Monday, 11 March 2019

Rethinking a healthy sex life

This past August, her exuberance, emotion and enthusiasm had already made Fu Yuanhui the most famous Chinese athlete at the Olympics. After winning a bronze medal in the women’s 100-meter backstroke with a personal best, she nearly exploded with excitement: “I was so fast! I’m really pleased! I’ve already… expended my primordial powers!” Her interview went viral with millions of hits worldwide.

Then she said something truly shocking: she was having her period. Noticing that the swimmer was grimacing after her relay team narrowly missed medaling, an interviewer asked if she had a stomachache. Yuanhui answered “It’s because I just got my period yesterday, so I’m still a bit weak and really tired. But this isn’t an excuse for not swimming well.”

When the New York Times, NPR and other media outlets covered the story of the Chinese swimmer who dared to mention that she was having her period as if it were the perfectly natural thing that it is, they focused on the fact that she’d violated a cultural taboo — indeed, it is virtually unheard of for women in China to publicly mention menstruation. But, they also missed an opportunity to counter the common misconception that menstruation impairs athletic performance or that it’s unsafe or inappropriate to swim while having your period.
Menstruation and athletics

I recall classmates in high school sitting out basketball practice because they had their periods. I assumed it was just because they weren’t feeling well. In fact, many girls have been told they are more likely to be injured, less likely to perform well, and that the best way to handle menses is to take it easy. Maybe. But the evidence for each of these is weak.
Injury

Much has been made about the apparent increased incidence of significant injuries — ankle sprains, anterior cruciate ligament (ACL) tears and others — in female athletes compared with their male counterparts. Blaming it on “hormones” is common. A 1989 study interviewed 84 female soccer players and found more reports of injuries during the premenstrual period and menstrual period, especially among those with premenstrual symptoms (such as irritability or breast discomfort). A 2007 study found that ACL injuries tended to occur more often during the first half of the menstrual cycle (in the week or two after the period). A 2009 study found that among eight healthy volunteers, hamstring flexibility increased at the mid-point of the menstrual cycle. That’s the point in the cycle that estrogen levels are rising or at their highest.

So it’s possible that variations in female hormones through the menstrual cycle change the function of bones, joints, tendons, or ligaments, and that these changes could have an impact on performance or likelihood of injury. Then again, these studies are simply observations of certain patterns — they don’t prove a connection between phases of the menstrual cycle and injury. In fact, we don’t know for sure whether the phase of the menstrual cycle truly has an important effect on tendency for injury. And if there is an effect, it’s not clear what to do about it.
Athletic performance

Studies find inconsistent effects on the impact of menstrual periods on athletic performance. For example:

    a group of swimmers were found to have poorer performance just before their periods started, and improved times during menstruation
    cross-country skiers were best just after their periods and after ovulation (which occurs midway between periods)

in yet another study, strength of handgrip and standing long jump distance were best during menstrual periods compared with other parts of the menstrual cycle.

A 1994 analysis reviewing the available research concluded that when it comes to having your period, “…for most women there is no significant effect… medals have been won and world records set in any phase of the menstrual cycle.”

Even so, many women don’t feel well just before or during their periods and it seems reasonable that this could affect athletic performance. Anyone who is in pain, tired, or just not as sharp as usual may not perform at their highest potential. And in elite athletics (such as Olympic events) in which the difference between a gold medal and last place may be fractions of a second, surely feeling poorly could make a big difference. A 2009 study concluded that taking an anti-inflammatory medication (called diclofenac, a drug that’s similar to ibuprofen) led to reduced menstrual cramps and improved exercise performance. In fact, some athletes try to avoid the issue altogether: they take oral contraceptive pills or other hormones to avoid having their periods during important athletic events.
The bottom line

There is much we don’t understand about the relationship between the menstrual cycle and athletic injuries or athletic performance in women. It’s probably true that individual factors, including overall health, type of exercise, degree of conditioning, and nutritional status matter more than the phase of the menstrual cycle.

Clearly, women with premenstrual or menstrual symptoms may not feel like exercising. But there is no compelling evidence that exercise or athletic activities should be avoided or altered based only on what part of the menstrual cycle you’re in. Good training may reduce the risks of injury and enhance performance much more than trying to time exercise around one’s periods.

Many have commended Fu Yuanhui for being so forthright about having her period even though it violated a longstanding taboo, but she could also be commended for avoiding the temptation to blame her period for a disappointing performance. “It’s a definite that you’re all going to screw up, but it’s not a definite that any of you will learn from that,” declared one of our medical school instructors, years ago. “Cultivate the attitude that allows you to own your mistakes, and then, not repeat them.”
How common are medical errors?

Medical errors are, frankly, rampant. A recent study used data analysis and extrapolation to estimate that “communication breakdowns, diagnostic errors, poor judgment, and inadequate skill” as well as systems failures in clinical care result in between 200,000 to 400,00 lives lost per year. What this means is that if medical error was a disease, it would be the third leading cause of death in the United States.

The article is specifically about fatalities secondary to medical errors, and how these are vastly underreported. They point out many reasons for this, the first being that cause of death on a certificate is usually listed as the physiologic cause of death. For example, “myocardial infarction” may be listed as cause of death for a patient who was sent home from the emergency room with chest pain and a diagnosis of acid reflux. We have no direct way of knowing that their fatal heart attack was due to misdiagnosis.

In the course of my training over a decade ago I saw many errors, such as a punctured lung during central intravenous line placement in the intensive care unit, postoperative morphine overdose requiring emergency intervention, cancer seen on an emergency room CT scan and never reported to the patient… I could go on. What was most common then was a culture of silence: there was not consistent nor complete disclosure to the patient. People would whisper about mistakes, never directly addressing the issue for fear of litigation, or even retaliation by the involved physician.
Preventing medical errors—and learning from the ones that do occur

As the BMJ article authors point out, we can’t develop safer healthcare without identifying and analyzing medical errors when they happen. They call for a national database of medical errors, so that the information can be compiled for quality improvement and prevention research.

Thankfully, I now work at an institution that recognizes this, and openly embraces errors reporting. We even have an easy-to-use online safety reporting system which my colleagues and I have used many times, for everything from blood test tubes being sent to the lab without labels, to the wrong vaccine being administered, to falls suffered by our patients while in the hospital.

Worried that these types of reports reflect more mistakes being made than normal? Think again: as the data supports, the vast majority of medical mistakes simply go unreported. The true number of medical errors, both fatal and non-fatal, is unknown. What we do know is that healthcare delivery cannot improve if these are not examined.

How does this work? I can pull an example easily from among my own recent mistakes:

A lovely patient of mine* in her late forties complained of fatigue, depression, and body aches, which I attributed to perimenopause and arthritis. She did have slightly elevated calcium levels, but I didn’t think much of it. I blamed it on her calcium supplements.

After more than a year, we finally discussed checking her calcium level OFF of supplements, and lo and behold, it was still high. We discovered that she had hyperparathyroidism, an overactive parathyroid gland that causes calcium to leach out of the bones. Indeed, hyperparathyroidism and high blood calcium levels can cause fatigue, depression, and body aches, among other things that she had, such as osteopenia (weak bones).

She asked for a referral to a surgeon and had her overactive parathyroid gland surgically removed. Her complaints resolved within a day after surgery.

I apologized for my error which had resulted in a delay of diagnosis of about two years, during which time she had not only felt awful, but also developed weakened bones. I offered to facilitate her transfer to a new primary care doctor. She declined, and said that she was appreciative of my honesty in discussing the error, and hoped it could serve as a valuable lesson.

I shared this error with my colleagues and in the system. I, for one, will never let any slight elevation in calcium go uninvestigated, and my colleagues have learned from my example.

My med school instructor was right: if we don’t own our errors, we are destined to repeat them. In medicine, honesty is truly the best policy.The 2016 summer Olympics had its share of exciting performances, upsets, and photo finishes. But for days after Michael Phelps’s first appearance at the games, it seemed all anyone could talk about was “cupping.” It’s an ancient therapy that left multiple circular discolorations on his skin. During “dry cupping,” suction is applied to the skin for several minutes; sometimes it is combined with massage, acupuncture, or other alternative therapies. (“Wet cupping” is similar except that blood is removed by making small cuts in the skin.)

Cupping is supposed to draw fluid into the area; the discoloration is due to broken blood vessels just beneath the skin, much like a bruise. Cupping has been popular in Egyptian, Chinese, and Middle Eastern cultures going back thousands of years, but increasing numbers of people worldwide have been adopting it. Celebrities and athletes have popularized it in the U.S. in recent years.
What is cupping supposed to do?

According to its advocates, cupping is supposed to promote healing and has been used extensively for sore muscles. But that’s only the beginning. Cupping has also been used for

    back and neck pain
    skin diseases such as acne and hives
    lowering cholesterol
    migraines
    knee arthritis
    improving immune function.

And there are many others. If cupping does help with these problems, it’s worth asking: how? From a biological perspective, it’s not clear how the application of suction and drawing blood into an area under the skin would provide all these benefits. A recent review of the treatment describes cupping as a treatment that can strengthen the body’s resistance, restore balance between positive and negative forces, remove disease-causing factors, and promote blood circulation. But exactly how is unclear.
Does cupping work?

A number of studies have examined this question, but unfortunately don’t seem to have  convincingly answered it. In fact, a 2015 review of the evidence found that cupping might provide some relief for chronic neck or back pain, but that the quality of the evidence was too limited to draw firm conclusions.

One problem is that it’s tough to perform a high-quality study on cupping. The best studies are “blinded placebo-controlled trials” in which neither the patient nor the researcher knows which treatment (real or placebo) has been given to a study subject. When medications are studied, coming up with a placebo pill is not difficult; it can be much more difficult to create a convincing placebo comparator for cupping. In addition, pain can be a difficult thing to measure and the placebo effect — improvement related to an expectation of benefit — can be quite powerful.

Still, there have been studies comparing actual acupuncture with convincing but fake (or “sham”) acupuncture.  Similar studies of cupping could be possible. And if cupping truly helped, you may not care if it’s due to the placebo effect.
Are there risks involved with cupping?

Most experts agree that cupping is safe. As long as those treated don’t mind the circular discolorations (which fade over a number of days or weeks), side effects tend to be limited to the pinch experienced during skin suction. It’s quite unusual that cupping causes any serious problems (though, rarely, skin infections have been reported).
So, what’s next?

If you want convincing evidence of effectiveness before trying a treatment, you may want to pass on cupping for now. But if you’d like to try something that’s safe and might help with certain aches and pains (and possibly other ailments), the main downsides seem to be the temporary skin discoloration and the cost — I found estimates online of $30 to $80 per treatment. Some people have it only “as needed” but others may have it monthly or even more often. Future research could prove that cupping is as good as the claims say it is — but we’ll have to wait for the results of high-quality studies to know if it’s true. Men have to accept many changes as they age — less hair, less muscle — but less sex doesn’t have to be one of them. In fact, 54% of men over age 70 are still sexually active, according to research in the January 2016 issue of Archives of Sexual Behavior.

What many men do need to change, however, is their mindset about this next phase of their sex lives. “Many continue to focus only on the physical aspect, so when issues like erectile dysfunction or unpredictable sex drives arise, it can trigger guilt, anxiety, and frustration,” says Dr. Sharon Bober, director of the Sexual Health Program at Harvard-affiliated Dana-Farber Cancer Center.

One way to overcome this barrier is to think less about intercourse and more about “outercourse.” This means to direct your attention and energy more on foreplay and manual stimulation with your partner. “The emphasis is on intimacy and closeness rather than performance,” says Dr. Bober. “This allows men to become less stressed and more engaged in connecting with their partner.”
What you can do

Here are some ways to better embrace outercourse:

Recreate date night. Make an effort to go out on a scheduled basis and experience something new together. It could be a hobby or an event you both have always wanted to check out, or even a quick day or overnight trip. “Doing something different can offer a sense of excitement that can bring you and your partner closer together,” says Dr. Bober. “Couples need to have romance and novelty to be emotionally, mentally, and physically stimulated.”

Focus on the nonsexual. When was the last time you and your partner just hugged, kissed, and explored each other’s bodies without the goal of sex? “Couples may say they don’t do that anymore because they are married, but do not underestimate the excitement of re-exploring the early rituals of courtship,” she says.

Mix up your sex routine. “Give each other a massage as part of foreplay, or try a different setting or time of day, like having sex in the morning when you both may be well rested,” says Dr. Bober. “Just having a conversation about how to change up the regular routine can be fun and exciting.”
Changes in desire

Men can lose interest in sex at times, but that is normal, says Dr. Bober. It often occurs because the sexual connection between your mind and body is out of sync. During these periods, it can be helpful to engage more in the mental side of sex, such as erotic thoughts, fantasy, and memories, says Dr. Bober. “This kind of mental engagement can be quite pleasurable for men without needing physical stimulation, and eventually it can help the mind and body reconnect.”

Desire also can wane if you are not involved with anyone. But again, do not feel under pressure to fill that part of your life. “You need to ask yourself if it bothers you,” says Dr. Bober. “If it is not something on your radar right now, no need to worry about it. You will know when you are ready for affection.”

Do not forget to take care of yourself so you can continue to enjoy your sex life. Many medical conditions can affect sexual drive and performance, such as obesity, diabetes, heart disease, high blood pressure, and high cholesterol. “If you want to be active, you have to stay active, and that means focusing on your exercise routine and being diligent about a proper diet and medical check-ups,” says Dr. Bober.

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