Shmirshky Read online

  Charting will help you tell the doctor how you feel. Think about it: when you are in PM&M you can’t remember yesterday, let alone what you felt like last week or last month. Filling out this chart every day will enable a doctor to better understand what you’re going through, track your progress, and find a course of action that works for you. Happy Charting!

  I learned about the shmirshky interview process through my own mistakes. I found my first doctor through a recommendation, but I didn’t interview her. I did interview the next doctor, but I didn’t spend any time preparing: I just listened and didn’t ask many questions. In retrospect, I could have saved a tremendous amount of time and energy had I brought my symptoms, questions, and advocate along for the ride. I wish I had done my prep work back then, perhaps I would have hit my Shmirshky Jackpot much sooner (more on this in chapter 19, “Shmirshky Jackpot”).

  Later on in my journey, I smartened up and took a different approach. I’m going to tell you about that now, so keep in mind, I’m jumping ahead in the story. You erlicks might have a problem with me leapfrogging around like this, but what can I say, I’m a shmirshky and this is how we talk, so here I go!

  With my lists of questions and symptoms, and with David in tow, I was off to find a doctor who would help us find me! David and I had two gynecologists to interview: one shmirshky and one erlick. (I would have interviewed a cat and a dog if I thought it would help.) The first interview was with the shmirshky. David and I were taken to an examination room. She seemed to want to interview my shmirshky first, so I figured, okay. I began rattling off my questions as she began perusing my shmirshky. Thank goodness this is not the custom for all interviews or they’d have to install stirrups on the set of The View. This doctor answered all my questions and was extremely open about her philosophy, all while examining my shmirshky—she was quite an impressive multitasker. She then announced that “everything looked good” and she would be happy to help me. (I wondered, if it didn’t look so good down there, would she have told me her practice was full?)

  In contrast, at our appointment with the erlick, we were guided into the doctor’s private office. I quickly glanced around the room and was relieved to see just two comfy chairs opposite the doctor’s desk, no stirrups in sight. This gynecologist was very interested in understanding how I felt, what I was going through, and what I had experienced along the way. David chimed in whenever he thought he could shed some light on my dark days. After much conversation, I whipped out my list of questions, but this doctor had already covered almost everything.

  Afterward, over lunch, David and I rehashed the interviews, weighing the pros and cons of each doctor. Although tests indicate that I have near perfect hearing, David heard a lot that I missed during these interviews. He was listening intently and was clearly able to recall in detail many differences between these two doctors’ philosophies and styles. My concentration, on the other hand, was impaired by my lack of sleep, by my highly emotional state, and by my nagging desire to rip off my annoying tight pants!

  At each of your interviews, get a feel for how the doctor’s office is run. Be sure to get answers to the following questions: How do you reach your doctor when you need to talk during office hours? Then ask what the doctor’s after-hours protocol is. For example, who is on call: the doctor, another doctor, a nurse practitioner, or an answering machine? Remember the game called telephone we all played at sleepovers? You know, when everyone gets in a circle and the first person whispers something to the next gal, and then she is supposed to repeat exactly what she heard to the next gal, and so on and so on until the last person stands up and repeats what she heard? The original message is a scrambled mess by the time it gets to the end. Don’t play the telephone game with your doctor’s office. It could result in a misdiagnosis.

  Next, get a feel for the doctor’s approach to his or her specialty. What is the doctor’s philosophy? Ask how he or she approaches preventative medicine and the treatment of symptoms. What tests and procedures does the doctor typically run? If there are controversial topics relating to the doctor’s field, ask what his or her philosophy is about these subjects. When you’re seeing a doctor for PM&M, ask about his or her philosophy on HRT23 and other PM&M treatments (more on that fun stuff later in chapter 15, “To HRT or Not to HRT?”). You will get a good feel for the doctor’s personality and approach to medicine by discussing these topics.

  Also, ask the doctor how he or she feels about patients getting second opinions before making major medical decisions. A doctor is at his or her best and brightest when prioritizing the patient’s well-being over personal ego. If your doctor has a problem with second opinions, think about switching to one who is not only comfortable with the practice but actually welcomes it.

  Many shmirshkies avoid finding a good PM&M doctor as a last line of defense in the shmirshky “I’m fine” cover-up. After all, deciding to get help means accepting that you need help in the first place. Remember that we can’t be “fine” all the time. If you’re feeling overwhelmed, try allocating a specific time for each task. A phone call only takes a couple minutes. And in the end, taking these few extra research steps will actually be a shortcut; the sooner you find the right PM&M specialist, the sooner you will feel better.

  Break the cover-up cycle and be honest with your doctor. This sounds easy, but it’s a bit challenging at first to be okay with not being “fine.” Think of the doctor-patient relationship like you would a business partnership. Would you go into business with someone who doesn’t listen to you and sincerely respect your opinion? You and your doctor are partners too. Both of you need to be able to communicate openly and freely. Your journey will be much easier if you have the right doctor on your team. Don’t settle for less than you deserve!

  CHAPTER 14

  shmirshky numbers

  In addition to your yearly Pap smear24 and mammogram,25 you need to get some other tests to help you monitor your PM&M. These test results will help give you and your doctor an idea of where you are on your PM&M journey, but they are not definitive indicators. You have to pay close attention to your symptoms and to how you feel. It’s not unheard of that a shmirshky’s hormone numbers will appear normal while her PM&M symptoms are through the roof, because every shmirshky lives differently, at different hormone levels.

  While the suggested test-result ranges I’ve included in this book can be helpful reference points, they should not be treated as objective benchmarks. Be sure to bring your Shmirshky Daily Symptoms Chart and tell your doctor how you feel, because this helps determine what the test results mean for your body and how best to approach your particular situation. Discuss all the different options with your gynecologist and get the tests you need.

  Below, I have listed the tests that I found helpful.26 You can get most of these done with one blood draw. Always ask your doctor’s office for a copy of your lab results and keep them in a notebook or folder. You may find you want to refer back to them later. There are lots of numbers here, but don’t worry, no long division! Okay, here we go: 27

  • Bone density: Bone density is the measure of calcium and other minerals in your bones. The bone density test, also called a DEXA scan, is a great preventative test. It can determine whether you have osteoporosis28 or even a risk of getting osteoporosis before you experience symptoms. When you go through PM&M, your estrogen29 levels decline, which can lead to a rapid loss of bone density, so this is important for the PM&M shmirshky to check. The test measures the bone density (strength) of both the hip and spine. It only takes a few minutes and exposes you to very little radiation (technicians are not even required to wear a lead apron). Suggested range:

  • T-score: greater than -130

  • CA-125 (cancer antigen 125): This protein is best known as a blood marker for ovarian cancer. It may also be elevated with other malignant cancers, including those originating in the endometrium, fallopian tubes, lungs, breasts, and gastrointestinal tract. Suggested range:

  • Less than
35 U/mL31

  • Cholesterol: A waxy substance produced by the body. It is needed to make hormones, skin cells, and digestive juices. Your cholesterol changes during PM&M. Too much cholesterol in your body can build up plaque in your arteries, which ultimately narrows the blood vessels and may cause a heart attack. You will need to fast for this test, so don’t eat or drink for twelve hours beforehand. Suggested range:32

  • Total cholesterol: less than 200 mg/dL

  • HDL (high-density lipoprotein, the “good” cholesterol): less than 50 mg/dL generally increases your risk of heart disease; greater than 60 mg/dL generally helps protect against heart disease.

  • LDL (low-density lipoprotein, the “bad” cholesterol [too much LDL in the blood can clog your arteries]): less than 100 mg/dL

  • Triglycerides (molecules of fatty acid): less than 150 mg/dL

  • Cholesterol/HDL (the ratio of total cholesterol to HDL): less than 5:1 is desirable; 3.5:1 is optimum

  • DHEAS: DHEA sulfate is a hormone that is easily converted into other hormones, including estrogen and testosterone. It is the adrenal hormone that triggers puberty and is found in the highest concentration in the body. DHEAS is the sulfated (S) form of DHEA in the blood. DHEA levels increase and decrease throughout the day. DHEAS blood levels are steadier, and therefore more reliable. Suggested range:

  • Age 30–39: 45–270 ug/dL

  • Age 40–49: 32–240 ug/dL

  • Age 50–59: 26–200 ug/dL

  • Age 60–69: 13–130 ug/dL

  • Age 69 and older: 17–90 ug/dL

  • Estradiol: This is the main type of estrogen produced in the body. It is secreted by the ovaries. If you’re still menstruating, be sure to have this blood test done during the first three days of your period. Suggested range:

  • Premenopausal: 30–400 pg/mL

  • Postmenopausal: 0–30 pg/mL

  • Free and Total Testosterone: Free testosterone is the unbound, metabolically active testosterone. Total testosterone includes both the free and bound testosterone. In shmirshkies, the ovaries produce testosterone. This benefits shmirshkies by helping to maintain a healthy libido, strong bones, muscle mass, and mental stability. Suggested range:

  • 30–95 ng/dL

  • FSH (follicle stimulating hormone): A pituitary hormone that stimulates the growth of the ovum (the egg and surrounding cells that produce ovarian hormones). This is one of the measures that can indicate if you’ve entered M (although it’s not a definitive determinant because your levels can fluctuate). If you’re still menstruating, be sure to have this blood test done during the first three days of your period. Suggested range33:

  • Shmirshkies who are menstruating: 1.7–21.5 mIU/mL

  • Postmenopausal shmirshkies: 25.8–134.8 mIU/mL

  • Progesterone: This is a hormone that stimulates the uterus and gets it ready for pregnancy.34 Progesterone also regulates the monthly menstrual cycle. Low levels of progesterone can impact your mood and cause irritability, among other things. Results will vary depending on when the test is done. Suggested range:

  • Pre-ovulation: less than 1 ng/mL

  • Mid-cycle: 5–20 ng/mL

  • Postmenopausal: less than 1 ng/mL

  • Thyroid workup: This blood test usually includes checking your TSH (thyroid stimulating hormone). If there is an irregularity with your TSH, you may need to get your Total T3 and Free T4 checked as well. (Free means it won’t be affected by your estrogen status, not free of charge!)35 Remember that the symptoms for both PM&M and a thyroid disorder can be very similar. Suggested range:36

  • Total T3: 60–180 ng/dL

  • Free T4: 0.89–1.76 ng/dL

  • TSH: approximately 0.3–3.0 mIU/L for those with no symptoms of abnormal thyroid function. A much wider range of approximately 0.5 to 5.0 or even 6.0 mIU/L is being used by labs and doctors who are not following the latest recommendations by the American Association of Clinical Endocrinologists.37

  • Vitamin D3 (Cholecalciferol): This vitamin, named after my husband’s first initial, helps to maintain normal blood levels of calcium and phosphorus, and helps keep your bones nice and strong. Suggested range:38

  • 40–100 ng/mL

  Most of these tests are simple blood tests, which is actually a nice break from having lots of things shoved in and out of our shmirshky at the gynecologist. When we go to the gyno for a Pap smear, we’re told to get undressed, put on a gown, and put our heels in the stirrups. When I hear gown, I start looking for something beaded and satin, but instead I get a paper towel jacket and a giant paper towel tablecloth to drape over my legs. During the exam, I never have a clue what’s going on down there. Do you? My gynecologist always tells me, “Just relax.” Yeah, I’ll relax when you stop sticking giant Q-tips up my shmirshky. I can’t wait to grab that huge paper towel, mop up all the gel they shoved inside me, and get the hell out of there. Doesn’t this process sound a bit archaic? At least upgrade the paper towel to two-ply or quilted. I hope the Brawny Man doesn’t walk in on me while I’m all saddled up!

  CHAPTER 15

  to hrt or not to hrt?

  Once your test results come in, be sure to make an appointment to meet with your doctor in person to discuss your numbers. Bring your advocate with you on this visit as well. I brought my husband so that he too would become more aware and involved in what I was going through. After all, we were going through it together. The more I included David in my journey, the more knowledgeable, helpful, and supportive he became. Plus, let’s face it, by this point I was a total bitchface half the time. David pretty much jumped at any opportunity to get back the wife he knew and loved.

  Remember that the results of your lab work are only half of the conversation. At this appointment you need to be sure to bring your shmirshky Daily Symptoms Chart and communicate honestly and openly about how you’re feeling. Ask your advocate to help encourage this during your appointment. Make notes before your appointment of all the things you want to talk about. Share this list with your advocate. The more clearly your doctor understands how you’re feeling and functioning, the more he or she will be able to help determine the correct course of action for you.

  Don’t feel rushed. Doctors are often on a tight schedule and they like to move quickly, but don’t let that frazzle you or steer you off course. Set the pace of your appointment so that you and your advocate can address all your questions and concerns.

  The big question at this stage is whether to HRT39 or not to HRT. In order to answer this question, we need to have a quick crash course on HRT. Basically, the way it works is that when you go through PM&M, your body begins to produce different amounts (usually smaller) of estrogen, progesterone, and/or testosterone hormones. These fluctuations often result in the symptoms that many PM&M shmirshkies experience. HRT is intended to supplement or moderate these hormone fluctuations and ultimately provide an umbrella for a shmirshky caught in a PM&M storm.

  Not all HRT options are created equal. The first distinction you will want to make is whether an HRT supplement is bioidentical or not (see Hormone Therapy Brands on page 156). A bioidentical hormone is identical to the hormone produced in your body. It may not have originated in your body, but it has the same chemical structure and even goes by the same name. Most important, it has the same biological function.40

  On the other hand, there are HRT options available that are NOT identical to the hormones in your body. They might be similar, they might even have a similar name, but they are not exactly the same as the hormones produced in your body.41

  The other important characteristic to understand is whether or not the HRT option is natural and/or synthetic. I say “and/or” here because the natural and synthetic labels are NOT mutually exclusive. Here’s how that works. Technically speaking, if a hormone is called natural, that means it is originally derived from a plant or animal source. A hormone is considered synthetic if the chemical structure was altered in a laboratory. Sometimes hormones are extra
cted from yams and then chemically altered. In this instance, the hormone is both natural and synthetic.42

  If you’re given a prescription for HRT and want to know what you’re getting, try asking the following questions:

  • Is this HRT option bioidentical? Or, in other words: Is this HRT option chemically identical to the hormone I produce in my body?

  • Was this HRT chemically altered in a lab? (If the answer is yes, then the HRT option is a synthetic hormone.)

  • Did this hormone originate in a plant or animal? (If yes, then that hormone is technically considered natural.)

  If the answer to all three questions is yes, then you have a plant- or animal-derived hormone that was chemically altered to become identical to a hormone found in your body—which means it is natural, synthetic, and bioidentical. I know it’s confusing, because natural and synthetic seem like opposites, but with regard to HRT, they are actually referring to two different distinctions. Whoever came up with these terms needs a talking to.43

  These distinctions are important, because just as your body reacts differently to a tablet of Advil than it does to a tablet of Aleve, different hormone therapy options have different potentially positive and negative results. When you take bioidentical hormone therapy, your body may react the same way it would if it produced the hormone itself, because, chemically speaking, it is the same as the hormone your body actually does produce. When you take hormone therapy that is not bioidentical, your body may react differently.44 Learn about how your medication options might affect your body before you decide with your doctor on a particular course of treatment.

  Now that you’ve gotten a handle on your HRT lingo, you need to learn about the WHI (Women’s Health Initiative)45 and the studies it conducted. There are many different viable interpretations of these studies, so it is best that you go online to the Women’s Health Initiative at www.nhlbi.nih.gov/whi and read about the studies for yourself. To further research what some experts think of the validity of these tests and their findings, do a Web search for “WHI pros and cons.” You can read for hours. Let me caution you right now, this is not fun reading! Many nights, I could have used some toothpicks to prop my eyelids open because the material is so technical and dry.