The call came on a busy afternoon, from a Family Practice office, referring a patient for a Gynecological procedure. The caller seemed unusually relieved to know that I in fact, performed this procedure. She had apparently called many other GYN offices, but no one would agree to take this patient. This puzzled me, as the young woman had good health insurance. The procedure she needed does require specialized training and certification, which I have, but it isn’t exactly the GYN equivalent of rocket science. I’m certainly not the only one who could have helped this young woman.
Amanda* is a pretty young woman in her 20s. She has a great job with a well-known company. Amanda loves music, has a great relationship with her family, and she absolutely loves to experiment with her hair color.
She spoke softly at first, on the day that I met her. With a shy smile, she explained that she had moved from another state. Because of the difficulty in finding GYN care, she had almost decided not to move. I had reviewed her medical history, and told her that I thought that we could get her procedure done promptly. It was at this moment that Amanda told me that she left something off of her paperwork. She lowered her head and said, “I didn’t write it down, but I have HIV.”
“Oh, okay,” I replied, “One of my grandchildren also has HIV. How are you doing?” At that moment, it was as though the weight of the world was somehow lifted from her. Amanda visibly relaxed into her chair. She looked up, smiled brightly, and told me, “I’m taking a new medication, and I just found out that my viral load is undetectable!”
In that moment, I instantly knew exactly why Amanda’s doctor couldn’t find GYN care for her. Even with the best of insurance, no one would touch this young woman. She almost didn’t move to my very “Red” state, which was her home. Though not particularly invasive, Amanda’s procedure involved multiple incisions to the skin and the careful use of very sharp instrumentation. The reason no one would touch her was those three little letters: HIV.
I have, professionally speaking, grown up with this epidemic. I remember that first day, in the spring of 1980. I was a student nurse in the Chicago area. Radio station WKQX reported on a very serious, and very strange outbreak of pneumonia, affecting gay men. Men were dying in downtown Chicago. I wondered what this could possibly be.
The rest, of course, is history. The strange disease was first called GRID, then something called HIV/AIDS. We didn’t fear too much at first, of course, because this was a disease that other people got. It would never touch me, or anyone I loved. I would probably never see a patient with HIV. How wrong I was.
HIV came to affect anyone, male or female, young or old. It didn’t care whether you were a baby in Africa, or a young man in Indiana, or a Grandmother in California. It didn’t care how you lived, or who you loved. In those awful years, everyone with HIV was going to die. This disease brought out the worst in us: hatred of others, fear, judgment, suspicion. In some quarters, how one acquired this disease became very important. People with HIV must have deserved it, and they were the untouchables of society.
I was tested for HIV numerous times, in those years. I second-guessed every needle stick, all of the times that blood splashed in my eyes and in my mouth. I, and many of my colleagues, anxiously awaited the results time after time, wondering if the work I loved would cost me my life.
Slowly, and with the efforts of activists who would not be silenced, the tide would turn. Science would prevail. Antiretroviral medications were developed, which were at first, very costly and had terrible side effects. As time went on, better medications would come along, and people would demand access to these medications. Now, the transmission of HIV can largely be prevented from mother to child, and between intimate partners. Current research focuses on a vaccine for HIV.
Though the epidemic of HIV is largely over, we cannot be complacent. New cases are on the rise in certain areas, and among some populations, especially in localities which ban comprehensive education regarding human sexuality. In the US, HIV rates declined from 2010 to 2015, but in Arizona, new infections increased by an alarming 35%, with most of these being among young people. Similar trends are seen in other “Red” states such as Florida and Texas.
My grandchild with HIV will live a happy, healthy life. In time, this child will grow up, play sports, experience teenage struggles, get a college education, marry, and become a parent. This child, and my patient Amanda, will likely outlive many all of my other patients who are HIV negative. I can honestly say: I would rather take care of a patient with HIV, than a patient with a condition which requires them to change their lifestyle, i.e. quit smoking, lose weight, or move one’s body. It’s very simple. If Amanda continues to take her medication, she will have a long, healthy life. She will also continue her successful career, marry if she chooses, and become a mother and someday, a grandmother. Her name will never appear on a quilt, unless her family makes an heirloom quilt for her.
For my family, and for Amanda’s, the struggle is no longer against a dreaded disease. These days, we still fight against fear, ignorance, and misinformation. The struggle today is against the ghosts of a disease past. To this end, we no longer hide. We refuse to be afraid. We speak up, because our family is just like any other family. Amanda is beautiful, talented, and lively. She has HIV, but it does not have her. Her presence reminds us that the face of HIV looks just like anyone else. She could be my daughter, or your daughter. She is anybody’s daughter.
“Are you tired, run down, listless? Do you poop out at parties? Are you unpopular? The answer to ALL of your problems is in this little bottle.” Lucy Ricardo, for Vitameatavegamin
The advertisements aren’t for Lucy’s highly intoxicating elixir, but one can’t turn on the radio, or peruse a glossy, upscale magazine without being bombarded by them. The verbage is always some variation of this: “Are you tired, gaining some weight, feeling depressed? Love life not what it used to be? Not as much energy as you used to have? Not as much drive and vigor? The answer to all of your problems is having your hormones balanced! Call our office today! Our special, natural hormones are safe and effective! I got my life/marriage/career/happiness back, and so can you! You’ll feel twenty years younger in no time!”
Dubious hormone “Doctors” appear almost daily on one particular local daytime TV show, alongside some perky, thirtysomething host. With an earnest look, and a sense of urgency typically reserved for a television evangelist, the hormone “Guru” looks directly into the camera. He assures the viewers that though they are circling the drain, into the dark abyss of aging, his very special hormones will save them from midlife disaster. The first 20 callers will get 15% off, so dial in now.
Ever since the Baby Boom generation began to hit midlife, anti-aging hormone therapy has become wildly popular, for both women and men. Hormone “mills” are popping up on every corner, it seems, promising a midlife “tune-up” to anyone who comes in. Many of these places dispense hormones in an “assembly-line” approach: get people in, obtain cursory history and lab work, dispense/insert hormones, and most importantly, slide the credit card. It’s a very big, very profitable business, and rife with hucksters.
How to spot a Hormone Huckster
When considering hormone therapy, one should watch out for certain warning signs, and these should prompt particular caution. Let’s examine some of these.
Does the hormone clinic make promises that people will: lose weight, have great sex, be happy, or feel like they are twenty-five again? Some of these things may happen, but no promises should be made, and no guarantees of results.
What is the clinical background of the doctor/practitioner? For example, if they have been running a cosmetic clinic, or a “medical weight loss” center, chances are, the clinician went to a weekend-type hormone course. The hormones are being added to the clinic to make money, period. But how will that cosmetic/weight loss person manage uterine bleeding if it happens? Do they have any background or training in GYN? Can they tell if a uterine biopsy is warranted? Can they do it, and can they interpret the results? Bleeding is only one of a number of complications that may happen. Hormones have some serious risks, and should be taken seriously. Hormones, particularly hormones in pellet form, should only be administered by Clinicians who are extremely experienced and qualified to provide them safely.
Does the Clinician or office claim that the hormones she/he uses are made in a particular way, that makes them unique, special, or better than any other hormones? If so, then that Clinician is not being honest. No hormone is unique or special. Hormone medications do not possess mystical powers. Hormone dosages may be specially made, but the hormones themselves are not.
If people claim that their hormones are safe, or safer than other hormones, then they are not telling the truth. For many people, the careful use of hormone therapy is safe, for a season of life. Generally speaking, however, a hormone is a hormone. If there’s a reason a woman should not use estrogen, for example, based on her individual risk factors, then no estrogen is safe for her. It doesn’t matter if the estrogen is made by a pharmaceutical company, or compounded, or labeled “bioidentical.”
An exception to this is Progesterone. The use of synthetic/artificial Progestins in menopause has been clearly linked to increased rates of breast cancer, while natural Progesterone has no proven link. It must be noted, however, that some breast cancers are Progesterone-receptor positive, and women with these cancers should not use Progesterone at all.
Finally, how does the clinic respond if a patient has a complication or a problem with hormone therapy? Is the Clinician responsive to the patient’s concern, or is the patient just “blown off?” Can the patient actually get an appointment? Are they offered a clinical explanation for what is happening? Are any further tests or procedures warranted? There are some very common challenges that can happen with hormone therapy. Patients must have their concerns addressed, and they must be assured that any serious complication would be detected.
Hormone Therapy at Serenity Women’s Care
Hormone therapy is a very big part of my clinical practice, and I am convinced that hormones can improve the quality of our lives as we age. Hormone therapy is something we don’t need to be afraid of, but we do need to have a healthy respect for the possible risks, based on our individual health and family medical history.
It’s important to remember as well, that there is no guarantee that anyone who uses hormones, or anyone who doesn’t use hormones for that matter, will not have health problems or develop cancer in their lifetime. Over the years, I have seen women who used oral estrogen for thirty years, and never developed breast or uterine cancer. Conversely, I’ve seen women who never touched a hormone in their entire life develop cancer
My own clinical approach to hormone therapy starts with a very detailed review of the patient’s medical history and family history, and all of her/his medical conditions and medications. I order comprehensive, but not unnecessary, lab work. A pelvic ultrasound and/or mammogram is usually ordered, based on the patient’s age, and whether estrogen is being considered. At a follow up consultation, the patient and I review her/his lab work in great detail, the patient’s symptoms, individual risk factors for major diseases, risks and potential benefits of hormone therapy, and I present my recommendations. Every hormone decision belongs to the patient alone. There is never any pressure to use hormones.
Hope, not Hype
When making decisions about hormone therapy, it’s important to have realistic expectations and to avoid the hormone hucksters. As I often tell my patients: the hormones in the world aren’t going anywhere. There is time for each individual to weigh risks and benefits, and to make the decision that’s right for them. Though hormones can help people feel better as they age, they will never be, as Lucy Ricardo said, “The answer to ALL of your problems.”