see? What do you advise? What do we do?
Dr. Rampur (45:40):
We treat pollen allergy, grasses and weed pollens, as you said. Trees are common in the spring season; grasses in the summer season between May and July. And weed pollens are common between June, July, and they go on up until September, October. So if somebody has severe allergy seasonal allergy, we would treat them consistently with antihistamines or nasal sprays. If they have sporadic, once in a while type of symptoms, they can just take medicines as needed. However, if they have persistent severe symptoms, I would ask. Let's say their symptoms are starting in February. I would start end of January or beginning of February, start the medication to prepare your respiratory system. Better to take on that allergen lower and stay on that consistently. But if you feel like your quality of life is being affected with symptoms every year, I would recommend allergy shots for them.
Dr. Pelman (46:35):
Dr. Ayars?
Dr. Ayars (46:36):
It depends on where you're listening to those podcasts. There's different pollen seasons, depending on where you are in the country. So, you know, if they are bothering you, most people, you know, we don't see most people with seasonal allergies cause most of the time now that a lot of these medications are over the counter, like Zyrtec, Claritin, Allegra, Flonase. Most of the time they can control it, but we see the more severe cases. And if that's the case, it is a good idea to get tested. You know, what I do is test all our allergens and I know what our pollen seasons are in this part of the country. So I say around this part of the year, start taking, you know, this nasal spray or this anti-histamine. And stop it, you know, at the end of the grass season, whenever that is, where they are in the country.
Dr. Ayars (47:14):
So it depends on where they are, but if you're not getting by with medications, you know, again, and that's why we test for things like dust mites, where you can do environmental controls, things like that. We usually try environmental controls, medications. And if that doesn't cut it, then that's oftentimes when we'll talk about allergy shots, which again, work very well, but are very labor intensive. So we try to, you know, environmental controls and medications first. And again, the classics are the anti-histamines and the nasal sprays like Flonase, Nasonex, Nasacort, things like that.
Dr. Pelman (47:43):
These are over-the-counter now as long= as well as a lot of the common anti-histamines right?
Dr. Ayars (47:48):
Yes. And they're very accessible. They're very cheap. So yeah, most of the time people can get by just doing those. But if they're not, that's usually when we say see an allergist get tested, cause we can come up with other strategies as far as what time of the year. Again, dust mites around here are the major allergen. So there's things we do as far as environmental control. So if you're not getting by with those medications, that's usually what I recommend getting tested.
Dr. Rampur (48:10):
So if you’re allergic to just grasses, you can take grass tablets. They are a sublingual form of immunotherapy. It's easier that you can take it at home. Usually the first dose is given in the allergy clinic and we monitor to make sure there's no allergic reaction. But you can take the rest of the doses at home every day. So it's easier for people who are just sensitized to process.
Dr. Pelman (48:33):
And we spoke a lot about allergy testing. Dr. Ayars, do you want to just explain what happens? Because a lot of people don't know. They go, well, how do you get allergy tested? Is it a patch test or what is modern allergy testing look like?
Dr. Ayars (48:47):
That's a great question. And it depends on what type of reaction you have. For things like asthma, you know, seasonal year round allergies, what we most often do as allergists is a skin prick test*. Basically it's just purified allergen. We put it on the skin, exposed to those things called mast cells that we all have. And if it forms basically a bump or a hive, that means you're positive. So that's most commonly what we do as allergists cause it's done in 15, 20 minutes and you have your results. We can go over them in real time. There's also a blood test to look for like we talked about that IgE or the allergic antibody, and that gives us similar information just not readily available. So either of those look for things like seasonal allergies, asthma, food allergies, that's another way to do it as well. So that's the most common way to look at that. Now there's other types of allergic reaction. I won't get into things like contact dermatitis, like poison ivy, things like that. That's called a patch test where we leave the individual allergens on a skin for several days, and then look to see if there's a reaction. By far and away, the most common tests, if you do go see an allergist, is a skin prick test, which again takes 15 to 20 minutes and you have your answers.
*Allergy Skin Tests: https://www.mayoclinic.org/tests-procedures/allergy-tests/about/pac-20392895
Dr. Pelman (49:50):
And then desensitization we talked about. Is this allergy shots that we're talking about?
Dr. Rampur (49:56):
Yes. So desensitization is a broad term which can be done for environmental allergens, but it doesn't mean that your allergies are going to completely resolve. So once you stop the allergy shot, some people may have recurrence of symptoms up to sometime as well. So we do desensitization for medications as well. For example, somebody has a history of allergic reaction to penicillin, and we do the skin testing and the skin test is positive. That means that they are allergic. So what we do is slowly introduce penicillin and with a very small dose, and we keep increasing the dose every 15 to 20 minutes to reach the maximum level. That's also called us desensitization, a drug desensitization
Dr. Pelman (50:42):
As we wrap up, I always like to give our listening audience the opportunity to look towards some resources that are available. So if either of you have some favorite resources for allergies that you would give patients or put out there, let us know, go ahead and just list them. Dr. Ayars, do you have some favorite resources?
Dr. Ayars (51:03):
Not really. I have my group of, you know, handouts that I give patients. The biggest one is dust mite control measures. Again in this part of the country, and a lot of the country that's the major year-round allergen. So, you know, things like dust mite covers, you know, washing the bedding at a certain temperature, things like that. But the American Academy of Allergy Asthma and Immunology is a great resource as well. Same with the American College of Allergy Asthma and Immunology. Those are our two big groups and they put out great information for patients. I've gone to that website is another great spot.
Dr. Pelman (51:32):
So say those again, the?
Dr. Ayars (51:34):
We call it the quad AI, American Academy of Allergy Asthma and Immunology (AAAAI). And the other one is the college, American College of Allergy Asthma and Immunology (ACAAI). So AAAI, ACAAI are great resources.
Dr. Pelman (51:48):
Excellent. And people can find those online?
Dr. Ayars (51:51):
Yup.
Dr. Pelman (51:52):
Dr. Rampur, do you have any other favorite resources?
Dr. Rampur (51:55):
I agree with Dr. Ayars and you know, one of the things that my patients find helpful allergyfreeskin.com. So this is recommended by one of the contact dermatitis specialists. So contact allergies are due to like preservatives and creams or personal care products that you use. They can cause chronic allergy type of symptoms. And we do something called patch testing that goes on their back. And this is not like an immediate skin prick testing that we do for other allergens. So once we find what they're allergic to, I typically give them the handout from the website on what they're allergic to and what they have to award. They can also find the allergen free products in this website called allergyfreeskin.com, which is recommended by a national expert as well. Obviously they have to verify before using the products, but they generally find this helpful.
Dr. Pelman (52:47):
And resources for their patients public out there would be primary care physician, family, doc, and then referral to allergy immunology as necessary.
Dr. Ayars (52:59):
Yeah. Most of the patients go to their primary doctor first, who are, but most of them are very good at managing this and, you know, go through the initial therapies. The anti-histamines like we talked about, the nasal steroids, things like that. But you know, still having symptoms despite that, that's when we usually recommend a referral to an allergist.
Dr. Pelman (53:17):
Excellent. Well, I think we covered a lot of ground. Anything else that either of you wanted to contribute that we forgot to mention or go through?
Dr. Ayars (53:25):
One thing I find fascinating is Dr. Rampur mentioned genetics in allergy. Allergy is actually a relatively new phenomenon. You know, the first case of seasonal allergies or quote unquote hay fever was diagnosed in England in the 1870s, and in the U S around that same time before that. It wasn't really an issue. And it's in industrialized places, classically was in the big cities where they'd see this. It wouldn't be out in the country. So we know not only our genetics in play, but the environment is as well as the early life exposures. We find that people that have the least amount of allergies actually live on farms and are exposed to the most species of animals. There's a great study with the Amish and the Hutterites, which are very similar lifestyle. Everyone knows how the Amish live, you know, right next to their animals and things like that.
Dr. Ayars (54:12):
Whereas the Hutterites actually practice differently where they have industrialized farming. So they're not as close to the animals. So the Amish have, I think seven fold increase in asthma as opposed to that genetically like almost identical population. So we know that early exposure along with genetics, so what predisposes people to allergies. And that's why we've seen such an increase over the past hundred, hundred years or so. So I find that fascinating, it's called a hygiene hypothesis. So you have to be genetically predisposed, but early life exposures also play a major role as to whether you're going to develop allergies or not.
Dr. Pelman (54:46):
But then we want to get peanut exposure early.
Dr. Ayars (54:51):
No, it is, it's fascinating. There's a lot of interplay with this. You know, again, antibiotics are some of the greatest inventions in human history, but you know, we get early antibiotics in life and you know, that does change your gut flora. Or, you know, the makeup of the things in your gut that are associated with immunity. So I find it fascinating that not only genetics, but early life exposures kind of shape your immune system and predispose you to allergies depending on your early exposures.
Dr. Pelman (55:18):
Yeah. We'll make a plug for an earlier episode. Listen to the episode, part two on your microbiome. Dr. Rampur, any other final thoughts?
Dr. Rampur (55:28):
I think we touched upon everything. Thank you for the great questions, but I just want to add something that I commonly see in clinics. It's called chronic idiopathic urticaria*. Idiopathic, meaning nobody knows why it's happening. And urticaria means hives. Hives that come and go randomly without a clear trigger. And a lot of my patients believe that they're allergic to pretty much everything. They stop eating. Some of them get horrified and they're itchy and hivey all the time. And I would like to say that this is mainly an immunological condition. Basically mast cells become twitchy and they start releasing histamine randomly without a clear trigger. It can happen anytime during their life. And they're typically treated with anti-histamines and no need to get concerned about allergies if it's happening repeated without a clear trigger. And they can also be triggered by heat or temperature changes, alcohol, pain medications. And I've seen people go on a cleaning spree, they changed their diet, change all their products. They spent hundreds of dollars cleaning their vents and everything, but nothing really helps. It's an internal phenomenon.
*Chronic Idiopathic Urticaria: https://allergyasthmanetwork.org/health-a-z/chronic-idiopathic-urticaria-ciu/
Dr. Pelman (56:36):
Interesting. Well, I'm sure we could spend hours going over other immunologic and allergic phenomena, but I think we've covered a lot of basics for people. And thank you so much for staying late in the office and allowing us to go through some of the basics here. Thank you so much.
Dr. Ayars (56:54):
Thanks for having us.
Dr. Rampur (56:54):
Thank you for having us.
Dr. Pelman (56:58):
This completes another episode of The Original Guide to Men's Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show's recordings are engineered and edited by Sean Fox. Episode titles and descriptions, as well as editing assistance, are provided by Dr. Kathleen O'Connor, PhD. Music for our show is San Juan Bell's, written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society. The Original Guide to Men's Health is an original publication of the Washington State Urology Society. Reproduction and use without the express written consent of the society is prohibited. For more information about men's health and previous episodes, as well as additional recommended resources, visit us online at https://theoriginalguidetomenshealth.org/ . This is Dr. Richard Pellman thanking you for listening, and reminding you to take care of yourself.
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American Academy of Allergy, Asthma and Immunology (AAAAI). Covers symptoms and treatment for a wide range of allergies and asthma.
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American College of Allergy, Asthma and Immunology (ACAAI). Lots of useful information on what allergies and asthma are, diagnosis and treatment.
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Allergy Free Skin Products safe for contact dermatitis allergies.
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The Original Guide to Men’s Health Podcast, Episode 13. Gut Health: Part B—Gut Microbiome
(Part B starts at the 40 minute 30 second mark). Early life exposure to foods and allergens can influence a person’s lifetime gut microbiome and allergy risk.
Episode Summary:
Back pain is usually short-lived and resolves with minimal treatment. But not always. Take care of your back by working on mobility, reducing risk factors, and consulting with physical therapists or psychiatrists if needed.
Guest:
Neelwant Sandhu, M.D., Rehabilitation and Physical Medicine Specialist, University of Washington Sports Medicine Clinic
During This Episode We Discuss:
- Back health
- When is evaluation indicated?
- Common issues such as back pain
- Causes of back pain, evaluation of back pain, treatment of back pain
- Strategies for back pain prevention
- When to see a physician or healthcare provider
- The role of physical therapy
- Serious back issues with neurological changes
- Serious conditions masquerading as back pain
Quotes (Tweetables):
“Back pain that is more severe, back pain lasting more than a few days, or weeks, something that significantly limits your daily activity, you can’t walk, you're bent over, those are valid reasons to go see your doctor. There are certain things we call red flags when it comes to back pain… fever and chills, any trauma or injury, heavy lifting or falling preceding back pain indicating the possibility of a fracture. Anything that might indicate a nerve problem in the back, which includes leg weakness, or bowel or bladder incontinence.”
“Be proactive, don't assume all back pains are the same, and work on reducing your risk factors.
Neelwant Sandhu, M.D.
Recommended Resources:
ACSM ( American College of Sports Medicine) exercises medicine Rx for health series website
Sports Institute U.W. medicine website
Episode Transcript:
Coming soon!!
Episode Summary: There is much you can do to watch out for, minimize, and manage the physical and mental changes that accompany aging. Among other things, learn how deep sleep, Tai Chi, and social engagement (appropriately socially distanced social engagement of course!) may reduce risks of dementia and other age-related health issues. Episode Guest: Vittoria Gassman, M.D., Medical Director, Jewish Senior Services; Clinical Assistant Professor of Medicine, Quinnipiac University School of Medicine, HaM.D.en, Connecticut. During This Episode We Discuss: * Healthy aging. * How to help those in your life at a more advanced age. * We review Geriatrics. * Who should have the care of a Geriatric specialist? * Common concerns and conditions associated with advancing age. * Retirement, loss, and change. * Tips for aging well. * The major risks associated with advanced age. * Strategies to prevent and minimize risks. * Tai Chi anyone? * Care for those of advanced age. * Recognizing dementia in your family member. * Advanced care recommendations, advice for nursing homes, assisted living.
Quotes (Tweetables): “ Most of the patients I see as outpatients in the office are well into their 80’s, if somebody's getting frail and there is a concern regarding dementia in the ’70s, then that person could definitely seek consultation, and in the nursing home where I work, the average age is 90, the mean age, so half the patients are over 90 and half of the patients are under.”
“Nursing home criteria are pretty definite, if your need help with 3 or more basic activities of daily living, That’s walking, bathing, toileting, dressing, those kinds of things.” Vittoria Gassman, M.D.
Recommended Resources: * The Alzheimer's Association * The American Geriatric Society
Episode Transcript: Dr Pelman(01:25):
On this episode of The Original Guide to Men’s Health, we'll be reviewing the aging male with Dr. Vittoria Gassman. Dr. Gassman is the medical director of Jewish Senior Services Institute on aging. She is a clinical assistant professor, at the Quinnipiac School of Medicine, Hamden, Connecticut, Dr. Gassman received her medical doctorate at New York University and completed her residency also at NYU. She's also certified in Geriatric Medicine. Welcome Dr. Gassman.
Dr. Gassman (01:59):
Thank you for inviting me to be with you
Dr Pelman (02:03):
To have a discussion about something that is relevant as we move through life, meaning as we age. And I think I'd like to start with just a review of what is a geriatrician. What is different about seeing a geriatric specialist than your primary care physician?
Dr Gassman (02:23):
Geriatrics is a fairly new specialty. Gerontology refers to non-physician specialists who study the aging process and older people and society. But geriatrics is the medical specialty that focuses on people as they get older.
Dr Pelman (02:47):
So when we look at an aging population and they have a primary care physician, when would they transition or should they transition to a geriatric specialist?
Dr Gassman (03:00):
It would be ideal if they could transition, if everyone could transition at a certain point, but there aren't enough geriatricians in the country. So we tried to educate primary care physicians and other specialists and teach them a little bit about geriatrics so that they can continue to help their patients. We mostly work as consultants in the hospital or in the outpatient setting. And if there's a concern, for example, about dementia, we often get consultations and a referral for a patient for that. And we try to look at the whole individual, the medications, talk to them about their psychosocial wellbeing, physical exam, which includes walking and how they get around, et cetera, it's time consuming. But if there are concerns that somebody is not doing well as they're aging, it can be a very helpful thing to do,
Dr Pelman (04:14):
What age would you generally say, the population that would be seen by a geriatric specialist by a geriatrician? Would somebody in their sixties or seventies, seventies to eighties, or eighties to you know; or is it just really, how is that individual doing? I mean, what age group do you recommend people start moving over?
Dr Gassman (04:34):
It’s gotten older and older. I think most of the patients I see as outpatients in my office are well into their eighties. If somebody's getting frail and there's a concern about dementia, seventies, then that person could definitely seek consultation. The average age is 90, the mean age. So half patients are over 90 half are under.
Dr Pelman (05:09):
Interesting, the aging process is somewhat subtle. Sometimes people sometimes have things that make it more dramatic, but what would you recommend to the population that begins aging, say later sixties to seventies, that they should start being aware of, and if they're not seeing a geriatrician, at least to make certain that they bring up to their primary care physician?
Dr Gassman (05:33):
Functional abilities are really important. We study what are called the activities of daily living. So if a person is having trouble walking, if they're having falls, if there are hygiene problems, people aren’t bathing, those kinds of things definitely could seek some geriatric specialist help. But I think in general, there's still a lot of things we don't know, but exercise and physical function are really important. We try to emphasize that with patients because many of the geriatric syndromes such as falls seem to be consequences of diminishing strength or balance and problems with the activities of daily living.
Dr Pelman (06:36):
So people should not get sedentary, to try to keep moving, keep exercising in some form, maintaining some musculoskeletal fitness, some muscle density range of motion, and that starts early and you just have to continue it.
Dr Gassman (06:51):
I'm a big fan of Tai Chi, as well as other types of exercise. I have attended Tai Chi classes myself, and I'm currently looking for a class, but it's a very interesting way to work on your balance. And it's the only exercise that has been proven over and over to decrease the risk of falls, even better than working with a physical therapist.
Dr Pelman (07:27):
So that can be an interesting thing to do for people that helps with the balance and, you know, transition from people playing sports to some seniors continue, but say a senior who golfs or plays tennis, but then loses some of the ability to do that as well. You would want them to move to something where they continue to be active and work on balance and movement skills. And you're saying Tai Chi is nice.
Dr Gassman (07:54):
And walking is good. Many people give up walking, but it's a great form of exercise. Doesn't have to be fast, but walking every day definitely maintains some form of physical functioning and muscle strength.
Dr Pelman (08:14):
Yeah. Do you have people walk with hand weights or anything to maintain some upper body strength when they do that? Or is that a separate, would you recommend a separate exercise set?
Dr Gassman (08:23):
We usually recommend a second set of exercises for that, but if people are quite fit and they want to use hand weights, that's perfect.
Dr Pelman (08:34):
It Is. This would be a daily outing?
Dr Gassman (08:37):
Yes. The government has recommended, you know, all different things, from three times a week to five days a week, but maybe a majority of the days in the week, people should be out there doing something.
Dr Pelman (08:54):
Then moving from exercise, to just being aware of things that are subtle, that change in eyesight, hearing, that becomes an issue, particularly hearing loss for seniors.
Dr Gassman (09:08):
Yes, that's very important. Hearing loss is widespread in the aging population and we expect there's going to be more of it because the baby boomer generation did have the delight and unfortunate consequences of listening to too much rock music and blasted their hearing functions. So, I know many older people resist getting hearing aids. They resist getting tested. It's a stigma that's been around for a long time. Probably starting when the hearing aids were very bulky and not nice to look at, but hearing aids now are tiny. They can't even be seen. And hearing loss is associated with developing dementia. Nobody wants to have dementia or any cognitive loss and hearing loss is definitely involved in that process so that can help motivate people to go get a hearing test and then hearing aids if they need them. The other problem with hearing devices is they're very expensive and Medicare doesn't typically provide them. Some of the Medicare Managed Plans, the Advantage Medicare plans will cover it. And that's a great thing because they can cost many thousands of dollars.
Dr Pelman (10:50):
The acuity of a hearing does fall off over time. So you would start with getting a hearing test, which is fairly easy to do on a range, but it's just making somebody aware that they need to be checked.
Dr Gassman (11:06):
The primary care physician should be doing what's called a whisper test. They stand a few feet away from the patient and they cover their mouth and, and whisper numbers. Or somebody could do that with their spouse and check each year separately. But if you can't hear whispered numbers from two or three feet away, there may be a problem.
(2) Whisper Test - YouTube
Dr Pelman (11:33):
If somebody requires a hearing aid, is that good for life? Or do you need to upgrade continuously as hearing changes or worsens?
Dr Gassman (11:40):
Yeah. I may be able to make adjustments as hearing worsens, but they don't typically need many new hearing aids. Of course, they're very small. They do get lost, but apart from that, you may not need multiple sets of them as, as hearing worsens as people age.
Dr Pelman (12:05):
And then you mentioned mental status changes. And of course we talk about people aging and just having normal loss of some memory. What distinguishes somebody who's truly getting dementia? And then in dementia is a spectrum Alzheimer's versus other forms of dementia. Go into a little bit about that because that compromises a significant portion of people's health if they do develop that.
*Episode 42 The Aging Brain: Normal Aging, Dementia and Alzheimer's
Dr Gassman (12:37):
We know that dementia increases with age, more than 50% of people in their nineties do have some degree of dementia and we're still not completely sure what can prevent it. There's some hope that a healthy diet and more physical exercise may prevent it, but there's nothing very obvious in terms of medication or vitamins. Nothing's been shown to really work in terms of medication. Many people start having problems with memory, especially with remembering names and associating faces to names. That's not thought to be all that significant, it's quite universal, but missing a few names here. And there is not really a warning sign, but when somebody starts to have problems in multiple areas of their life, for example, at home, in terms of their family relationships and or at work, completing their work tasks, that already is a big red flag. And that person certainly needs that dementia evaluation.
Dr Gassman (14:10):
Most of the dementia in this country is Alzheimer's disease. It hasn't been clear to the public. And I hear this question all the time. What's the difference between dementia and Alzheimer's? I'm not sure which word is scarier, but they're both pretty scary. But in the United States, approximately 75% of dementia is Alzheimers disease. And the rest are comprised of things like vascular dementia, which means an accumulation of small strokes or TIA, does seem to rob the patient of their memory and other faculties and some more rare variants, such as Lewy Body Dementia, which is very associated with Parkinson's disease and some or others. But the vast majority is Alzheimers and it's very gradual and insidious. And I find that most people, and especially the families, don't recognize it as it gets worse and worse. I did a lot of primary care myself over the years, and I can honestly say that I missed it many, many times in my practice.
*A transient ischemic attack (TIA), sometimes called a mini-stroke, is a sudden, short-lived neurological condition. It is caused by a small, temporary blockage in one of the blood vessels that carries blood to the brain.
*Lewy body dementia, also known as dementia with Lewy bodies, is the second most common type of progressive dementia after Alzheimer's disease. Protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement (motor control). Lewy body dementia causes a progressive decline in mental abilities.
Dr Gassman (15:43):
And I think the issue for families and primary care doctors is that when you have a lot of contact with the person, it's hard to see the changes. You know, it may feel that it's just the patient's personality or they're just getting more stubborn or that they've always been like that. And now it's more so, but this disease, it takes over the brain very slowly and sometimes an outside consultant can see it. A geriatrician or a neurologist can more quickly put their finger on it. Unfortunately, we've spent a lot of time in this country researching dementia, and we haven't gotten very far unfortunately. We do have some medications, but they're not very helpful. They seem to stabilize the patient at the level they're at. But I think scientists have been working on a hypothesis about a cause of Alzheimer's disease, which is called the amyloid hypothesis.
Dr Gassman (17:00):
There's this substance in the brain called amyloid and all the treatments in terms of medication have been focused on this and then the last year or so, there's been a lot of rethinking. And it seems now that the amyloid is not the cause of dementia, but it's something that happens along with it or as a byproduct of the disease. Luckily there is a lot of research going on. I really recommend the Alzheimer's Association* website, which has a lot of helpful information, very accessible to families and patients, et cetera. And there's a lot to learn about this. It's fascinating.
*Alzheimer's Association | Alzheimer's Disease & Dementia Help
Dr Pelman (17:58):
And unfortunately it's still just dementia in general. And trying to be healthy, we know that good sleep has a significant impact on the development of dementia. So, you know, sleep specialists, making certain that you don't have sleep apnea* seems to be at least one of the issues involved in the onset of dementia.
*Episode 19: Sleep Health and Sleep Apnea
*Sleep apnea affects the body by interfering with sleep. You might choke, snort, or snore while you sleep. Obstructive sleep apnea affects the body by increasing the risk for adverse clinical outcomes ranging from decreased daytime alertness and quality of life to cardiovascular morbidities and mortality to increased risk for hospitalization.
Dr Gassman (18:22):
Yes, I agree with that. There's even some very interesting research about that, that I think it's mostly been done in animals, but there are some small studies in humans showing that there may be a whole new organ in our brains that is responsible for draining out of the brain toxic byproducts of metabolism, including the amyloid, et cetera. That seems to function best when somebody is in the deep sleep stage, and REM it's an important sleep stage, but it's like sleep. And that's when you have dreams, but everybody cycle through various stages of sleep, three or four or five kinds every night and deep sleep may turn out to be a key time when our brains get rid of toxins. And that's just very fascinating to me. You know, I mainly work in a nursing home and very few people in the nursing home get a good night's sleep. We try to work on things like decreasing the sound, having the lights low, trying to get people, good sunlight exposure in the daytime that can help with sleep. But most of them have very fragmented sleep patterns. I know you're a urologist. So, you know, bladder spasms and having to urinate every two hours all night long, it's very disruptive to sleep.
Dr Pelman(20:09):
Yes, it's one of the major issues we see. I always try to make certain that the issues with nighttime urination or nocturia is something that is looked into as there are many other reasons besides just bladder, prostate issues, people who have sleep apnea for instance, will get up thinking they need to urinate. And it's really they're awake because of air hunger. Sometimes they have mobilization of fluid just due to physiological issues and you know, some of it's reversible. So it's a great point you make, and it is something robs people of valuable sleep time and should be looked into, but it isn't always, it isn't always bladder prostate for looking at the population that needs to control cholesterol, blood pressure that certainly prevents some of that microvascular disease you were talking about that can lead to dementia. So just good health and taking care of those issues as well can help.
Dr Gassman (21:10):
Yes, blood pressure control, cholesterol, diabetes, all the traditional cardiovascular risk factors are probably implicated in the development of alzheimer's. So making sure your blood pressure is at a good level, keeping your cholesterol well controlled and really working on the diabetes can help postpone or prevent dementia too.
Dr Pelman (21:43):
If we look at the opportunity to look at a different spectrum of the mental issues, meaning depression, certainly as people age and lose function, perhaps can't work anymore. Maybe lose a spouse. You see a spectrum of issues
Episode 16. Mental Health: Part 1—General Depression; Part 2—Deeper Depression, Suicide and Suicide Prevention.
Dr Gassman (22:02):
Depression is really widespread in this society. And I think you're right. You talked about losing the spouse and losing the job or the functional role in society. That's very important. I think especially men who retire, I think do have a hard time adjusting to that retirement. If they haven't made some preparations ahead of time, you know, thinking ahead of time what you're gonna do with all that free time can be really helpful. And we do see some men who really get into their hobbies, develop new hobbies, take up bridge or other games. And all that is very healthy. Men are much less likely than women to lose their spouse because men still have a shorter life expectancy at every age. So women are much more likely to live without a partner for many years. And we see that in the nursing home, most men, even over 85, about a third of them are still married, which is much better than for women.
Dr Gassman (23:30):
Three quarters of them are widowed over 85. So that partnership, that companionship is so important. You know, there's not too much you can do at the end of life about that, but having some other social contacts is really important. People who do volunteering or some participation in the community, they really get a benefit from that. It's not just “they're helping others.” It's good for them. And it can even be phoned volunteering, you know, having a phone pal who you call once a week. That can be a great activity, even if somebody is at home, but you know, in the real world where all of that is really important at my nursing home, we're lucky we have what's called the work center. It's a, most nursing homes don't have this, although they could try and create a similar thing, and some definitely do, but it's basically clerical work.
Dr Gassman (24:39):
And many residents of the nursing home will come and work there morning and afternoon, five days a week, except for holidays. And it's a social activity. So that's nice, people talk and make jokes with each other and it's friendly. But I think underneath that is this hidden sense of having a purpose. It's very important to people. And you know, if a man has been deeply engaged in his career or his job, that finding some way to recreate that in retirement and then all day, which I think is, is just critical. I have patients who get an infection and I asked them to stay in their room for a few days and take medication. And the first question they asked me, they say, but doctor, can I go to work tomorrow? And you know, even if they have a fever and they want to get back to their usual routine and that's a very important human trait, we want to feel like we have a purpose.
Dr Pelman (25:54):
And that's something that if somebody is listening and they have a parent who maybe is becoming more socially isolated, that's as difficult as somebody who becomes sedentary. So they need to make sure they become engaged in some sort of activity, some sort of social event you've brought up in the nursing home. So let's move a little bit into as people age, when they want to transition from independent living or maybe independent living into a different living situation. When does that occur or how do you advise patients regarding that? Or they say, “well, we've been living in our own house. We're thinking of going into an assisted living situation or an independent condo with assisted living, possibly nursing home attached to it.” What do you advise people?
Dr Gassman (26:41):
Unfortunately our health system in the country is very fragmented and it's really up to individuals and their families to find what the resources are near them. Assisted living was meant to be for pretty independent, healthy seniors, but they have much more for people who are frailer, not quite as into and needing more help. Nursing home’s criteria are pretty definite. The criteria to get into a nursing home is if you need help with three or more basic activities of daily living. So that's walking, bathing, toileting, dressing, those kinds of things. And if you need help with three or more of those, you probably can be in a nursing home. And along with those functional problems, obviously comes the medical issues that create those problems with function. So a patient might have heart failure, diabetes. They may have a few falls and a hip fracture because of that. But to get into a nursing home in general, the criteria are functional problems in three or more basic activities of daily living.
Dr Pelman (28:12):
And we were doing this recording in the time of COVID-19. And obviously people are worried about transmission of it, whether it's this virus or something that comes along, or even flu during normal flu season through a nursing home. So that's something. You're a medical director of a nursing home, and you have a nursing home population. You want a nursing home that is well supervised and has plans for taking care of issues like this.
Dr Gassman (28:40):
Right? It's been terrifying in the state of Connecticut. I don't think we're doing too badly, but we are scrambling to keep the vulnerable older people safe. One thing is there is a new model for nursing homes called the Small House Model. Have you ever heard of that?
Dr Pelman
No.
Dr Gassman
So it's been around for a while, I believe on the west coast, and somewhat in the Midwest, they are building new nursing homes on this model. And our nursing home in Connecticut is built on the Small House Model. And it's been great for decreasing the transmission of infections. We've been in the building three years and we've seen it with the flu and hopefully we're going to see it with the COVID-19. Basically there is no giant dining area for everybody to go to. And there are no long halls with the nursing station in the middle, and it looks like a hospital. Rather, it's the whole home that is built, broken up into a 14 person unit.
Dr Gassman (30:03):
They call them houses and there's a door in a doorbell for each one. And then there's 14 people with private rooms and baths and some common areas like a kitchen, which looks like a nice suburban kitchen and the dining room, dining area, a living room, and a porch for fresh air. It's been very helpful for isolating people who are sick in their rooms and decreasing the risk of infection going all over the building. So I'm grateful that we have that and your listeners, if they're looking for a nursing home or even in assisted living, the new ones seem to be built on this model.
Dr Pelman (30:55):
It looks like it's a more successful model and hopefully newer homes will be following that pattern. So any resources that you would refer people to? That they could find online that you would tell them that they, if they want more information, as far as aging?
Dr Gassman (31:13):
Number one is the Alzheimer's Association. They can go with their different chapters in every state and different regional associations. And there is a lot of really good information there about aging and dementia. And the other resource I'll mention is the American Geriatrics Society.* They have information for the public and for patients also all different topics about healthy aging and about diseases as well. And I think those are very good sources. There are so many on social media, and the internet is just wonderful, but there is so much potential with that. But there is a lot of misinformation, and not good sources that you can trust. And I hope the public will, you know, keep challenging and checking out the sources that they're using and making sure that they're reliable and consistent.
*Alzheimer's Association | Alzheimer's Disease & Dementia Help
*Home | HealthInAging.org: Powered by professionals at the American Geriatrics Society, this website provides expert health information for older adults and caregivers about critical issues we all face as we age.
Dr Pelman (32:26):
Just summing up, staying healthy as we age. It sounds like we should continue to be active and not be sedentary and active. Not only physically, but mentally and socially engaged.
Dr Gassman (32:39):
Yeah, I think you've got it. Absolutely right.
Dr Pelman (32:43):
Well I really appreciate you spending time, and it's been wonderful. Aging is the spectrum that we all face. And so it's great to have a resource and hopefully there'll be more geriatricians in the future.
Dr Gassman (32:57):
Yeah, that would be great. And thank you so much for this opportunity.
Dr Pelman
We appreciate it. Thank you, Dr. Gassman.
Dr Gassman
You're welcome.
Episode Summary: Genetics is a growing part of health care and is used to identify heritable genetic variants that increase the risk of certain diseases and conditions, including some types of cancers. Among other things, learn why breast cancer-related variants are also related to prostate cancer, and why you should be leery of direct-to-consumer tests for heritable disease risk indicators. Episode Guest: Gail P. Jarvik, M.D., Ph.D., Endowed Chair in Medicine and Genome Sciences, and Professor and Head of Division of Medical Genetics, University of Washington, Seattle WA. During This Episode We Discuss: * What do we mean by Medical Genetics? Multiple aspects to this science. * What can an examination of your genetic history accomplish? * Who should have genetic testing? * What type of cancer history should prompt a visit to medical genetics? * The role of a genetic counselor. * Do you know your family history? * What can be done if a risk is identified? * What about the genetic tests identifying ancestry/family descendants? * Can genes be manipulated? * When genes go wrong, what happens?
Quotes (Tweetables): “I would hope to see more people being screened for these things that are high penetrance. About 3% of the population would have what we call actionable genetic changes), something that we could do something to protect your health.”
“The national precision medicine program called ‘All of Us’, which is enrolling nationally, you can go online to their web portal, and if you're one of the people selected, they will be generating and sharing the genome information (for free) that they find with the participants.”
“ I am very leery of direct-to-consumer genetic testing. I think people often don’t understand what they’re buying, and it can be a danger to people because we have had patients who thought they were tested for something that ran in their family and they were not.” Gail P Jarvik, M.D.
Recommended Resources: * The National Association for Genetic Counseling website * The Undiagnosed Disease program of the NIH * Local Departments of Medical Genetics * The National Precision Medicine Program * The All of Us Program
Episode Transcript: Dr Richard Pelman (00:07):
Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven't yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men's health with renowned experts and embark on a journey towards better health!
Dr Pelman (01:25):
On this episode of The Original Guide to Men’s Health, we will be interviewing Dr. Gail P Jarvik MD PhD. Dr. Jarvik is the [Endowed Chair in Medicine and Genome Sciences, the Division Head and Professor of Medical Genetics, at the University of Washington, Seattle. Dr. Jarvik completed medical school at the University of Iowa and was in the MD-PhD program, completing her PhD at the University of Michigan. Dr. Jarvik undertook her residency training in internal medicine at the University of Pennsylvania and came to the University of Washington in Seattle for her fellowship in Medical Genetics. Dr. Jarvik is the President Elect of the American Society of Human Genetics. And we'll soon ascend to the presidency of that society. Welcome Dr. Jarvik.
(02:18):
Thank you for taking the time. Medical Genetics is awesome and such a rapidly expanding field. So for listeners who are going, what is Medical Genetics? Why don't we just give a little overview of what that is?
Dr Jarvik
Medical genetics, I think is a little known field of medicine, where we focus on disorders that run in families and these cut across any specialty that you can imagine from heart disease to childhood disorders, even though there's one training in medical genetics, we tend to do our practice as pediatric genetics versus adult genetics. I'm an adult genetics provider. So I see patients often, I would say about half our business is people with cancer risk in their family, but many other disorders, on the pediatric side, of course they're seeing children with congenital anomalies, children with intellectual disabilities and other syndromes to try and make those diagnoses and provide care plans.
Dr. Jarvik (03:22):
So there are obviously multiple aspects to medical genetics. One is who should be tested? Why should I be tested? And then the testing isn't just enough to send off blood or a swab, but you need counseling. There should be somebody who's advising you as to what can be done or what can't be done. So how it an adult, let's say, we'll start there, look towards medical genetic testing.
So yeah, my first question is, which adult probably wants to have medical genetic testing? And those are people with disorders that run in their family. As I mentioned, cancer, breast cancer, ovarian cancer, colon cancer, but cancer at early ages, multiple people with cancer, multiple generations with cancer might all require a referral to medical genetics, many other disorders, hemochromatosis, you know, Marfan syndrome. Our disorders get rarer after that. And we are sort of experts in very rare disease.
*Hemochromatosis.org - An Education Website for Hemochromatosis and Too Much Iron-”Hemochromatosis is an iron disorder in which the body simply loads too much iron. This action is genetic and the excess iron, if left untreated, can damage joints, organs, and eventually be fatal.”
*”Marfan syndrome is a genetic condition that affects connective tissue, which provides support for the body and organs. Marfan syndrome can damage the blood vessels, heart, eyes, skin, lungs, and the bones of the hips, spine, feet, and rib cage. Some complications of Marfan syndrome can be treated or prevented, including heart disease, bone deformities such as a curved spine, eye conditions, crooked teeth, and collapsed lungs.”
-Marfan Syndrome | cdc.gov
Dr Jarvik (04:29):
And sometimes we'll see those patients and sometimes we’ll see patients with undiagnosed disease as well, to see if it's genetic. Then the next step is to ask for referral to medical genetics, you would often be seen by a genetic counselor out in the community, in an academic center, there would be an MD Medical Geneticist. There are only about 5,000 trained genetic counselors in this country and half that many trained MD geneticists, and many of the genetic counselors are actually accompanying. So it can be hard to access genetic services in some regions of the country.
Dr Pelman
Okay. Would most people come to a medical geneticists as referral from their provider?
Dr Jarvik
Right. Most people do come as a referral from their provider, but you know, many people will find that their providers actually know little about medical genetics as well. And so it is a good idea. If you have a history of disorders in your family, that seemed more than coincidence, or disorders that are happening at early ages, ask your physician whether they've considered sending you to genetics, whether that's a useful thing for you.
Dr Jarvik (05:37):
And the scope of looking into sort of a familial link is okay, we look at blood work and history. The first step is really a very careful family history. And that tells us a lot in medical genetics that tells us whether we're seeing a clustering of disorders that look it's more than chance. And it tells us what kind of genetic tests we should be thinking about for that patient, or even is there a genetic test that's appropriate for this patient? So coming back to cancers, if patients have family histories of early onset cancers, any ovarian cancer, bilateral breast cancer, those are signals that this is not the usual type of cancer and you should consult a medical geneticist and the sort of syndromes that run together of which people are advised.
Dr Pelman
If they end up with a colon cancer of a certain type, it's usually coming from a medical provider.
Speaker 3 (06:39):
Yes often, but we absolutely have self-referred patients whose providers never really looked carefully at their family history. Honestly. So the family member says, “gee, this is happening to my aunt uncle, my brother. Yeah. Right.” And ideally we would see the effected family members. So if you have a sister who has breast cancer at 39, that would be alarming. Ideally the sister with cancer would see the medical geneticist because her test result is necessary to do a really good job with the unaffected family members. We need to know what is the change in the person who has the cancer. There are some things we can do if we can't get that person. And unfortunately with cancer, sometimes the people that you want are deceased. So there is still testing, but the most informative thing is to be testing the person with the disease. And we're becoming more enlightened about family history, but you know, we're probably going back two generations, you go back three and people don't really know what somebody had most of the time.
Dr Jarvik (07:43):
It is very common that people don't have a good idea of their family history, not just in adoption situations, but depending on how much older your parents were, if you moved to a different area of the country, family history can be quite limited. And in fact, in some of these population-based studies where they do genetic testing in several of these studies, about half the people who they found with a genetic change, that is what we call actionable, which means something that we can actually do to prevent disease or prevent death. About half of those people did have a family history that someone didn't notice, but about half of them did not have the family history that would have gotten them a referral to genetics. So we're leaving a lot of people on the table when we just start with family history.
Dr Pelman
So if we identify a potential genetic issue, I know that in some instances we would advise more rigorous screening or the particular disease in that individual. So if it was breast cancer, you might say, you need to be really careful and we need to have you screened more than the average population.
Dr Jarvik (08:41):
Yes. So screening depends on the family anyway, but if we find one of these genetic changes that puts you at high risk of cancer, we would start screening at an earlier age 25. In fact, for some of these disorders, we would alternate mammograms with breast MRI, which is not typical for other women. And we also would be concerned about the risk of ovarian cancer and a much smaller risk of pancreatic cancer in people with those changes. So it's common for us to have someone come in and say, I have a family history of colon cancer. We find a genetic change for colon cancer, and that changes their colon cancer screening, but we're also screening them for endometrial cancer because the same genetic changes can cause both of those risks.
Dr Pelman
Would somebody listening say, gee, I, I just want to go and get screened, not knowing if there's anything genetically screened.
Dr Jarvik (09:40):
There certainly are people who are interested in having the screening and there are actually large self-employed insurers. So not your standard insurance company, but a company that's large enough that they are the insurance for their employees that will pay for the service for their employees/insurees to get a screening test that looks at the most commonly actionable things, which are these colon cancer, breast cancer, ovarian cancer, but also hyperlipidemia as a product. And that's something that also boutique medical practices will sometimes offer. But, your average doctor probably doesn't offer.
Dr Pelman
So besides identifying who's at risk and increasing screening and, or in hyperlipidemia, you know, you need to run your lipids and we need to treat the lipid condition. Are there other remedies that are being looked at with genetic splicing and things that people hear about?
Dr Jarvik (10:47):
Right. So most of the genetic conditions that we screen for in adults, we have preventative measures. (Against) We're increasing the screening where and making some lifestyle changes, we're not really fixing the underlying disorder now. So I'm sure that a lot of people have heard of these gene editing, CRISPR-CAS9*. You know, there's a very tiny number of diseases which have gene therapy treatments. They're often pediatric, but not all. Some eye diseases for adults, for example, but for the average person, we're not going to be fixing that underlying change. We'd have to get it fixed. And you know, every cell in their colon, right? It's not a tractable problem at this time. So we really are trying to prevent the disease. The nice thing about colon cancer, genetic changes is that most colon cancers start with polyps.
CRISPR Explained CRISPR: Gene editing and beyond
Dr Jarvik (11:46):
So if people really do get their colonoscopies on schedule, get those polyps removed, we can prevent the cancer from happening. In the case of breast cancer. We are generally screening to make an early diagnosis, which leads to a much, much better outcome. Although many women do have mastectomies too, which reduces your risk of breast cancer by about 99%. Similarly, those women at risk for ovarian cancer will often have their ovaries and fallopian tubes removed, which also dramatically reduces the risk of that cancer. So again, preventative strategies, not really “turn this into a different gene for you.”
Dr Pelman
If you listened to the episode we did on GI screening, then, you know, individuals at risk could really start screening at 40. But if somebody was found to have a syndrome, they might even start…
Dr Jarvik (12:42):
Yes, they would start significantly earlier depending on what the genetic change was. Absolutely. And you know, one of the goals in genetics is to be able to target some of these preventative strategies to people more precisely. And right now we're doing single gene changes, but we are moving toward a world where you have many, many genes that actually affect your risk of cancer, but they do it in a teeny little bit, but you can add them all together in something we call a risk or, and so the genome Institute at The National Institute of Health is very interested in moving forward on these risk scores and seeing if they can develop risk scores that are predictive of disease that can benefit people and can help target screening ages. So for some people with high risk scores, they may start beginning their colonoscopies, at less than 50. In a perfect world, we'd have people who have low risk scores who don't have to get it until 60.
Dr Jarvik (13:36):
I mean, that would be ideal, but that's the direction that research is moving in. Those are not ready for prime time now, although I suspect they're being sold in a few cases now, but we will see genetics as more of a tool for the general population, and not just a tool for rare people, in the next 10 years.
Dr Pelman
So if I'm listening to this and I go, well, so-and-so in my family had colon cancer. They would be a potential candidate for genetic screening..
Dr Jarvik
Yes. Especially depending on the age, you know, these cancers become very common in older people. If your relative had breast cancer or colon cancer in their seventies or eighties, that's much less likely to be genetic than if they had it in their, you know, 50 or below. So that's probably a bit bigger signal that you want to talk to a medical geneticist.
Dr Pelman (14:26):
No, it was particularly somebody, very young who got something like that. People were wondering, should I be sending my DNA off to one of these labs that advertise I can send them a swab?
Dr Jarvik
Yeah. That's a very good question. And if they did that, they'd be joining literally tens of millions of people who have sent those off. I think for medical purposes, no, I've never done it. My colleagues, as far as know, have mostly never done it. Some of us have done it just to see what you get. The medical information from those tests is generally not very useful. It is a little like two times risk, you know, that's not very actionable. My bigger concern is that we have patients who would have a single genetic change, that gives them a high risk that is not on the test. So for example, the biggest company that offers this test, the only high penetrance IE genetic changes that are very likely to cause cancer, they have for breast cancer, are three that are common in Ashkenazi to Jewish people.
Dr Jarvik (15:29):
If you are not asking as you Jewish, you're going to get a negative result. That's going to come back. “You don't have a high risk breast cancer change,” but there are literally thousands of other high-risk changes in those genes that are not on the test. We would not want people to be misled and think, oh, “I don't have to worry about breast cancer.” And my sister, at age 40, because I had this screening test that says, “I don't have those genetic changes” because you're not probably being tested for what your sister has, unless you're Ashkenazi Jewish.
Dr Pelman
So we're doing the Original Guide to Men's Health, but we certainly have female listeners. And so the BRCA* gene, I know for men, carries some penetration for the prostate.
*(1) BRCA Genes and Breast Cancer - YouTube
Dr Jarvik
It does particularly for men with aggressive prostate that becomes metastatic. Those are men that should be evaluated to see if they have these BRCA1 or BRCA2 genetic changes.
*(1) Dispelling myths of BRCA gene mutations - YouTube
Dr Jarvik (16:22):
And then that puts their family members at risk. Right.
Dr Pelman
Right, and so then there are some companies that you can order that particular test from?
Dr Jarvik
There are not companies that you can direct-to-consumer order that test. That tests actual sequences. Those genetic tests are not available direct-to-consumer in an FDA approved way, that I'm aware of. There are companies that you can work with that will actually have a doctor who works for the company who will help you order the test. But the bigger tests that you hear about, the ones that you're finding in the drug store, or, you know, at Kmart, those are not offering you a comprehensive test. So you really want to go through a healthcare provider and to a medical geneticist. Yeah. And in an ideal world, you would talk to a medical geneticist or genetic counselor to make sure you're getting the right test because we absolutely have had patients who through a non-expert provider got the wrong test and then thought they were clear of something that turned out to be a fightable genetic problem. When we found the patients ordered a completely different tests that was then abnormal and found that change for them, but they didn't get the right test because unfortunately most general providers are not expert in genetics at this time that the training really needs to improve as genetics becomes a routine part of medicine, which is happening more and more every day. The medical education needs to improve for providers.
Dr Pelman
Can we get an overview of a term. We keep using it. “Gene,” if people are wondering why I kind of get that, it's there, but what is it?
Dr Jarvik (18:02):
Sure. So, you know, you have DNA, right? You'll get half your genetic material from your dad and half your genetic material from your mom, approximately. And there are genetic changes in these units called genes. And those genes make proteins. There are actually genetic changes that can cause disease. In other parts of the genome. Most of the genome is not these genes, right? So, you know, we just use, gene's as a sort of a shorthand for, “there's a change in this thing in your DNA that puts you at higher risk of disease.” And they're actually changes that, put people at lower risk of disease, but we don't talk about those medically very often.
Dr Pelman
A lot of what we've been reviewing are “you're born with these genes” rather than something happening to your DNA. That changes it.
Dr Jarvik (18:54):
You know, it's funny, we call things, cancer genes, the breast cancer gene, but those genes are there to protect you actually from getting cancer. And what happens is some people are born with a change in that gene. So it doesn't work well in protecting them from cancer. And then, you know, obviously if that genetic change caused cancer, you'd have cancer in every cell that was the right tissue, every breast cell or every colon cell, what has to happen is a second change happens in one cell in the organ of interest like the colon and the gene that you inherited. Isn't good enough to fix that. And often there's a second change in your other copy of the gene. So if you've got a change copy from your mother, that's not working well. If in one cell that copy from your father gets somehow damaged or lost, that's when you'll start having a single cell develop into a cancer.
Dr Pelman (19:48):
And, these are different than mutations that are affected because of say radiation or something else. Effecting your existing DNA.
Dr Jarvik
So you've correctly used the word mutation, which means a new change in the DNA. But a lot of people will say, “I have a mutation in the breast cancer gene,” not technically correct. You have a change. The technical term is a pathogenic variant or a disease causing change, but commonly called mutations. But truly a mutation is a new change and radiation can cause, but your genes actually are copying themselves all the time. Things go wrong. The system's not perfect. That's why we have these repair systems that can, that some peoples don't work as efficiently as others. Yeah. And they, you know, things happen and your body really is amazing and that it can repair these defects. The whole system works is incredible.
Dr Pelman
I've always been under some assumptions that as we age that we may not be as efficient.
Dr Jarvik (20:46):
I dunno if that's true, whether the aging body is less able to repair than the younger body, or there are certainly changes that accumulate over time. And we see that for risks of like leukemia and lymphoma, that people start getting sort of clones that develop that there is one change that starts to out-compete other parts of the bone marrow, for example, depends on what repair system, whether it is working better or worse with time, but definitely changes accumulate over time. So if we were to then look at, what we would hope happens, as somebody is investigated, they are found to have a gene that links them to a particular disease process. They're screened more vigorously if there's intervention, medically it's undertaken.
Dr Pelman
When you go to meetings for the future of medical genetics, what would you hope to see?
Dr Jarvik (21:46):
So I would hope to see more people being screened for these things that are high penetrants, about 3% of the population would have what we call actionable. Something that we can do to protect your health, that's not a big segment, but that's a lot of people who we could be preventing heart disease or cancer in. There's a group of disorders in that category. I would like to see genetics rolled out to more people. So I'd like to see these risk scores confirmed. There are some significant issues with them, particularly because the risk score is developed in people of European ancestry. Don't generalize to people of other ancestries and most research in this country is still done in people of European ancestry. So there's a lot of work from the National Institute of Health to try and develop these sorts of risk scores in other populations.
Dr Jarvik (22:41):
It's a very different thing for those risk scores. If a single genetic change causes disease in one person of one ancestry at virtually always will affect every ancestry, the risk scores are completely different. So let's look at the fact that we have a population that certainly is coming from all parts of the globe to the United States, not just Europe. And, as you said earlier, medical genetics is becoming more progressive and we're understanding much more about it. So what else is exciting that you'd like to let everybody know about? Well, I think a really important issue right now is training the workforce in medicine to take care of people with genetic issues. That means that every doctor needs to understand genetics better, but it's still remains a specialty where there are a limited number of providers.
Dr Pelman
So here in the Pacific Northwest, there are not training programs for genetic counselors.
Speaker 3 (23:41):
Genetic counseling is the terminal degree. They're board certified, most states licensed under their professional agency. And we need more people who are genetic counselors. We are starting such a program at the University of Washington. We hope to be enrolling in 2021 for an 18 month program for a master's degree, starting with a little over a dozen people, and that will serve our region. It's very difficult to recruit genetic counselors to rural areas. We have what we call the WWAMI region here, which is Washington, Wyoming, Alaska, Montana, and Idaho. There is one other program in our whole region, which is quite small and it's distance learning for much of it. So we would be the only cited program in that region. And, I can brag and say that the University of Washington is a genomics powerhouse and we're overdue to be contributing to the training of these professionals.
Dr Pelman (24:39):
And without us going through all the various diseases that might be recommended for somebody to be screened or looked into, is there a site that somebody, when they finish hearing this broadcast could go to and say, “oh, here's a list of diseases that may be, I need to pay attention to, or with it to get further information.
Dr Jarvik
No, there is the National Association for Genetic Counseling* has a website that can help you find a genetic counselor in your area. Not so sure about a site. I think it really is talking to your physician, or you might want to think about what is common in my family that I'm worried about and look up those disorders. The NIH has some resources. So you have to be careful that you're looking at some medical resource rather than an ad ad, right? Exactly. I'm very leery of direct to consumer genetic testing.
NSGC
Dr Jarvik (25:32):
I think people often don't understand what they're buying and it can be a danger to people because we've had patients who thought they were tested for something that ran in their family that were not because what the change that is in their family, wasn't on the test. So if you really think you have a genetic issue, you should not be thinking about these direct to consumer options, but you should be looking for medical care. And these are distinct from people who just want to do the ancestry issue and absolutely go wild with the ancestry. A lot of people like the ancestry, another thing people can think about is the national precision medicine program called All Of Us. So All Of Us is enrolling nationally. You can go on their web portal and they are, getting medical information from participants, but also we'll be generating genomes for those participants.
National Institutes of Health (NIH) | National Institutes of Health (NIH) — All of Us
Speaker 3 (26:23):
So if you enroll and you're one of the people selected to get your genome sequence, they'll be sharing the information that they find that's clinically actionable with you for free. At a medical grade, those tests would have to be repeated if they're positive in a clinical setting because they're research-based tests, but we are actually one of the sequencing centers for the all us program. So I have high confidence in our abilities. And if people are interested in getting their genomic information, that is high quality without making an investment, that is an option that would also help medical research. It's a really exciting program, collecting people from every ancestry, rural, all sorts of diversity in that program and going to help us understand how to use genetic information in health.
Dr Pelmam(27:14):
And that is again, is called the All Of Us program. So they can just go to their computer, look it up there.
Dr Jarvik
Yeah, don't go to their program, find the homepage. There's an enrollment thing. And the enrollment page actually has a lot of educational videos. So you understand what you're signing up for. And again, they're investigating your DNA particularly, and everybody's DNA is unique to them, which brings up, of course, some people's concern that I don't want my DNA out in a database. So these things that we're discussing are secure. Yeah. So, I mean, it's still a good question. So the All Of Us program is generating data for research use that genome sequence is available. It is going to be de-identified in a way that doesn't directly connect, you know, identify easily identifiable information, but the database will have health history information. It's not impossible that those could be reconnected. So if people are very concerned about that, that may not be something they want to do.
Dr Jarvik (28:11):
From my standpoint, you know, once you know that you're at risk of a disease, which the program would return to you, if it's a high risk disease, you want that information and you have to tell your doctor about it. So it's in your medical record, your insurance is going to find out about it. Genetic changes cannot be used to keep people from getting health insurance. They can be used to keep you to change or change the costs more likely for long term care, disability, insurance, life insurance. We don't know of companies that do that, but it's legal. Whereas using that information for health insurance or employment is not legal under current law. But you do need, there's something we can do with that information. So that's a choice. People can make many people make the choice to say, well, I want that information.
Dr Jarvik (28:59):
Even if there's some risk of an insurance company finding out.
Dr Pelman
And that's really an important point you made, they cannot deny you insurance.
Dr Jarvik
That's actually against the law to deny you health insurance, and it can not be used for employment. And then it can't deny you a Medicare ether, RMS, or Medicaid.
Dr Pelman
If somebody had no insurance, are there ways for them to get checked?
Dr Jarvik
Yeah, I'm not an expert on that. I mean, we live in an unfortunate health insurance environment where we have a lot of people without insurance. I don't know what the public health programs are. And I know even Medicare does not do preventative testing so that if your sister has a colon cancer, genetic change, and you're covered by Medicare, and you want to be tested for that, the program will not pay for that test. If you get cancer, then they'll pay for that test.
Dr Jarvik (29:47):
Medicare has a very limited suite of preventative healthcare things that it does under law. And this is not one of them. So these tests are not easily accessible to everyone. We are very appreciative that these new sequencing technologies have dropped the cost of these tests. Significantly. You used to routinely pay three to $5,000 for some of these tests. There are options that are self pay that are in the hundreds of dollars. Now for some of these tests. And that's made a huge change to the accessibility of these tests for people who were insurance denied or not insured. However, there are still families for which that's a significant burden. And we've seen families where people literally pitched in to cover the one test.
Dr Pelman
Yeah. I think you have a suspicion that it's worth spending the money or finding the money for that, or seeing what's available at least.
Dr Jarvik (30:43):
That's something we talk to our patients about the cost benefit of the test. If they are going to self pay for that test, then we will talk to them about what's the possibility it will be a positive test. What's the possibility that that will change their healthcare. That's part of the counseling that we do when people would need to pay it out of pocket.
Dr Pelman
And I can imagine the people are listening, going well. I wish they'd be more specific about disease, but there's just too many to mention. I guess you could go to the computer and look up inheritable diseases. And if you're concerned that would lead you into a world…
Dr Jarvik
That would be a huge thing. Yeah, I think it really, I would focus on what the diseases are in my family. And am I worried that we have more than the average person?
Dr Jarvik (31:28):
But you know, it's certainly true that some of us carry genetic changes that put us at risk of disease without really a family history that would alert us.
Dr Pelman
Excellent. It's been highly informative. Anything that you want to contribute before we close up?
Dr Jarvik
I do feel like we probably haven't given enough attention to pediatric diseases since I'm an adult doctor. And I think pediatricians probably are a little more attuned to when to bring genetics into a case. But as an adult doctor, we see people who have had a syndrome their entire life, they were born with it. We didn't have the tools in the past to make a diagnosis, and we often have those tools now. So I would suggest to people who have a family member, who's always been affected with a disorder that has no specific diagnosis to consider whether they need a geneticist involved to make that diagnosis because it can impact other family members.
Dr Jarvik (32:28):
And then the other really interesting national program that I should mention is the Undiagnosed Disease Program that the National Institute of Health funds and it's often centered in genetics, but these are programs around the country for people who have had a long medical odyssey and still don't know why, what is wrong with them in order to be qualified for the program you need objective findings. So unfortunately that doesn't help people with like pain and fatigue, but if you have structural kidney anomaly, if you have muscle wasting, if you have some clearly objective measurable finding, intellectual disability among them, that program is open to people who have had long medical odysseys. It's completely free to them. They can apply through a national portal, the Undiagnosed Disease Network portal, and be seen for free at a regional expert center. So that's another program that's out there.
The Undiagnosed Diseases Program (genome.gov) Undiagnosed Diseases Network (nih.gov)
Dr Pelman (33:25):
Yeah. There's some neurologic issues that are very tough to nail down. To be specific about.
Dr Jarvik
In adults rheumatologic, neurologic are common issues, but we've seen all sorts of things. We have a Undiagnosed Disease Site here at the University of Washington in Seattle and on the pediatric side these are often children with congenital anomalies, but also children who develop disease at 2, 3, 4 years of age. That's had an unusual course and not, it does not run in the family. And sometimes we are just making a diagnosis in these individuals. Of course we don't figure them all out. But sometimes we can actually recommend specific treatments based on what we find.
Dr Pelman
Well, thank you.
Dr Jarvik
It's my pleasure.
Dr Pelman
Yes. Thank you very much.
Dr Pelman :
This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan Bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society. Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men's health visit wsus.org or visit your physician or care provider.
Episode Summary: Early diagnosis—for pre-diabetes, diabetes, thyroid issues, osteoporosis, and low testosterone—is critical for a quality long life managing or even reversing these challenges. Screening and treatment are effective and available. These health issues are under-diagnosed in guys because the symptoms are in that category of ‘my arm is not falling off, I don’t need a doc.” Except for one condition: erectile issues can get guys to the doc. Early diagnosis—for pre-diabetes, diabetes, thyroid issues, osteoporosis, and low testosterone—is critical for a quality long life managing or even reversing these challenges. Screening and treatment are effective and available. These health issues are under-diagnosed in guys because the symptoms are in that category of ‘my arm is not falling off, I don’t need a doc.” Except for one condition: erectile issues can get guys to the doc. Episode Guest: Arthi Thirumalai, M.D.. Assistant Professor, Endocrinology Division, University of Washington During This Episode We Discuss: * What is necessary to know about common endocrine disorders? * What are the associated risk factors with these diseases? * Understanding the symptoms and signs of these conditions. * Understanding management requirements and the importance of treating these conditions. * What is Low Testosterone (LT)? * Male contraception.
Quotes (Tweetables): “For prediabetes what will be offered is intense lifestyle modification, that essentially includes exercise activity (150 minutes of moderate exercise activity or 75 minutes of vigorous activity per week), in addition to eating a healthy diet. We recommend less than 10% of your daily caloric intake coming from refined sugars and less than 10% of the daily caloric intake being from saturated fats. So leading a healthy lifestyle in terms of diet and exercise is the first step that most people try. That said you don’t need to stop there, you can add medication, the most common being Metformin.”
“Most men are not aware of the existence of low testosterone associated when you're on certain medications. The two that come to mind are chronic steroids like Prednisone, and chronic narcotic therapy opiates.” Arthi Thirumalai, M.D.
Recommended Resources: * The American Diabetes Association * The American Association of Clinical Endocrinologists AACE
Episode Transcript: Dr Richard Pelman (00:07):
Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven't yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men's health with renowned experts and embark on a journey towards better health!
Dr Richard Pelman (01:26):
On this episode of The Original Guide to Men’s Health, we are going to be exploring common diabetic and endocrine disorders, with Dr. Arthi Thirumalai. Thirumalai is an assistant professor of medicine Division of Endocrinology here at the University of Washington School of Medicine. She did a residency and fellowship in endocrinology at the University of Washington and has research interests in andrology and male contraception clinically. She sees a variety of endocrine disorders and diabetes. Welcome.
Dr Arthi Thirumalai
Thank you very much.
Dr Pelman
So let's start with the common endocrine issue diabetes, and maybe even go before that, into what's called pre-diabetes metabolic syndrome.
Dr Arthi Thirumalai (02:16):
So given that everybody is aware of the obesity epidemic, what we're seeing is rapidly increasing numbers of individuals with this entity called metabolic syndrome. This condition is defined mainly by the presence of three or more of the following problems. The first feature being increased in abdominal circumference. So waist circumference that is more than certain set parameters there’s a rise in blood pressure. Typically we think of numbers that are over about 130/85, rise in fasting blood glucose, over 100 milligrams per deciliter, and then cholesterol abnormalities that could either be triglycerides that are getting elevated over 150 milligrams per deciliter, or an HDL that's falling under certain parameters, men and women, those numbers being different. So when somebody has more than three of these, we consider them as having metabolic syndrome and just by looking at those individual components. We know that all of those are risk factors for heart disease. And so we pay more attention to these individuals and try to modify these risk factors earlier so that it doesn't evolve into diabetes. And it doesn't evolve into heart disease.
Dr Pelman (03:23):
Say we have a patient who has not entered into the healthcare system, they're listening to this and they go, “well, I guess I could go get my blood pressure taken.” I would have to go to a lab and have somebody order the blood work. Anything else that might give them an idea that they're heading in that direction?
Dr Arthi Thirumalai (03:43):
Well, you know, everybody has a sense of how much they weigh. And if you feel like you are an unhealthy weight or borderline overweight, then those are definitely the people that I would target more specifically to go meet with a primary care doctor to get your weight checked, figure out what your body mass index is, and are you at risk for any of these problems? As you mentioned, screening blood pressure is actually recommended for all adults over the age of 18, which is really the definition of adulthood. And then even screening for diabetes is recommended in anybody over the age of 40, especially if they're overweight or obese, and screening for diabetes has become a lot simpler than it used to be. Originally, people might've thought you need to do this thing where you take a glucose load and then do a measurement at one hour or two hours. But it's not as complicated as that anymore. A simple test called the hemoglobin A1C* on your blood on a random day. you don't need to fast, could be a starting point to see if you might have pre-diabetes or diabetes.
*All About Your A1C (cdc.gov) --When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin.
Dr Pelman (04:40):
Somebody who gets their blood drawn and has a normal fasting glucose or blood sugar, but has an abnormal hemoglobin A1C, is that possible?
Dr Arthi Thirumalai (04:50):
It is possible because prediabetes is essentially defined as somewhere between normal and diabetes. And there are two components to that. One is called impaired fasting glucose, and the other is called impaired glucose tolerance. And the problem of the two is a little different. In impaired fasting glucose the main problem is that the liver is responsible for making extra glucose in the body and it's doing too much of that. And so they may be time when they eat and their glucose may be normal, but when they wake up in the morning, their blood sugar is high. Whereas in impaired glucose tolerance, what ends up happening is that they're not able to dispose of the glucose that is absorbed from any food that they eat in the proper way. And so the word prediabetes really encompasses both of these problems. They could either have one of the two abnormal or both of them abnormal, just not abnormal enough to call it diabetes. So you could have a normal fasting glucose, but still be pre-diabetic because your glucose tolerance is impaired.
Dr Pelman (05:47):
So again, we're talking about prediabetes or metabolic syndrome, if left unchecked, what happens?
Dr Arthi Thirumalai (05:55):
Well, about a third of them will progress to diabetes. And actually the numbers have been skyrocketing as the times have gone by. And if you look at the CDC data, comparing 20 years ago to now, the rates of pre-diabetes have gone up and the rates of diabetes have also gone up. What's actually even more interesting is that men are more likely to have undiagnosed diabetes or undiagnosed pre-diabetes compared to women. I think women tend to encounter or interact with the medical system more often just by reproductive needs. And so they get diagnosed earlier. Women tend to have other symptoms that they might seek help for earlier than men do. So I think this is definitely something important for men in the early adulthood, 18 to 30, 30 to 49 to consider. Whereas older men tend to seek medical help more often, so are less likely.
Dr Pelman (06:41):
Then somebody, again, maybe pre-diabetic not getting treated, not turning into full blown diabetes, or they're in the other you said two thirds. They have high blood pressure. That's going to cause issues for them. What other manifestations form the pre-diabetes can be problematic for them if it's not treated well?
Dr Arthi Thirumalai (07:02):
So I think the thing that to focus more on is what are the associated risk factors? So somebody might have a genetic cholesterol problem that they're not aware of and having pre-diabetes on top of a second risk factor puts them at higher risk for heart disease. And they may have an early heart attack or a stroke in their forties or fifties that they might have otherwise prevented by seeking medical attention early. And the same goes if there's another risk factor like smoking or they're overweight, then multiple risk factors add up and put them at risk for more serious problems.
Dr Pelman (07:35):
Now, if they're not yet diabetic, we're still talking about pre-diabetes, they do seek care. What are some of the treatment options for these people?
Dr Arthi Thirumalai (07:45):
Right, so in general, for most people with pre-diabetes, what will be offered is intense lifestyle modification. And that essentially includes, what we consider appropriate exercise activity, which should be at least one 50 minutes of moderate intensity activity or 75 minutes of vigorous activity per week. In addition to which they need to eat a healthy diet. The definition of that is a little tenuous, but in general we recommend less than 10% of your daily caloric intake coming from refined sugars, less than 10% of the daily caloric intake being from saturated fats. And so leading a healthy lifestyle in terms of diet and exercise would be the first step that most people will try. Having said that, you don't need to stop there. You can also add medications. And the one that's usually offered is Metformin therapy. It's a drug, that's an oral medication, a tablet that's been around for decades. And so there's no concern about safety at all. And it has been shown to very effectively prevent the progression from prediabetes to diabetes. And it can sometimes be a little difficult to tolerate side effects, but if you titrate the dose up slowly, most people do completely fine.
Dr Pelman (08:54):
What sort of side effects would be concerning?
Dr Arthi Thirumalai (08:57):
Most people experience a little bit of stomach discomfort, so they can get a little bloating, a little gassiness, some abdominal cramping or even diarrhea. But usually we start at a very low dose and very gradually increase the dose. There’re also extended-release formulations of this drug that helps circumvent those side effects. Those would be effective ways of preventing progression from prediabetes to diabetes.
Dr Pelman (09:18):
And I remember reading something about Metformin, a longevity study, that it might be the longevity drug.
Dr Arthi Thirumalai (09:24):
Yes. And actually lots of studies are ongoing for anticancer effects of Metformin as well. So I don't think we've exhausted all of the utilities of this drug yet, but definitely a very safe drug and very effective.
Dr Pelman (09:35):
I've had some patients who are concerned though, “I have to go on this medicine.” I said, “well it may not be bad for you, it actually might do better than the person next to you who's not taking it.”
Dr Arthi Thirumalai (09:45):
Some people will raise concerns that, oh, my kidney is going to be damaged by this drug. And I think that stems from some misinformation, there is a dose reduction that is recommended in people with kidney disease, but it does not cause kidney problems. So I just want to make sure that we always talk when I'm talking to my patients, that they understand the difference between a dose adjustments for a medical problem versus it causing that problem.
Dr Pelman (10:07):
So the lifestyle modification would include smoking sensation, with somebody helping them do that, exercise, diet, and we might see blood pressure get better.
Dr Arthi Thirumalai (10:24):
Absolutely, lowering cholesterol drops the risk for diabetes, and you can decrease all that through just exercise. And the other piece is alcohol consumption too. Especially for people with diabetes, high triglycerides, a lot of the time the problem is alcohol intake. So we recommend safe limits, which is usually one drink per day at the most for women and not more than two drinks per day for men.
Dr Pelman (10:44):
And of course watching those refined sugars that they sneak in there.
Dr Arthi Thirumalai (10:51):
It's so important to pay attention to packaging. And most packages will now have how much added sugar is there, and how much total sugars are there. So it's just important to pay attention to those.
Dr Pelman (11:03):
So we want to control the issues with high blood pressure to prevent stroke and heart attack, improve cardiac function, longevity. So if you think you're at risk and you're listening to this, go get checked. Well, let's move on to diabetes, a very common condition. And people get an idea that, aren't there two forms of diabetes?
Dr Arthi Thirumalai (11:26):
Actually, a very good question. So there are more than two forms of diabetes, but there are two large buckets of diabetes. One is auto-immune diabetes. And the other is the form that’s caused by insulin resistance, there is a small third category that is not related to either of these two, but they're very rare. So most likely a physician will think about that if the, if it applies in that situation, the first one which is type one, or the autoimmune diabetes, is due to auto antibodies. Your immune system makes them and then they go and attack beta cells, which are small cells inside the pancreas that are normally supposed to make insulin. And this used to be thought of as the “juvenile version” of diabetes where children were diagnosed. But what we're seeing more and more is that people can get diagnosed at any age with this condition.
What Is Type 1 Diabetes? | CDC
Dr Arthi Thirumalai (12:12):
I have a patient who was diagnosed at the age of 52 with type one diabetes. But the point is that the mechanism is the destruction of the ability to make insulin. So these people don't make enough insulin of their own. And the primary treatment for this is with insulin. Type two diabetes the problem is a little different. So the problem here is that they're making insulin, but the tissues that respond to insulin are not responding the right way. For example, the liver, the muscle, and the fat cells are the main tissues we think of as responding to insulin. And in terms of response, what they're really doing is taking up the glucose that you make from absorption of food, and then disposing it in the right way. And if you're not able to dispose of that glucose properly, your blood sugar goes up. And so this is considered a problem of insulin resistance. It is definitely linked, to a great amount, with obesity and being overweight. Having said that there were several people who are obese, but do not have diabetes. And there are several people who have severe insulin resistance but are not overweight. So it isn't an absolute connection, but there is definitely a correlation between.
Dr Pelman (13:12):
Now recognizing diabetes is important because of its effect on heart disease and general health.
Dr Arthi Thirumalai (13:17):
Actually heart diseases, and the thing is that we worry the most about it because diabetes is actually considered as equivalent to kidney disease, or Alzheimer's in terms of overall risk of death. But it is the single biggest risk factor for heart disease, which is the leading cause of death. And so it's important to think about diabetes control from a heart disease perspective. But again, there's also other complications like kidney disease, chronic kidney disease, diabetes cause complications in terms of nerve damage. So people get neuropathies and pain in their hands and feet. People can also get erectile dysfunction from neuropathy. And so diabetic neuropathy is one of the leading causes of erectile dysfunction in men. And then there's also retinal damage. So eye changes that can happen from diabetes. And so it's very important to control diabetes,
Speaker 2 (14:03):
And the endothelial dysfunction, the small vessel dysfunction from diabetes, it's not been checked and treated in run-on causes and contributes to the erectile dysfunction, besides the neuropathy. So good motivator for the guys if we want to maintain erections.
Dr Arthi Thirumalai(14:21):
Yep. Absolutely get checked. And we're also realizing more and more that diabetes contributes also to poor bone health. And this is again true for older men because as you age bone loss is a real thing and men are not always going to get checked for bone loss or osteoporosis like women are. And so if they have uncontrolled diabetes or have lived with diabetes for several decades, it puts them at risk for it as well.
Dr Pelman (14:42):
So we've spoken about the auto-immune and then insulin resistance. Now, somebody, before we go to treatment, who hasn’t been good about going and getting checked, what symptoms might they have?
Dr Arthi Thirumalai (14:56):
So type one diabetes very rarely presents sort of insidiously, it's usually associated with symptoms. The symptoms that they can experience are increased thirst, increased urination, increased appetite and weight loss. So those are the ones we typically experience. People can also present with an acute infection and then get diagnosed with type one diabetes or just a severe crisis called diabetic ketoacidosis, where they end up in the hospital with a lot of nausea and vomiting and abdominal pain. Type two diabetes, on the other hand, can be very sneaky. It can be lingering for months and months or years, even where people have no symptoms at all. Sometimes people will ignore subtle symptoms like, “oh, my vision got blurry after I ate that big meal and then it went away,” but those can be some subtle symptoms that people can experience. And also the nerve pain, neuropathy can be something that can happen acutely, and people will feel tingling or numbness in their feet or hands that can get better. And again, it get worse over time. And so they might ignore it, but those would be symptoms to watch for and get screened for diabetes.
Dr Pelman (16:01):
So the thirsts and excessive urination that comes on. “Gee, why am I so thirsty all the time?” Now, if somebody says, why? I go to my doctor once a year for a physical, we would assume that most people would have a hemoglobin A1C as a screening test.
Dr Arthi Thirumalai (16:15):
I think having said that, I have seen that not all primary care doctors will utilize a hemoglobin A1C. A lot of them will do the fasting glucose. I think if your fasting glucose is completely normal, it's reasonable. If you don't have a strong family history of diabetes, just use that test. But if you have a strong family history of type two diabetes or the fasting glucose is creeping up over time, and it was very close to that 100 mark that you should really get screened with a hemoglobin A1C. The other group of people that I would recommend to hemoglobin A1C are people who have other medical problems like thyroid disease or kidney disease and where you might be missing the picture with just that one glucose measurement. So you just want to make sure that you're checking everything.
Dr Pelman (16:58):
And so then someone is diagnosed, what are the treatment options for them?
Dr Arthi Thirumalai (17:02):
So the world of type one diabetes or auto-immune debt diabetes is still largely insulin dependent. So most people will only be treated with insulin over their entire lifetime. There is a role of some of the other newer agents, but it's really not FDA approved yet, and so it's more exploratory in terms of treatment. In type two diabetes, on the other hand, we've gone from Metformin and a couple of drugs like glipizide, glimepiride, and insulin to 15 new drugs getting headed in the last 15 years or so. So there's a lot of newer medications, the focus being either weight reduction or reduction of cardiovascular disease or prevention of progression of chronic kidney disease. So there are a lot of new medications. And typically what a doctor will do is start you. I said, on lifestyle modification and Metformin therapy, and if you're unable to achieve your target glucose control with that, then they will add on a second agent, which can be anyone of a category of drugs called SGLT2 inhibitors, which are drugs like Jardiance, Farxiga, or Invokana, or the injectable drugs like GLP1 receptor agonists, which are go by the names of Victoza, Trulicity or Zambak.
Dr Arthi Thirumalai (18:15):
And sometimes in some select individuals, they might add glipizide or glimepiride, or pioglitazone, those three drugs are less used in patients who can afford the other medications because they do unfortunately come with the side effect of weight gain, but they're definitely very cost efficient. And so for people in whom that is a factor, those would be the second line agent. When adding all of these does not effectively control somebody's glucose, that's when we resort to insulin and insulin comes in two forms. One is a long-acting injection where you only inject once a day, and then there's short acting versions, which you have to inject every time you're eating. And that would sort of be the last step in the management of type two diabetes.
Dr Pelman (18:53):
Has data shown that if you treat the diabetes, you can reverse the condition, or you just stop them from progressing?
Dr Arthi Thirumalai (19:00):
That's a terrific question. So I think it depends to some extent on the duration of the problems, for example, if somebody comes in with a month's worth of nerve pain, like they're feeling very numb in their toes, it's tingly all the time, but it's only been going on for a month. A lot of the times, if I can bring their blood glucose down, those symptoms will reverse. This is true for early retinal changes as well. Like if they have just a few changes in the retinal exam, those will reverse with better glucose control and even early changes in the kidneys, like small amounts of protein in the urine can be reversed effectively with intense glucose control. It's the people that have been living with these symptoms for a long period of time that are less likely to see full reversal of those problems. It will still be improved to some extent with intense glucose control.
Dr Pelman (19:48):
So you're going to still be controlling and at least halting progression, improving somebody’s lifespan.
Dr Arthi Thirumalai (19:57):
Absolutely, as well as morbidity. Like if somebody has really bad neuropathy, they put themselves at risk for infections of their toes or fingers and amputations. If somebody has really bad retinal problems, they put themselves at risk for blindness due to complications of that. And again, with kidney damage, of course, putting yourself at risk for chronic kidney disease and failure, and the complications that come from them.
Dr Pelman (20:19):
Now, many people would be concerned about, “oh, I have to go to insulin right away.” First of all, there is a lot of support in most areas, have a diabetic clinic and support staff.
Dr Arthi Thirumalai (20:32):
Yep. Absolutely. So most even primary care clinics will usually have the ability to meet with a nutritionist and go over the basics of how you should structure your diet, what components to include in every meal, how to break down at the different meals the day and how much calorie restriction to implement. So that support definitely exists. And then when you go to specific diabetes clinics, there's a lot of ancillary staff. You see a physician, you see pharmacists that help you gauge the different systems of drug coverage and what are your best options in terms of obtaining different drugs and are there programs that they can use to get discounted rates for medications, most diabetes clinics will also have certified diabetes educators that can help patients understand better how to manage their blood sugars. And you control that.
Dr Pelman (21:19):
And most insurers are going to cover diabetic treatment, right?
Dr Arthi Thirumalai (21:22):
I think the cost of drug treatment is reducing, but it is still a problem. The population that tends to face a problem is obviously the Medicare group of people, as well as people whose private insurance is not offering very good prescription drug coverage, but that is improving rapidly over time. I hope it would improve faster, insulin coverage is still an issue in terms of cost. And the bigger concern is checking your blood sugar. The test drips tend to be expensive, but it is definitely something you can work with your physician on and see how to optimize it.
Dr Pelman (21:56):
And if somebody says, “well, I'm listening and I don't have a job at the moment, and I don't have health insurance,” they shouldn't not get taken care of.
Dr Arthi Thirumalai (22:03):
In fact, if you actually don't have a job and your income is lower than a certain limit, most clinics will be able to get you on some sort of financial aid system that will help you get the supplies you need.
Dr Pelman
Because it’s not going to go away.
Dr Arthi Thirumalai
Nope
Dr Pelman (22:14):
You are just going to get sicker and have more issues. So we've explored diabetes. Pre-diabetes what else could we look at as a common endocrine issue?
Dr Arthi Thirumalai (22:29):
So thyroid disease, I think tends to get missed in men because the symptoms of thyroid disease can be very similar to that of low testosterone. And when men experience these symptoms, the first place their mind goes to is low testosterone because it's advertised so much. And then they might go and specifically ask their primary care doctor to check their testosterone level but checking the thyroid might get missed. So the symptoms of thyroid disease can be one of two directions, too little thyroid hormone can present with symptoms of fatigue, feeling very sleepy, feeling tired all the time. It can have cold intolerance, which is, they feel cold all the time. They can also experience constipation and weight gain and a lot of dry skin. So if anybody experiences those symptoms, they should definitely ask their primary care doctor to check their thyroid level. On the other extreme is also hyperthyroidism, which is too much thyroid hormone, which can present with a sort of this burst of energy, unable to fall asleep at night. They can feel warm all the time and flushed. They can feel palpitations. They could feel shaky or jittery or can feel extremely anxious and also lose weight. So if people experience those symptoms again, important to ask your primary care doctor to check your thyroid level.
Dr Pelman (23:42):
And when we assume that for a general yearly physical, at least some thyroid is getting screened.
Dr Arthi Thirumalai (23:47):
That's a very good question. So the USPSTF, which is the United States Preventive Services Task Force does not recommend screening routinely for thyroid dysfunction. And the vast majority of primary care doctors are probably going to follow those guidelines and not be routinely screening for thyroid disease. However, if you look at the Endocrine Bodies, the American Thyroid Association actually recommends screening. Thyroid levels are a TSH in everybody over the age of 35 and the American Association of Clinical Endocrinologists or AACE recommend screening older people, without an emphasis on what age to start at. I think in general, my practice has been that anybody who is over the age of 65, I will screen them for thyroid disease, but anybody else who has other risk factors, like if they have autoimmune conditions like type one diabetes or vitiligo or Crohn's disease or celiac disease, those were people I would start screening even earlier around age 35. And I would screen them every five years.
Dr Pelman (24:44):
So thyroid disease is somewhat age-related.
Dr Arthi Thirumalai (24:47):
Is age-related as well as it is auto immune. So if it runs in your family, you are more likely to get it. If you have another auto-immune disease, you're more likely to get it. And the older you get, the more likely you are to get it.
Dr Pelman (24:58):
And then treatment is if you're hypo, you get thyroid replacement?
Dr Arthi Thirumalai (25:03):
Yeah, it’s sort of like taking a vitamin, it's a pill that you take every day. The dose could be very variable depending on the cause of low thyroid function and the degree of it. And if you have too much thyroid hormone that can be treated in one of two ways, one is either pills or there's also something called radioactive iodine therapy, where they give you sort of a radio labeled iodine that you swallow as a pill. And it just kills off the cells in the thyroid gland that are making too much thyroid hormone.
Dr Pelman (25:29):
And then you just go and replace it.
Dr Arthi Thirumalai (25:32):
It depends on the cause. And the vast majority will end up on some replacement of thyroid hormone and some people get away without any, it's well tolerated. It's very well tolerated. And the doses that are used for treatment of hyperthyroidism, there's really no concern that it would result in cancer or anything, very treatable.
Dr Pelman (25:49):
Good to find out about. And if left untreated?
Dr Arthi Thirumalai (25:54):
That's an important point, especially as you get older. So untreated hyperthyroidism, even if that is too much thyroid hormone, which is not even to the level that the blood tests are, frankly abnormal, they might just be subtly abnormal. That has actually been shown to increase your risk of both osteoporosis and atrial fibrillation in people over the age of 50. So the recommendation is that if you're over 50 years of age and you have a low TSH, even with a normal free T4, which is the thyroid hormone level, the recommendation is to consider treatment in anybody over the age of 50.
Dr Pelman (26:28):
Nice. Now we've talked about pre-diabetes diabetes, thyroid, what else?
Dr Arthi Thirumalai (26:35):
So osteoporosis Is the other thing that I think we should discuss, because I think men tend to, again, not think about their bones as much. They don't worry that they're going to have a fracture, whereas it's so drilled into women that, you know, once you go through menopause, you're at risk for bone loss and you need to check on this. But the reality is while the risk of osteoporosis is lower in men than in women, it isn't zero. And so, especially as you get older, once you're over the age of 80, the risk goes up considerably. And as people are living longer and longer, over 80 is a significant chunk of the population. And having osteoporosis puts you at risk for having a fracture. And the fracture could be from something as simple as slipping on something and falling down and breaking your hip.
Dr Arthi Thirumalai (27:20):
And the problem with all of this is that when you have a fracture late in life, it puts you at higher risk of death from that fracture and recovering from it. And so I think it's important to think about the people that I screened for osteoporosis, the men that I screen for it would include anybody who's on steroids like prednisone for long periods of time. Anybody who's on it for more than three months really should be screened for osteoporosis and treated for it. So I'm talking people with rheumatoid arthritis or Sjogren's disease or lupus, anybody with diabetes, I would screen for osteoporosis in their later life, because it does increase your risk of low bone density. And then men who have no testosterone, I would screen for osteoporosis. There are some people who are on normal doses of steroids, like hydrocortisone or things like Cushing's disease, or have had pituitary surgery or traumatic brain injury and are on replacement.
Dr Arthi Thirumalai (28:11):
Even those people that we think we're giving normal levels of steroids to, I would still screen for osteoporosis people with celiac disease or any absorption disorders. Treatment for osteoporosis, it usually consists of drugs that are either an infusion that you take once a year or pills that you take once a week. Again, very effective drugs that have been shown to reduce your risk of fractures considerably the side effects of those, again, tend to get hyped online, but really they're mostly very well tolerated. And the risks are not really something to worry about.
Dr Pelman (28:46):
And I think I recall that if we maintain muscle mass and movement helps maintain our bone health.
Dr Arthi Thirumalai (28:51):
Absolutely. In fact, if you look at the recommendations for daily activity, it includes not just cardio, but also resistance training. And that's extremely important for the bones because the bones don't care so much about what the heart is pumping, but what the muscles around the bones are doing. And so it's very important to include weight training as part of your workout regimen, especially the older you get. There's actually studies that have looked at CT scans of people's muscles as they age, and the muscle competency goes down drastically as you age. So the loss of muscle is very real and it's definitely something to pay attention to.
Speaker 2 (29:27):
Yeah. I remember a Stanford gerontologist who coined something, a term “frailty scale” and people who are sedentary are at a very steep slope into frailty. And so if you keep moving and maintain some muscle mass, you're going to be much better off. But let's talk about testosterone. Now we did an episode on testosterone, but from an endocrinologist point of view, what would you contribute on testosterone?
Dr Arthi Thirumalai(29:57):
So I think most people, most men, are now aware of the existence of low testosterone and the need to treat it. And so they're watchful for the symptoms of low testosterone, but I think what people may not be quite aware of is the risk of developing low testosterone when you're on certain medications. And the two that come to mind for me are chronic steroids like prednisone and chronic narcotic therapy or opiates. With how many people we now have on chronic narcotic prescriptions, as have all sorts of pain syndromes, the prevalence of hypogonadism in these people is going up. And we don't always look to screen for low testosterone in these people. A lot of the times their symptoms might be missed or overlooked. And so it's important to look at these individuals and screen them for a low testosterone. The other group that I think is important is any gentleman who presents with a fracture without a clear mechanism, or a clear cause of trauma. Like, as I said, you slipped and fell down, broke her wrist or broke his ankle. I think those are people that we should consider screening for osteoporosis as well as low testosterone, because low testosterone is one of the single biggest risk factors for bone loss in men. And so they need to be screened for the presence of low testosterone as well.
Dr Pelman (31:12):
And then we go and replace and monitor, but there really are criteria or replacements clinical and laboratory, correct?
Dr Arthi Thirumalai (31:21):
Yes. And I think that one of the problems is a lot of people come in with the idea, “but this is low for me.” And “shouldn't this be more in the middle or the upper end of normal?” And the reality is that's actually not true. So unless you've happened to check your testosterone level throughout your life, and you know, this is definitely lower than your baseline. There's no such thing as “this is low for me.” I think it's really correlation of low testosterone as well as the symptoms that makes the most sense to make this diagnosis. As you mentioned earlier, I do a lot of research in andrology. So we take a lot of healthy men in the age range of 18 to 30, who participate in our trials. And a lot of them have testosterone levels that are about 200 or 250 nanograms per deciliter, which would be considered low in a lot of cases, but these men are healthy and fine and virile and have no symptoms whatsoever. So I think this is something that is important for people to remember that as the assays get more and more refined, the lab value, cutoffs.
Dr Pelman (32:18):
Other endocrine issues are more rare concerning pituitary tumors and anything that you want to go over in those?
Dr Arthi Thirumalai (32:28):
And, you know, I would say that whenever you see massive changes in your body in terms of weight distribution, or you've had massive weight gain, that's something to probably at least talk to your doctor about. And if your primary care doctor feels it's important for you to meet with an endocrinologist, because you can get certain hormone excess, like excess growth hormone, or excess cortisol production that could present with changes like that. Anybody that is presenting to the hospital with inability to, you know, resolve an infection without the need of extra lots of medications in an ICU state should be concerned about not enough cortisol. Those are very rare disorders though. I don't think these are really something people need to have in the back of their mind on a day to day.
Dr Pelman (33:09):
If somebody, has an abrupt change, when the libido in a male who says, “I used to be really, really interested in sex and that just changed,” that there certainly can be screened. Correct?
Dr Arthi Thirumalai (33:21):
Absolutely. Yeah. Any rapid change that you're noticing is definitely worth bringing up to your doctor.
Dr Pelman (33:27):
Right, and then since it's an interest of yours, talk about male contraception.
Dr Arthi Thirumalai (33:34):
So, the joke in our group is that we've always been 5 to 10 years away from the next birth control method for men. The world of male contraception is very interesting. My personal area focuses just hormonal male contraception, where we try to give men testosterone like agents in the form of either an injection or a pill or a patch or a gel that they can apply. And then what it does is it gets absorbed into their blood and suppresses the production of hormones from the brain that then tell the testicles to stop making testosterone and sperm. But by virtue of this drug being present in their blood, it will act in place of testosterone and make them feel completely normal. This field has been researched over the last 40 to 50 years now. And though we have a lot of regimens that work effectively in the vast majority of men.
Dr Arthi Thirumalai (34:19):
The problem we've run into is making a regimen that is easy for men to use and also completely safe in terms of both side effects, as well as what we would be considered safe in terms of changes in blood pressure or cholesterol changes. Currently, our group is actually working on a few different formulations that are novel androgens. So those are modifications of testosterone that have been made. One of them is called dimethandrolone undecanoate. And the other is called 11-beta-MNTDC, both of these are being investigated as pills. So we're hoping that we could make the next male pill, but they're very early in the stages of development. They've pretty much just done phase one trials at this point, but it's promising in that they definitely suppress the hormones to the levels that we want to see. And they've very well tolerated by the men that took them.
Dr Arthi Thirumalai (35:06):
We obviously need to see longer studies before they go anywhere. But the agent that is actually furthest ahead right now is a combination gel. So it's a gel that consists of testosterone, which is an FDA approved drug, but also has an investigational product called nestorone, which is a progesterone like agent. This is actually used in female birth control rings. It's never been used in men in long studies. There have been sort of six month long studies that we have done in men that have shown that the drug works very well. It brings sperm counts down zero. So right now there is an efficacy study going on, which is recruiting couples, where they will only use this drug as their birth control method. And we'll see how effective it is at preventing pregnancies. This is an ongoing study at the University of Washington as well as multiple other sites throughout the world. We're hoping to complete this study within the next year or at the most two, and then show we should have results shortly.
Dr Pelman (36:02):
And then you brought up an interesting point on testosterone is a birth control, but for young men who are listening, want to make certain, they don't go on testosterone if they want to be fertile. Correct?
Dr Arthi Thirumalai (36:13):
It isn’t that the chances are zero, but you diminish your chance of being able to successfully father a pregnancy considerably with testosterone therapy. So that is an important discussion to have if you require testosterone therapy, because there are alternate agents that can be used in that.
Dr Pelman (36:28):
Absolutely. Well, I remind our audience of resources that are available. So let's go back to diabetes.
Dr Arthi Thirumalai (36:36):
The American Diabetes Association website usually does have a lot of resources that you can be guided towards. The American Association of Clinical Endocrinologists also has a lot of resources that you can go to. So that's the ADA and the AACE websites, but, Facebook has actually become a very good place. I have a lot of patients, especially with type one diabetes who tell me that they find all these different groups about how to manage type one diabetes, how to use glucose monitors and things more efficiently, how to use their insulin pump. And I think these are amazing resources for people living with these problems. Nowadays, if you have type one diabetes, there's a lot of research studies that are ongoing about diabetes technology, clinical trials.gov is a very good source to find what trials are ongoing and definitely in Seattle, multiple locations that are doing a lot of research. There's also a lot of type one diabetes research that is in relatives of type one diabetes. So those who do not yet have diabetes but are at risk for getting diabetes. And so the Benaroya Research Institute or the BRI is doing a lot of those trials.
Home | ADA (diabetes.org) | American Association of Clinical Endocrinology (aace.com)
Dr Pelman (37:37):
Excellent. Well, Dr Thirumalai, appreciate your time. This was wonderful. Thank you very much.
Dr Pelman :
This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan Bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society. Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men's health visit wsus.org or visit your physician or care provider.
Episode Summary: Interesting things happen during sleep that impacts our health in a surprising number of body systems (sexual, cardiac, neurological, metabolic). Many careers, the modern world (devices), our health, and sleep apnea all interfere with good sleep. In this lively episode learn the scientific and medical reasons good sleep is critical, and how to make good sleep work in your life. Episode Guest: Scott Bonvallet M.D. Medical Director of the Overlake Sleep Disorders Center in Bellevue WA; Board Certified in Internal Medicine, Pulmonary Medicine, Critical Care, and Sleep Medicine. During This Episode We Discuss: * The importance of good sleep for our well-being effect on other areas of our bodies. * Night time frequent urination, voiding (nocturia) related to sleep apnea. * Weight gain related to sleep apnea. * Alzheimer’s Dementia related to obstructive sleep apnea. * Increased risk of stroke and heart attack with sleep apnea. * Sleep disruptors. * Sleep disorders. * Diagnosis. * Evaluation and treatment options for sleep disorders. * Tips for improved sleep health.
Quotes (Tweetables): “Other myths are that you have to feel tired or sleepy to have sleep apnea, about ⅓ of people with sleep apnea will deny being tired or sleepy.”
“About 90% of men with sleep apnea snore. In women, about 50% of women with sleep apnea don't snore at all.”
“People who have obstructive sleep apnea have decreased amounts of REM sleep, thereby it’s implied, and probably accurate to say having untreated sleep apnea increases the risk for Alzheimer's dementia.” Scott Bonvallet M.D.
Recommended Resources: * Sleepfoundation.org * Sleep and Health CDC
Episode Transcript: Intro (00:07):
Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven't yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men's health with renowned experts and embark on a journey towards better health!
Dr Pelman (01:26):
Are you feeling tired? Fatigued? Maybe you're getting up and you think you have to empty your bladder, but it could be sleep apnea. Stay tuned for this episode of “The Original Guide to Men’s Health“. Where we interview Dr. Scott Bonvallet, a sleep expert. On this episode, of “The Original Guide to Men’s Health,” we'll be looking at sleep, what interrupts sleep, and sleep apnea. We're fortunate to be interviewing Dr. Scott Bonvallet.] Dr. Bonvallet completed his medical schooling at the Medical College of Wisconsin. And then he went to Oregon Health Science University for his residency in internal medicine. After that, he went to the University of Colorado for his fellowship in pulmonary disease, pulmonary medicine, and critical care where he was also exposed to sleep medicine. He became board certified in internal medicine, pulmonary medicine, critical care, and sleep medicine. He is an expert in sleep medicine, and we're fortunate to be able to speak with him today about issues that interrupt our most vital asset, our ability to sleep. Dr. Bonvallet. Welcome. Thank you. So, a little background about sleep disorders. There's many reasons why people have sleep disorders. Do you want to just give a general overview of what you do and what kind of things you look at?
Dr Bonvallet (02:42):
So, I'm the medical director at Overlake Sleep Disorder Center based in Bellevue Washington. And we've had a sleep center here in Bellevue since 1999. And we see all types of sleep disorders to include disorders such as insomnia, sleep apnea, narcolepsy, and then other specific types of sleep disorders that are more common. For example, in adolescents, one of the more common sleep disorders quite frankly, is simply insufficient sleep, in that most adults are relatively sleep deprived, in that the average adult needs probably at least seven hours of sleep per night. And studies have shown that the average adult probably, at best, gets six hours of sleep per night on average, but we also see disorders as mentioned, like obstructive sleep apnea. And that's a disorder where people will have episodes where they stop breathing during the night. And then that can interrupt their sleep. Not to mention it is associated with decreases in oxygen level in the bloodstream, which can have effects on the heart and brain long-term. And it's probably one of the most under-recognized sleep disorders. There is in the United States.
Dr Pelman (04:03):
In general sleep disorders, there’s more than just sleep apnea, restless leg syndrome. Is that part of what could happen?
Dr Bonvallet (04:10):
That is correct. That's a disorder where people will have uncomfortable sensations in their legs, particularly in the evening and at nighttime that can interfere with your ability to get to sleep. And it can also interrupt sleep once you've made it to that point of falling asleep and that people can continue to have twitching of their legs that prevents them from getting into a deeper sleep.
Dr Pelman (04:33):
And what about somebody who has a hard time falling asleep? They just say, “I can't turn my mind off.”
Dr Bonvallet (04:38):
So that's very common. A lot of that relates, often, to these days where people have bad sleep habits or sleep hygiene where they'll commonly do work-related tasks right up until bedtime or use electronic media, whether it's for work or for leisure that is stimulating and can interrupt our ability to get to sleep. Some of the light that's emitted from electronic devices like iPads and iPhones is of a wavelength that stimulates a receptor in our retina that then sends a signal to the brain to wake up. And so that's a phenomenon that's evolved over the years where people are reliant on that kind of technology, whether it's again, for work or just for their own personal entertainment.
*The wavelength of light most commonly scrutinized for this is “blue light.” Most electromagnetic waves are invisible. But a small band of waves, known as visible light, can be detected by the human eye. Visible light waves vary in length from 380 nanometers (violet light) to 700 nanometers (red light). The longer the wave, the less energy it transmits. Blue light has very short, high-energy waves. In fact, they’re only slightly longer and less powerful than ultraviolet (UV) waves (which are too short for people to see with the naked eye)
https://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side https://www.healthline.com/health/what-is-blue-light#is-blue-light-bad-for-your-eyes
Dr Pelman (05:26):
In, uh, advice to general public, how to get the best sleep to guys, how would you tell somebody to prepare for going to sleep?
Dr. Bonvallet (05:34):
Well? I think it's first of all, very important to try to maintain a regular schedule, and that is we do not vary our sleep, or our bedtime, by more than an hour later/earlier with any sort of frequency. And the same holds true for our awakening times because otherwise our internal clock gets thrown off and doesn't know whether we're supposed be asleep at 11:00 PM or awake. That's important. And I also think it's very important to allow yourself to have time to wind down and so doing work-related tasks like answering emails and things like that, that can be stressful right up until bedtime is counterproductive. As it pertains to being able to get to sleep. Regular exercise helps, there's data that shows that exercising 30 minutes per day increases your deep sleep, or what we call stage three sleep, by about 50%. So that is also important for sleep as well as other things. So those are some of the little things that we can do. And again, trying to get or achieve, you know, seven hours of sleep per night is important. It's been shown that sleeping less than that can contribute to weight gain, increases risk for diabetes. And that's independent of also having other sleep disorders like obstructive sleep apnea!
Dr Pelman (06:55):
Just being mad at exercise. You wouldn't advise exercising just before going to bed.
Dr Bonvallet (07:01):
Well, that was actually the older recommendations, but there really isn't a lot of data that shows that exercising right before bed interferes with our ability to get to sleep. And often it's hard. If you work all day, have dinner, and then it's time to go exercise. It's hard to be able to do that without it being right before bedtime. So, it really doesn't make a big difference as far as when we time our exercise.
Dr Pelman (07:29):
Okay. So, it's, if that's the time that somebody can find to exercise, then do it. It's better than not.
Dr. Bonvallet
Correct.
Dr Pelman
Okay. Now, if we're looking at one last human need, which is to eat. Is there any information about meals and going to sleep?
Dr Bonvallet (07:44):
So, it’s recommended that we try not to have any significant meal, at least within three hours of bedtime. And that's for a variety of reasons. One is simply things like acid reflux can be more pronounced if we have a meal right before bedtime, and then various hormones that participate in the digestive process can actually interfere with our ability to fall asleep. And so, it's suggested that most people try to eat at least three hours before bedtime, if not longer. And alcohol, well, alcohol can affect our sleep. It has been shown that, for example, one to two glasses of wine or beers can help with our ability to get to sleep. But more than that, actually what occurs is it may help you get to sleep, but as the alcohol wears off, it can actually cause you to awaken in the middle of the night and interfere with depth of sleep. So, alcohol isn't necessarily prohibited or recommended that we not consume alcohol before bedtime, but with moderation.
Dr Pelman (08:53):
And moderation is always the right. Any advice about stimulants, coffee, caffeine, even tea has some ability to keep people awake?
Dr Bonvallet (09:03):
So, its recommended that we refrain from drinking any sort of caffeine containing compound, whether it be tea or coffee or an energy drink, at least within six hours of when we try to go to sleep, otherwise it will interfere with our ability to get to sleep.
Dr Pelman (09:21):
So, then you had spoken about obstructive sleep apnea. And as urologists, I see so many patients who come in because they're up to empty their bladder at night, we call it nocturia. And while that's multifactorial, I always tell them, go get a sleep study and they go, “why?” And I go, “well, you just told me daytime's normal. Why does your bladder or prostate care whether it's night or day? And you're telling me you're out five to seven times a night to empty your bladder. I think something else is driving your need to get up.” So, go a little bit through sleep apnea for us, a little bit of the physiology, what happens?
Dr Bonvallet (09:56):
Sure, so sleep apnea is a disorder where people by definition will have this abnormal closure of the throat or upper airway while they're sleeping. And the prevalence of sleep apnea has been shown in men to be about 10 to 12% of the population and in women about five to 6% of the population. And there are a lot of myths about sleep apnea. One of which is that you have to be overweight. It's been shown that about 30% of people with obstructive sleep apnea have, as we say, a normal body mass index or BMI. And it isn't all about weight. Although clearly people that are overweight or obese have a higher prevalence of sleep apnea. Also, by the way, obstructive sleep apnea can cause weight gain. And it does not have to do specifically with the fact that people are tired and don't exercise, but more related to the fact that there's an interference of our ability to get into the deeper sleep or REM rapid eye movement sleep.
Dr Pelman (11:01):
And we make a multitude of chemicals and hormones in REM sleep. Some of which are, as we described them, anti-obesity hormones, one of which is known as leptin. And so, it's been shown that people with obstructive sleep apnea not only produce less leptin, but are also resistant to leptin interestingly, and are prone to weight gain. Other myths are that you have to feel tired or sleepy to have obstructive sleep apnea. And about a third of people with sleep apnea will deny being tired or sleepy. They are, they just don't know it. And, and when you treat them, the majority will come back and state that they, you know, they feel that their energy level is improved as it pertains to nocturia or frequent urination. At nighttime, it's been shown that about 25% of people with sleep male and female will complain of nocturia.
Dr Bonvallet (11:58):
And one of the theories behind it is that patients with obstructive sleep apnea, as a result of the apnea and strain that it puts on the heart, will release a chemical into the bloodstream known as atrial natriuretic peptide. That is like the body’s own diuretic. * And it makes us have to urinate at nighttime. And so that is one of the contributors to having to urinate excessively at night. The other is that people with sleep apnea are not in a deeper sleep in, so it takes less urine in the bladder to have that sensation of urgency to urinate. Whereas if they were sleeping deeper, they would have to have more urine in the bladder to have that sensation. So that's the relationship between sleep apnea and having to urinate frequently at nighttime and as you know, as well or better than myself, a lot of men presume because all their buddies are talking about their issues with their prostate and having to urinate frequently at night.
*A diuretic is a compound found in food/drink/or medicine that increases your urination in either frequency, volume, or both. They make you produce more urine in essence.
(13:00):
And think that that is why they are having those symptoms and it turns out they have obstructive sleep apnea. I had a patient that in fact, I think you sent me that woke up probably hourly to urinate. And I remember him wondering why in the world was he seeing a sleep specialist and he snored loud and felt tired but presumed. It was because he had to urinate frequently at night, turned out to have sleep apnea. We treated him with the device known as C-PAP and now he hardly awakens at all to urinate. And he's memorable because you could tell he was initially not happy having to be here and undergo a sleep study, but now he's sleeping much better because we've treated his sleep apnea.
Dr Pelman (13:44):
So, if patient just skeptical, they usually go, “I don't have that.” And I go, I tell patients, “You don't know till you go for a sleep study,” is that true?
Dr Bonvallet (13:53):
Correct. I mean, there are some patients that, um, with sleep apnea, who’ll sleep very restlessly on occasion. Who’ll wake up gasping for air and complain about being tired and sleepy. But like I say about a third of people with sleep apnea, think that they're fine. And part of it has to do with how we compensate for sleep apnea. One of the things that happens is our adrenal glands make extra amounts of adrenaline and cortisol, which are stress hormones that help alert us a little bit artificially. But the point is that you don't have to be tired and sleepy to have sleep apnea.
Dr Pelman (14:28):
So, patient who snores, is that kind of a key or not necessarily?
Dr Bonvallet (14:33):
Well, In men? It is in that I would say probably 90% of men with sleep apnea, snore. And if you look at snoring in general, about a third of people that snore will have sleep apnea, but in women about 50% of women that have sleep apnea, don't snore.
Dr Pelman (14:54):
It isn’t necessarily a key, but it's something to look into.
Dr. Bonvallet
Correct.
Dr. Pelman
And, uh, if we took a guy who is looking towards a sleep study and goes, “I could never spend the night in one of those,” how do you do that?
Dr Bonvallet (15:09):
Well, so a lot has changed in sleep medicine in that the traditional testing used to be performed in a sleep center like we're in here where you would spend the night where monitoring brainwaves like EEG and breathing and leg movements and things like that. But as you mentioned it's a foreign environment. You're hooked up to a lot of wires. It could be very uncomfortable. And there's now technology to do portable sleep apnea testing, where there's a device that patients can take home. So, they attach themselves or hook themselves up in the comfort of their own home. They're more comfortable there and it's a pretty decent way of screening or testing for sleep apnea. So, it's a lot less invasive than it used to be.
Dr. Pelman (15:55):
So that resolves one of the barriers, not having to spend the night in a sleep facility, but then patients sometimes are concerned about, “well, if I have it, I can never wear one of those devices.” So, we're talking about C-PAP now that isn't necessarily the only treatment, but why don't you go through some of the treatments including C-PAP and what C-PAP is.
Dr. Bonvallet (16:15):
Right, so in the milder cases of sleep apnea, you can argue that it, it doesn't need to be treated, as it typically does it disrupt sleep, nor does it cause issues with urination at night. In mild to moderate cases, some people are candidates for what's called an oral appliance or mandibular advancement device, which fits into the mouth and is adjustable. And it pulls the lower jaw forward, widening the space between the tongue and the back of the throat. Um, the primary treatment though for sleep apnea is this device called C-PAP, which stands for continuous positive airway pressure. And what it is a device that applies a small amount of air pressure, typically delivered through the nasal passage, into the back of the throat to splint open and apart the soft tissues of the airway. So that as you are descending into the deeper sleep, where those structures are wanting to collapse down on top of themselves, you have enough air pressure that it prevents it from collapsing.
https://www.youtube.com/watch?v=Rsr8mPble4s
(17:18):
So, you continue to breathe and are allowed to go into a deeper sleep that you were not able to get into before. If you look at the average person that we put on C-PAP, they probably have, if you add up snores, apneas and near apnea, that interrupt their depth of sleep. The average patient that we put on CPAP probably has at least 150 to 200 interruptions per night in their sleep from those events on C-PAP, you'll have maybe five or six events that truly interrupt your depth of sleep per night. So typically, the change in sleep quality is pretty dramatic, even though upfront, it seems daunting to put a mask like that on and wear it at nighttime. The devices have changed quite a bit in that they're so quiet that you can't hear it. I've not had a bed partner complain about the noise from a C-PAP device.
(18:19):
And at least five years nowadays, the devices have the ability to self-adjust to the degree of narrowing of the airway, such that if you're on your back or you're in REM sleep, you need more pressure than on your side or in a lighter sleep stage. They also now have the ability to upload data to the cloud so that we're able to monitor patients remotely and intervene early on if needed. And so the devices have come a long ways, but definitely patients have trepidation upfront about wearing C-PAP. But once they experience deeper sleep, they feel significantly better. Other interventions, surgeries for obstructive sleep apnea overall have been pretty disappointing. There's not a single surgical procedure out there that has, as we say, a curative success rate of better than 20%. And the reasoning behind that is that the collapse of the airway has been shown to be at multiple levels. It's not as simple as we used to think, and that it's not just from the tongue falling backwards and collapsing the airway, but the collapse has been shown to be above the tongue, below the tongue, and from the sides. And so, because of that, it's not as simple of a disorder to address surgically. And I'm not sure that we're ever going to have a surgical alternative That's going to be better than C-PAP.
Dr. Pelman (19:42):
During your discussion, you reminded me of something I wanted to ask earlier back in diagnosis, but asleep partner, be somebody who could potentially, uh, tell somebody you got to go get checked. What would they be looking for?
Dr. Bonvallet (19:58):
Well, typically it would be loud Snoring, just generalized restlessness. Unfortunately, only about 20% of people who have sleep apnea will have a bed partner that notices the apneas. So, it's very helpful if they notice the apnea, but not helpful if they don't. And part of it has to do with the fact that our apnea’s are more pronounced when we go into REM sleep and our propensity to go into REM sleep is later into the night where hopefully the bed partner is sleeping. That's part of the reason we think that the bed partner doesn’t notice it and it could be very subtle. So again, helpful if they notice. It means nothing If they don't.
Dr Pelman(20:38):
You actually carrying through on treatment. I always remind patients that it's just not the benefit of feeling better the next day. I want them to understand that there was a really big study in neurology, not urology, but neurology about dementia and treated and untreated sleep apnea. You want to go into that?
Dr Bonvallet (20:59):
Sure. So, so there's been recent data over the last few years, showing for example, that the brain just like any other organ system has metabolites or byproducts of its own metabolism that need to be excreted, and if they accumulate, they can be toxic. One of those toxins, so to speak, is what has been recently described as G amyloid protein and G amyloid protein has been shown to accumulate in brain tissue, been in higher-than-normal amounts in individuals with Alzheimer's type dementia. And it's been shown to delay the electrical transmission of current from one brain cell to the next. And that's how brain cells communicate with one another. Unlike any other organ systems and studies have shown that these toxins to include G amyloid protein are predominantly eliminated only when we're sleeping. And particularly when we're in the deeper sleep like REM sleep. And so, people that have obstructive sleep apnea have decreased amounts of REM sleep and thereby it's implied, and probably accurately, that that's the mechanism by which having untreated sleep apnea increases risk for Alzheimer's dementia.
Dr. Pelman (22:23):
So, it’s not a small thing. It was actually a significant number of people.
Dr Bonvallet
That's correct.
Dr. Pelman
And besides dementia, we talk about diabetes, which you mentioned.
Dr Bonvallet (22:33):
Absolutely, so if you look at patients with hype to diabetes, the prevalence of sleep apnea, depending on the study, is 60 to 70%. And one of the hormones that is felt to play a role, in how we respond to insulin is growth hormone. So, people, as you know, with type two diabetes, their pancreas works fine*. They just have relative resistance to insulin and growth hormone has been shown to help augment how we respond to insulin and growth hormone is predominantly made during stage three sleep. And so, patients with obstructive sleep apnea, once again, have relative reductions in REM and stage three sleep and thereby decreased production of growth hormone. And that is one of the things that we believe is the reason that untreated sleep apnea can contribute to insulin resistance. The other thing that I did forget to mention as it pertains to specifically men's health is, is for example, testosterone production. So, it's been clearly shown that untreated sleep apnea can be associated with decreased production of testosterone. All of the things that go with that as well as whether it's related or not to erectile dysfunction. So obstructive sleep apnea has been shown to be associated with erectile dysfunction and treating it as you are aware as well, can improve that significantly.
*At early stages this can be true, however uncontrolled diabetes can lead to gradual exhaustion and degradation of certain pancreatic cells, known as beta cells, which are the pancreases insulin secreting cells.
Dr. Pelman (24:03):
And also for years, we've had an association of an increased risk for heart attack and stroke for untreated sleep apnea.
Dr Bonvallet (24:10):
That's what sort of put sleep apnea on the map. It was starting about 15 years ago, studies came out showing that there may be a link between untreated sleep apnea and coronary artery disease, as well as stroke. And now it's pretty well established and that if your sleep apnea is of a certain severity or worse, and it's never treated that the prevalence or the probability of having a coronary event or stroke is two to three, fold that of, as we say, age matched controls at is people the same age who don't have sleep apnea. So that's the data that came out that really made people take obstructive sleep apnea seriously, to include myself as a critical care specialist. I deal with a lot of patients with stroke and coronary artery disease and 15 to 20 years ago, I wasn't fully convinced. And then as the data came out, I've seen a lot of patients with coronary artery disease and untreated sleep apnea in treating their sleep apnea, improve their cardiovascular function.
Dr Pelman (25:16):
And going back to treatment with C-PAP that can reverse a lot of this correct. And absolutely, you know, patients again, reticent to wear a device, but once they get used to it, they won't travel without it.
Dr. Bonvallet (25:29):
Yes Correct. It's funny. Most people will go without, as I would, C-PAP for a couple of nights after wearing it for a while, just because of the relative nuisance of having to take it with you. But if you at baseline had been stopping, breathing 65 times an hour and on your C-PAP it's once an hour, and then you go away for a couple of days without your C-PAP you're right back to stop and breathe in 65 times an hour. And, and that's a that's a hard shock after you've gone with better sleep for quite some time. So everybody goes without it, not that you have to take it with you everywhere you go. But most people after they do that little test once or twice, they'd take it with them.
Dr Pelman (26:07):
Yeah, they adapt. They like it. They feel better and they protected their health. What about diagnostic new, you know, the new technology, a phone or watch, how good are these in helping?
Dr Bonvallet (26:18):
So the truth of the matter is none of them have been validated as it pertains to measurement of depth of sleep. And they will admit it up front. I think that they're decent at many of them at differentiating wake from sleep, but not very good at differentiating whether you're in REM sleep or stage one sleep. And it's caused a bit of a problem, be honest, and that people will get a device that supposedly tracks their sleep. And they get this report that says that they're not sleeping very well or not getting very much deep sleep. And then they start to ruminate about that issue. And then they end up developing a sleep problem because of the device. So I'm a fan of the activity monitoring devices. Most of them I think are decent. At least those that you were at differentiating, whether you're awake or asleep, but they are not accurate nor have they been validated in measuring your depth.
Dr Pelman (27:21):
And then are there medications as far as people say, well, I really need to take an Ambien every night. I mean, go into medications for sleep treatment. I've never been in favor of that patients. Post-surgery say, can you write some Ambien? I go, you'll change your normal sleep pattern and become reliant. Was I off base, or no?
Dr Bonvallet (27:40):
No, no, not at all. I mean, that's a scenario of consultation that we see a fair amount where we, as you know, we'll automatically admit patients in the hospital, prescribe a sleeper, so to speak, sleeping medication, to help with sleep that night in, most of them help a bit. And then the patient is getting ready to be discharged and asphalt. Could you write a prescription for Ambien as well? And often doctors will do that. And then they get their primary care doctor to do it. And now we're a year out and they then stopped the medication, and their sleep is significantly worse. They become reliant on the medications. There's no magic sleeping medication out there. If you look at the process of how we sleep and the various neurotransmitters that help put us to sleep, you then understand why there's not a medication that works perfectly for everyone.
(28:43):
There's also now data showing that long-term use of, as we call them hypnotic agents, sleeping type medications may increase risk for dementia. And so, we're getting even more conservative about prescribing medications like that. Also, lots of medications, to include Ambien, people develop tolerance to it where initially a certain dosage works fairly well, but after a few weeks, it's not working as well. And they doubled their dosage and, and ultimately, it quits working. And then there's other things, as you may be aware with some of the medications, Ambien's been the one that's been talked about the most, where people have some abnormal behaviors in their sleep where they'll eat in the middle of the night, they'll get up and send texts or emails with no recollection. One of the scariest scenarios that I had ever seen was a patient that lived in Issaquah and had taken Ambien before bedtime and at about three, four in the morning, he “quote unquote” wakes up and he's driving his car down first avenue in downtown Seattle. And clearly wasn't asleep, but pretty scary in that he had no recollection of getting into his car or driving to Seattle. And so, there's consequences to taking these medications. So, we're being much more conservative about prescribing them.
Dr Pelman (30:11):
A portion of the population may be listening, who work nights they sleep during the day. Do you have patients that you try to give advice and how to get better sleep in an abnormal sleep cycle?
Dr Bonvallet (30:23):
Yeah, that's a great question because I do have a lot of patients. Obviously, I have a lot of patients that are nurses. I have physicians that work night shift, first responders, things like that. The problem is that hardly anyone stays on the same schedule when they're not working. And so even if they're getting, let's say seven plus hours of sleep out of every 24 hours, it's occurring at different times. And when that happens, your depth of sleep can be significantly less. And so, what we try to tell people to do, particularly people that work night shift is not for example, to go home, sleep three or four hours, and then, you know, do chores at home or things like that. And then try to get another three or four hours before they go to work that they need to try to get a block of sleep like they would at nighttime. Studies have suggested that you're probably better off going home after, for example, night shift and sleeping, then rather than waiting till later in the day, it's important to minimize light exposure.
(31:32):
So, in people that work night shift, they're sleeping during the day. So, getting like room darkening, blinds, things like that are beneficial in making sure that there aren't interruptions and that your sleeping room is quiet. Melatonin has been used, and I've found that it works hit or miss part of the problem is it's a supplement. And so you don't really know what you're getting. It's not regulated by the FDA, like pharmaceutical medication would be, but typically the dosages that we suggest are like three to six milligrams of melatonin before they try to go to sleep. So, things like that, but it's, it's a problem. It's, because, you know, for example, firemen and paramedics, I mean, they're on a very crazy schedule and it's not like as they ascend the ranks from working night shift and get more seniority in their working day shift now in the first responders, I mean, that's, that's their job. And so, as time goes on, that takes a toll. I have a lot of patients with that are first responders that have been on those variable shifts. And one of the things that happens is that people gain weight too, from not getting good quality sleep, and now they've developed sleep apnea. And so trying to be on a schedule after your night shift, so to speak is helpful, not breaking it up, things like that help
Dr Pelman (33:01):
Any other naturopathic substances that you've heard about or would use besides melatonin?
Dr Bonvallet (33:07):
No, I mean, they've studied the various supplements out there, like valerian root things like that. There's not any supplement out there that in clinical trials has been shown to be more effective than placebo, but melatonin in some people is effective.
Dr Pelman (33:22):
Yeah. And as we wrap up, I always like to ask, is there any online resource that you direct patients to?
Speaker 3 (33:28):
As far as sleep apnea goes, there is, for example, the American Academy of Sleep Medicine, which has its own website and a link for the public and patients. The National Sleep Foundation is another good resource. The Sleep Apnea Foundation is another, so there's a lot of good resources out there on the internet. There's also a lot of stuff that's not very helpful or accurate on the internet, but those are a couple of good ones.
Home Page - Sleep Education - American Academy of Sleep Medicine National Sleep Foundation (thensf.org) Sleep Apnea: Symptoms, Risks and Treatments - sleepapnea.org
Dr Pelman (34:01):
And anything that we didn't cover that you think you'd like to talk about?
Dr Bonvallet (34:06):
Well, I think it's important. One of the years that I have interest in a bit, partly because I'm a father is just the importance of good sleep habits in, in kids and teenagers. You know, one of the things that is, I'm sure you recall as well, is that teenagers have a propensity to want to go to bed later and awakened later. And there's been a push towards delaying the start times of high schools. And there are few schools in King County that have done that, and it's been shown to be associated with, improvement in SAT scores, less absences, things like that. And then also just simply electronic media with kids. I mean, it's very common that kids will take their phones to bed and they're texting friends or watching YouTube or getting on Facebook when we, as parents, think that they're sleeping. But I think it's important to try to establish good sleep habits, you know, at an early age in kids and try to restrict as best we can at least, you know, things that interfere with their sleep like electronic media in the middle of the night.
Dr Pelman (35:16):
I think we ran through a great summary of sleep issues. I think in the future, I'll try to put a podcast together about reasons. Why guys get up to empty a bladder at night that have nothing to do with sleep apnea, which there are multiple other reasons, multifactorial problems that can affect somebody, but that's a different subject, a different time. So I thank you for your expertise on sleep.
Dr Bonvallet (35:41):
Here. Thank you. Thanks for having me.
Dr Pelman:
This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society. Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men's health visit wsus.org or visit your physician or care provider.
Episode Summary: In this 2-part episode, learn how the health of your gut, from intake to exit, depends on your personal medical history and diet, and, we are now learning, the diversity and character of your gut bacteria — the microbiome. Highlights: Colonoscopies get a surprisingly good rap these days, stool samples are amazingly useful, and your diet is important because it feeds and influences not only you and your gut but also your 100 trillion bacteria friends. Episode Guests: Part A: Upper and Lower Gastrointestinal (GI) Disease and Screening
Guest: Alan Smith, M.D. Gastroenterologist, Confluence Health, Wenatchee Valley Hospital, and Clinics
Part B: You Are What You Eat: The Role of the GI Microbiome in Health.
Guest: William R. DePaolo, Ph.D. Associate Professor of Medicine, University of Washington, Director of the Center for Microbiome Sciences & Therapeutics During This Episode We Discuss: PART A: Upper and Lower Gastrointestinal (GI) Disease and Screening * Common Gastrointestinal problems. * Learn about symptoms, signs, evaluation, and treatment of Colon Cancer, Inflammatory Bowel Disease, Reflux, Hepatitis. * What is appropriate screening for colon cancer, esophageal cancer, rectal cancer? When to start, who should be screened? * Risk factors for Gastrointestinal Cancers. * Advances in diagnostic tools.
PART B: You Are What You Eat: The Role of the GI Microbiome in Health * What is your microbiome? * How does it influence your health and immune system? * How do you improve it? * What about supplements and probiotics? * Can your microbiome predict your health status, risks for disease? * Can you transplant your gut microbes? * What research is being done on your gut microbiome? * What are the current limits of understanding and use of the microbiome environment?
Quotes (Tweetables): “Rectal bleeding should be investigated, we do find unfortunately colon cancers occasionally in patients in their late 20’s and 30’s, so that’s why we don't ignore rectal bleeding at almost any age”
“Focusing on diet weight loss, plenty of time before you lay down at night after a big meal, and reducing the size of your meal, can all be terrific strategies( to help with reflux).”
Alan Smith, M.D.
“We have one hundred trillion bacteria that reside inside the gastrointestinal tract, that's about the same number of human cells that we have, that means we have as many bacteria in our body as human cells, so, a one-to-one ratio."
"These bacteria have a huge amount of genetic diversity, for every one of our human genes, there are about a hundred bacterial genes. So that's an incredible amount of influence that these bugs have on us. So what do these bacteria do?"
"They are essential for a number of physiological functions. They are responsible for our immune health, they help to strengthen our immune system, and to make sure that we don't have reactions against food or our own tissues, they are very important for digestion, energy as well as hormonal regulation and recently it's been found they are very important for our central nervous system.”
“Looking for a quick fix as far as dieting, weight loss, things like that using these online companies, you have to be very skeptical of the services that they're offering and if they're promising more than they can give.”
William De Paolo, Ph.D. Recommended Resources: * American College of Gastroenterology ( AGA ) * American Association for the Study of Liver Disease
Episode Transcript: Coming soon!!
Episode Summary: Take-home messages from this heart-rending episode: First, we need to normalize talking about testicles, with frank talk and humor. Second, Carpe Testes! — guys should start regularly checking the health of the family jewels at puberty. Testis cancer has a very high cure rate if caught early. Episode Guests: Christopher Porter, M.D., Director of Clinical Research at Virginia Mason Medical Center, Co-Director Urologic Oncology, Fellowship Director, Urologic Oncology, Virginia Mason Medical Center
Nancy Balin J.D., Founder, The Family Jewels Foundation During This Episode We Discuss: * Testis Cancer, the importance of self-exam, early diagnosis, evaluation and treatment. * Testis Cancer is not a uniform disease, variations in cell types make some types more concerning and difficult to cure. * Following Testis Cancer, limiting or eliminating radiation or chemo therapy for localized Stage 1 with appropriate cell type. * Stigma and how to destigmatize talking about testicular concerns with young men. * Teaching young men about testis, testicular exam and testis cancer awareness. * Teaching parents about testicular awareness. * Advances and cures in Testis Cancer. * Guidelines for follow up, how long until you're considered cured? * New potential genetic markers. * The importance of an opinion on Testis Cancer from a high-volume center.
Quotes (Tweetables): “I became a testicular cancer educator because I lost a child to the disease. Jameson Jones was 14 when he was diagnosed with late-stage testicular cancer, he had symptoms for about a year, which is why he was diagnosed so late and why he eventually died of a disease that was cured 15 years before he was born”. Nancy Balin, J.D.
“In terms of diagnosing and self-awareness, we believe that young men should perform a self-exam beginning at puberty and if they have questions should ask their general doctors about the exam or whether it's abnormal or not.”
“Testicular Cancer is the most common tumor for young men and is extremely curable if found early”. Christopher Porter, M.D.
Recommended Resources: * American Urological Association Guidelines on Testicular Cancer
Episode Transcript: Speaker 1 (00:06):
A baseball game, a day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures. Whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body. After all, it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body. If you know you should, but haven't yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast as we explore men's health with renowned experts and embark on a journey towards better health.
Speaker 2 (01:31):
On today's episode of the Original Guide to Men's Health, we'll be speaking about testes cancer. We'll be speaking with Dr. Christopher Porter, director of clinical research at Virginia Mason Medical Center. He is co-director of urologic oncology and director of the fellowship program for urologic oncology. We'll also be speaking with Nancy Baylin. JD. Nancy is the founder of the Family Jewels Foundation. Testes cancer, it's a significant issue for young men. We need to know more about it. Stay tuned. As we start today's episode on testes cancer, I think it's probably reasonable to have Nancy tell a story. Nancy, go ahead.
Speaker 3 (02:17):
I will. Thank you, Dr. Pellman. I became a testicular cancer educator because I lost a child to the disease. Jamison Jones was 14 when he was diagnosed with late stage testicular cancer. At that time, they called it stage four. Now it's 3C. He had had symptoms for about a year, which is why he was diagnosed so late, and why he eventually died of a disease that was cured 15 years before he was born. He went through four cycles of BEP. We got him into remission the first time and he went to high school. We were told after two years of remission that, “oh, he's not going to get it again, he's not going to get it again.” And we continued with his surveillance. Jameson relapsed at the end of his freshman year at Washington State University. And I knew because it was such a late relapse that we were probably going to lose him that time.
Speaker 3 (03:05):
He still fought the good fight for a year and a half: four courses of chemo, four courses of high-dose chemo, a stem cell rescue, and nothing was enough, and he died on October 7th, 2010, when he was 20. He left behind two younger sisters who were then 12 and 18. So the first mission that we accomplished was to endow a scholarship in his memory for siblings of kids who have cancer. As the years passed, and I saw more and more at times, young men who would ask online or elsewhere that I'd seen them, how come I didn't know that my testicles weren't supposed to hurt? How come I didn't know the symptoms of testicular cancer, as they themselves would be diagnosed late stage, and then they would die. And I became more and more passionate, which is the word people most often use about me, about educating about this cured cancer. One of my repetitive things I say about Jameson is that its ridiculous and angering and painful that my child died of a cancer that was cured before he was born, but not so curable when you wait a year with your symptoms. My entry into the testicular cancer world came because I was a caregiver twice for a boy and then a young man with cancer, and then we lost him to it.
Speaker 2 (04:16):
And you have been an advocate in many senses since then. You have taken upon the legislation to try to promote education about testes cancer awareness and testicular exams. You have taken on advocacy at events to spread information. So I want to look at Dr. Porter for a moment. And as you had referenced, we generally think of testes cancers as a curable disease in this day and age. But Dr. Porter, it still is a significant disease, and let's start with detection. What do young men need to be aware of?
Speaker 4 (04:53):
Thanks Dr. Pellman. Thanks so much. That's a tragic story and sort of grips your heart when you hear that story. We do hear it here. We're one of the centers for testicular cancer, and we do a lot of it. The disease, although very curable for the vast majority of men and young men and boys, can be fatal if it's of a certain type or if it's delayed in the diagnosis. So in terms of diagnosing and self-awareness, we believe that young men should perform self exams at the beginning of puberty, and if they have questions, should ask the general doctors about the exam and whether it's abnormal or not. That should be then moved up a ladder preferably to a urologist at a time when that self exam is abnormal. I can tell you that we teach self-exam to all men who come to me after they've had testis cancer, because there's a risk, a five percent risk of harboring contralateral disease at a later day. And so we teach them, and they all tell me that they're going to teach their siblings or their children at the right time. But that's the main stay, it’s really self-exam.
Speaker 2 (06:12):
It's not that difficult. I think if they can achieve instruction from a physician, it could be their primary care doctor, their practitioner, their nurse practitioner, or their PA, but learning to do an exam and realizing that, as I tell patients, your testes ought to be isomers in chemistry, we learned about the left and right, they should be equal. And I get them familiar with the exam. And I say, if anything changes, don’t wait.
Speaker 4 (06:37):
That's right. I usually tell them this is normal today. Check it in the shower tonight. And then you'll know if something changes, right. And then come in.
Speaker 2 (06:47):
In then frequency, I tell patients once a month and I say, just pick the first day of every month in the shower. It's easy to remember. It's the first day of the month. Check yourself. In this day and age, there's certainly a lot of instruction on YouTube. And there is a great British piece of Rihanna teaches a testicular exam.
Speaker 4 (07:06):
I’ve seen it.
Speaker 3
Oh I haven't seen that one. I have a few others.
Speaker 2 (07:09):
And as only the British could do, it's wonderful. But it is available. So even if someone doesn't have access to their practitioner to learn, they can get the idea of what they should be doing by going to YouTube. Besides the self-testicular exam, what else should we be aware of? Who's at risk?
Speaker 4 (07:28):
Well, clearly a family history. Men who've had an undescended testis. Evidence may be that some men who have had “a hernia repair,” cause that may have been an undescended testis they didn't know about. That's probably about it in terms of risk factors.
Speaker 2 (07:45):
I see occasionally a patient who had a testicular ultrasound, maybe because they had an inflammation, infection, or benign swelling. There are some swellings that are benign, but you should go to your practitioner and find out. But they see microscopic calcifications. The radiologists always point that out and practitioners are generally concerned about the risk for testes cancer. This is more rare, but if somebody has an abnormal testes ultrasound with calcification, are they at a slight increased risk?
Speaker 4 (08:17):
So the literature is actually sort of divided on this. If you look at the urological literature, we don't think they are. If you look at the radiologic literature, they suggest that there is. In essence, I tend to follow them for about usually a year, and then if it hasn't changed, I teach them self exam after that.
Speaker 2 (08:37):
I remember a lecture from one of the army physicians who said, “you know, we have troops that have this issue, microscopic calcification with testes.” And he said, “we can't be ultrasounding them all the time. They're on the move. So we teach them the self-testicular exam.” So I think that's a good solution for this. Let's look at a young man who finds something abnormal and comes in. And your first step is of course, a physical exam, and you agree that there is something abnormal. What else happens?
Speaker 4 (09:08):
You know, the first step is a history. We take a fertility history as well. The next step is whether there's a family history of cryptorchidism, a hidden testicle, etc., undescended. Then we confirm it with a physical exam. They very often have already got an ultrasound showing something. We go through that with the patient. And then we explain that the vast majority of solid tumors that have flow within the testes are malignant in young men. And we recommend at least one sperm bank because there is some evidence that they may be infertile afterwards if that testicle is their only good one for making sperm. So we would perform the radical orchiectomy within 24 hours of them sperm banking. And we scan their abdomen and pelvis and chest and draw their markers of course, their tumor markers.
Speaker 2 (10:10):
These are blood tests that certain testes tumors make substances that we would assay for in the blood. Certain types of tumors don't make anything but certain types do.
Speaker 4 (10:21):
So, they're called beta-HCG and alpha fetoprotein, and there is a new test that's going to be coming out very soon that's going into a phase three trial out of Vancouver called, it’s a micro-RNA test, which is positive for just about every germ cell tumor. So that's coming out on the next phase of our ability to diagnose germ cell tumors.
Speaker 2 (10:47):
Now, people hear radical. That's just a term that we as surgeons use when we're removing an entire organ. And it's important to take the entire testicle. It’s done through an inguinal incision, like a hernia incision. It’s generally a same-day surgery. And that allows us to remove the tumor in a very specific way so things aren't contaminated and other body parts, and to have the ability to then have the pathologist tell us what cell type. So testes tumor is a variety of cell types.
Speaker 4 (11:17):
There's generally two main categories. One category is seminoma, that's one cell type, and the other one is non seminoma, which is everything else. Both of those germ cell tumors are exquisitely sensitive to chemotherapy and both of them carry an excellent prognosis in general.
Speaker 2 (11:37):
So part of that after removal is in the staging, the scanning, CT scan or MRI. Is pet scanning used?
Speaker 4 (11:45):
Very rarely. So a CT scan is the mainstay of scanning the chest, abdomen, and pelvis. We tend to do it prior to the orchiectomy. We then follow it. We then expect them if they are stage one, the preferred approach is surveillance. And in that regard, we obtain between five and six scans in the next five years, the majority in the first two years, because that's the highest relapse rate. They'll get mockers periodically through that time.
Speaker 2 (12:15):
So if somebody has a scan that shows fairly massive lymph node involvement, they're going to get more chemo than somebody who shows no lymph node involved.
Speaker 4 (12:26):
Correct. So patients who have no lymph node involvement, the preferred approach is not to treat them, but to follow them conservatively with scans and markers. There are some small instances where we do treat them, but it's rare. For patients who have disease in the retroperitoneum around the kidneys and the great vessels, those patients are almost certainly treated with upfront chemotherapy. The bulkier the disease and disease not in the lymph nodes, but in other solid organs, would raise their stage and require more chemotherapy.
Speaker 2 (13:04):
So the utility of the markers is not only looking at a scan to see if there's improvement, but to see the markers decline and go away.
Speaker 4 (13:12):
That’s right. So the markers are very good if they are high to begin, with a very good prediction of control of the disease.
Speaker 2 (13:20):
And then you continue to follow those through the time period, that's the intense follow up. When can you tell somebody that you've treated that they're “cured,” at what point?
Speaker 4 (13:31):
So if you're in stage one disease, that's disease that hasn't spread, and you're followed, the vast majority of people will not relapse after two years. There is a small, but finite relapse rate between two years and five years. But when you get to five years the relapse rate is very low. It's not zero, but it's very, very low. So you generally, at five years, we can tell them if you're stage one and you haven't had a relapse, you're probably out of the woods. If you're stage two or three, and you've been treated with chemotherapy and then have needed or not needed consolidative surgery to remove any residual lymph nodes, which is important, we follow them after that. And usually by two years, if they have not relapsed, we consider them to be close to being out of the woods, but we'd like to get them to the five-year mark.
Speaker 2 (14:22):
When we look at young men, obviously it's a group that, at the height of vitality, they do well. This, you know, people think chemo is extremely toxic, but they do return to normal function afterwards. They shouldn't shy away from treatment because of the concern about, oh I'm going to be debilitated for the rest of my life.
Speaker 4 (14:44):
Yeah, that's right. I think young men are obviously very resilient and they do well on the whole from chemotherapy. So it's not nothing to be terrified of but something that's important to use.
Speaker 2 (14:59):
And then, you know, we refer to testicular function, we have two main functions. One is fertility, we talked about sperm banking before chemo or surgery. The other is male hormone production, generally male hormone production survives this.
Speaker 4 (15:16):
It does. There's obviously two testicles. Before taking the testicle out for cancer, we always draw a testosterone level because we like to know where they're starting. And then we monitor them closely after removal of that testicle for symptoms of what we call hypogonadism for low testosterone because that one testicle that we took out could have been the main producer of testosterone. So we like to keep an eye on it and it can always be replaced appropriately if we need to.
Speaker 2 (15:46):
Yeah. Removing a testicle is of a concern cosmetically to a young man who, as peers, is potentially an athlete be showering or will potentially be dating. Parents are concerned. We do have prosthetics. Very good prosthetics. So for an appearance across the shower room, you wouldn't know any difference.
Speaker 4 (16:09):
Correct. Yeah. And so you bring up a good point. We offer all the men who undergo orchiectomy removal and at the same time placement of the prosthesis. They don't all take it and it can be done later. So they have time to think about it. In our experience here, we have a lot of men that do think about it and then if they want it, we'd do it at a later date. The experience down in California has been more people take it up earlier on.
Speaker 2 (16:39):
So Nancy, at gatherings where you're trying to educate the public about testes cancer, what sort of things do you bring up? Do you go to the parents, the young men, or both?
Speaker 3 (16:48):
Both. I was provoked into a lot of memories by Dr. Porter's answers to your questions. One is where you were talking about the fact that this is a young man or even a young male’s cancer. Jamison was a boy when he was diagnosed, and 13 when he started having symptoms. So when I'm talking to, I have two demographics that I approach. One is the target demographic, I think of it as young males ages 15 to 44. And the other demographic is their parents because those are my peers. So when I approach young males, say a scouting troop, what I like to say is I'll go anywhere where young males gather. So in fact, I'm going to a high school tomorrow to teach health classes all day long. So say it's a high school group. I have a PowerPoint, of course.
Speaker 3 (17:29):
And I have pictures up there. And I say to these, I ask these students, so what is it about you guys that makes this a young males cancer? Makes a perfect storm of bad facts. What is it about you guys, about young males? And I have a little cartoon of Superman. And usually a hand flies up and somebody says, well, we're invincible. And I say, that's right. And then I have a cartoon of an evil doctor with a big syringe in his hand. And they say, well, we don't like to go to the doctor. Yes, that's right. And then I have a photo of a polar bear with his paw over his eyes. And the caption is OMG, this is so embarrassing. And I tell them, the combination of you're feeling invincible, you're not wanting to go to the doctor, and the fact that this is embarrassing.
Speaker 3 (18:09):
It's about your, your genitals, your testicles. It's a very bad list of factors. And it is the reason that Jameson waited a year before he told us that he had symptoms. In my tri-fold, my pamphlet that encloses a shower card, there's a quote on the front, and that is Jameson talking. He was in high school for the first three years of his remission. And I found out years after he died from a female friend that, when they were in high school, and she was a female friend he was chatting with, he said to her, it just kept getting bigger and bigger but I was too embarrassed to tell my mom. So I feel that I can legitimately say that Jamison died of embarrassment. So I talked to the young guys about that, and because of my demographic, what I know, I grew up with sisters.
Speaker 3 (18:55):
I didn't grow up with boys. So when I acquired a stepson, I did not know how to talk to him, I didn't know what to do with him. And I quickly learned from Jameson that young male humor is the Hangover movies, Stephen Colbert's The Daily Show, it is talking about farting at the dinner table, I mean, it's just a whole different genre of humor. And what I knew instinctively is I could not approach a group of young males and say, be sure you don't get cancer. You know, what I do is I approach them with humor, which is why my foundation is called the Family Jewels Foundation, which is why my 5k is called the Family Jewels 5k, which is why when I have a wine walk, because being in the Woodinville area, you have to have a wine walk, it's going to be called, and they won't be there, but the parents will be there.
Speaker 3 (19:36):
It's going to be called Checkout Our Low-Hanging Fruit. And why my pub crawl in Kenmore every year is called A Ball Crawl. I have a slide in my PowerPoint, which has at least a couple of dozen euphemisms for testicles. If you Google “euphemism for testicles,” you find them all. And I am happy to say that I am not too embarrassed to use any one of them as a pawn. If I see a tree that has two bulges in it, and it looks enough like a penis and testicles to me, I'm going to take that picture and I'm going to use it somewhere because I reach them through humor. They start listening to me because it's funny. I mean, testicles are funny. They're funny looking, they're weird, some of them are hairy. I mean, they're just, they're weird. And guys don't want to talk about it.
Speaker 3 (20:20):
When I talk to their parents, Dr. Porter was talking about puberty being a good time to start self exams, and I, of course, I agree that the major youngest age is 15 of the demographic. So right, when parents ask me, so I have a three-year-old son, when should I talk to him? I say, today. You start today. You talk to your kids in an age appropriate way, such as when you're bathing your child and you're cleaning him and you talk about, okay, so you clean the testicles and you check them. You check everything and make sure it's okay. When you teach junior that when he falls down and smashes his elbow and it really hurts, he should come tell mama that his elbow hurts. Well, if other parts of his body hurt, they're all body parts. So you come tell mama or daddy or your coach or somebody, your health teacher, if your testicle hurts. I use a lot of hashtags because, look at my demographic, they're all over the internet and social media, and my favorite hashtag is, one of my favorite hashtags is, there’s nothing embarrassing about cancer.
Speaker 3 (21:11):
I have a series of signs I call nut notes that I bring. In fact, I have them in my car because I'm going to the high school tomorrow. And they are little sayings, some of which I've stolen from the Brits. The Brits have a great sense of humor about testicle cancer. There's multiple groups and they are funny. They have testicle costumes they wear at their parades. I don't think we could get away with that in Woodinville and Bothell. But they have some funny sayings and I've copied a few and I've made up a lot of others. The one I stole from them is, check your nads lads. My personal favorite is [inaudible].
Speaker 2 (21:48):
So we want to desensitize the people really concerned and the embarrassment about sharing that something is different. And the word here is, if something is different, tell somebody.
Speaker 3 (21:59):
And I’d like to say, I also liked that Dr. Porter just parroted exactly what I said. When I finish telling a guy my 30 second lecture about testicles, which is, and you'll correct me if I need to change this of course, they shouldn't hurt. They shouldn't have lumps or bumps, unlike breast tissue, which can be lumpy and bumpy. And they shouldn't be radically different sizes or growing or shrinking. But I say to them, so when you go home and tell your best buddy about this embarrassing conversation you had with a middle-aged woman, what I want you to convey to him is this, and this is the message I want you to take away. I know you're down there, because babies start going down there when they're like nine months old. I know you're down there. And then they always laugh and they look embarrassed.
Speaker 3 (22:38):
While you're down there, because you're down there, give them a check. And here's the takeaway. You know what they're like on a normal basis. If there's ever a change, don't wait. That's the message I tell them. If you forget the rest of this embarrassing conversation, what I want you to remember is, don't wait. And the way I try to drive through the embarrassment of a young man listening to this lecture from me is I tell them so look, we've already talked about the middle-aged female part. So I know it's not going to happen to you because, you know, I know he feels invincible. But when you go to your soccer practice and you tell your buddy about this incredibly weird conversation you had with the middle-aged woman and you tell them my 30 second lecture about testicles, and he looks at you and says, “crap, I got to go to the doctor because I have one of those.,” then you may have just saved your best buddy’s life.
Speaker 3 (23:22):
How awesome is that? And I do that to try to drive around the invincibility and instead have a little part of the back of their brain that remembers this because Jameson had symptoms for a year. He was a cross country runner. Could nobody in the locker room have seen that one of his testicles was getting to be the size of a baseball? On the other half of my side of who I educate are the parents. So I already told you about, you know, age appropriate start today. You use one of those embarrassing car conversations when you both look through the windshield and don't have to look at each other. But there's a part of the story that involves the grownups in the family and that is that we knew that Jamison was having pain in his testicle.
Speaker 3 (24:01):
We were all good parents. We went to his cross country meets. He was a cross country runner starting in junior high. And we all saw him double over the finish line. We had no idea that we should be considering that he might have cancer. Well, we thought that he wasn't wearing tight enough running short support. So every time somebody saw him double over, we would bug him. “Jameson, you've got to buy better training shorts.” So when I was on the way to the emergency room, when he was writhing around the living room floor complaining about testicle pain, I thought, oh buddy, you finally bought yourself a torsion. It never occurred to me that it could be cancer.
Speaker 2 (24:34):
So that's a torsion twisted testicle, which is painful. And while he did have pain, many of the lumps are painless. In fact, I'd say the majority of the testes cancers that I have seen have presented because somebody felt something that's different, not because it necessarily hurt.
Speaker 4 (24:49):
Yeah. They are. They can either be painful or tender or as you know, painless. And anything abnormal really is key.
Speaker 2 (25:01):
So besides a potential new genetic marker, what else have we potentially evolved to in our ability to look at this disease?
Speaker 4 (25:13):
The disease is constantly being examined. So it's one of the great champions of chemotherapy, right? So it is platinum sensitive. And so we're trying to work out better and better ways to limit toxicity. We know we can cure just about everyone if we get it early enough, and we know that we don't have to cure folks that don't have disease that spread. So really the disease, the point is we're trying to limit toxicity and limit the early treatment. So for example, for patients with seminoma in stage one disease, we're recommending against any form of radiation because radiation can come back and harm them with secondary cancers later in their life. And similarly, we're trying to limit the use of chemotherapy in men who don't have the disease that spread because we don't know what chemotherapy does to them 10, 15, 20 years down the line. They don't need it. From a surgical standpoint, we're trying to do the appropriate surgery on the right patient and spare the nerves where appropriate, and that's for a large disease in the retroperitonium that is left after chemotherapy. And similarly, there are some cases where there's extensive disease that spreads that we have to go off to surgically at all different sites, and so those need very aggressive care. So it is really, do the right thing for the right patient at the right time. And you really need a place that does a lot of it. I think that's a real take home.
Speaker 2 (26:54):
Yeah. I think the Centers of Excellence for testes cancer is an absolute. The level to which we have achieved the sophistication of who should be watched and who should get what combination of chemo for how long is not the occasional practitioner.
Speaker 4 (27:14):
Right. And we run a testicular cancer tumor board here every two weeks and we're happy to see any cases that want to be reviewed. So we don't keep them here, but if they need to be reviewed and advice given, we're happy to do that. I think that's really a good resource for the practitioners in the field.
Speaker 2 (27:36):
Well, any last comments?
Speaker 3:
Well, depending on the audience of this podcast, what I would urge is that parents, grownups, anybody who's listening to this podcast, normalize the conversation about body parts, about testicles. Testicular cancer does not have a national champion that turns the month of October pink. In fact, right now April is testicular cancer awareness month. One thing that the foundation did was we sought a governor's proclamation that in fact, April is testicular cancer awareness month in Washington, because it is all over the country. And we got that, which we're going to try and do a health event in Olympia. It's one group of people at a time. And the pushback that I get is, oh, you know, at schools, “I don't know if parents are going to be comfortable with you talking about that.” And my reaction to that, I can't get angry because I know why Jamison waited, but what I do is I tell Jameson’s story and I tell them that that sort of embarrassment is what took him from us.
Speaker 3 (28:37):
And an example I use even more often is if you look at our logo, it's supposed to be a little stylistic, but it's a scrotum with two jewels in it. Jameson’s favorite color was green so they’re emeralds. And it's a shape of a scrotum with jewels in it, hence family jewels. So I show my logo and I test people and I say, so can you tell what that is? So women look at it and they say, “yeah, I can see that right away.” They say “yeah I see.” And I test them and I say “yeah, it’s a scrotum with testicles.” Men, almost a hundred percent do this: they look at it, and then they look up and they look at me and they back up because then they realize what it is and they’ve gotten embarrassed, and I say to them “you know that backing up thing you just did, that embarrassment? That’s why my stepson died.”
Speaker 3 (29:20):
And I watched that. I watched the realization flow over them like, oh, this is embarrassing. That man, that poor kid died because of his embarrassment. So I watched them surmount the wall of, okay, I need to talk about this even though it's hard. So my takeaway message is, talk about it, talk about it, talk about it. People complain about their hypochondriac kids. That's the kind of kid you want to get testicular cancer, God forbid, if any kids should get it. The strong, silent types, they're the ones who wait. So teach your kids, teach your students, your athletes, your patients, your everything. If something is off or different about your body. Don't wait. Tell somebody.
Speaker 2 (30:10):
Dr. Porter, last comment.
Speaker 4 (30:11):
So first, thanks Nancy for being such a great advocate for this. I think the main point is testicular cancer is the most common tumor of young men and is extremely curable if found early. So if you feel something wrong, talk about it, number one. Number two, I would urge after you've been seen to at least get an opinion from a high volume center who do a lot of it so that your best possible outcome with the minimum side effects can be afforded to you.
Speaker 2 (30:49):
Well, I appreciate both of your expertise and your time.
Speaker 3 (30:54):
Thank you Dr. Pelman, this is great.
Speaker 4 (30:56):
Thank you, Dr. Pelman.
Speaker 1 (30:57):
This completes another podcast chapter of the Washington State Urology Society’s, Original Guide to Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urologist Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to thank Sean Fox for his invaluable technical assistance The music theme, San Juan Bells, was written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men's health, visit wsus.org or visit your physician or care provider.