My Blog

my son's journey

04/02/2012 22:32:00

now that it's behind me, i feel like i can talk (a little) about what these past few months have been like.

as some of you know, my middle son, ryan, age 12, was diagnosed with a large brain tumor in eary january.

fortunately, it is not cancer, but may have genetic repercussions later.

for now, however, we are celebrating his remarkable comeback.

his presentation was very subtle for such a large mass.

ryan complained occasionally about dizziness with his "spin move" in basketball - thank God he's athletic or it may have presented much later. after consulting peds ENT, then peds neuro, we obtained an MRI of his brain and were told that he had a large acoustic neuroma: 1 in a million in kids!

luckily not cancer, but still a large tumor, in his internal auditory canal, compressing his brain stem, and putting him at risk. we sought several opinions for his care, based on the rarity of this tumor in little ones. after meeting very talented people at Columbia and Mass General, we ended up at the House Ear Institute in Los Angeles. they have extensive expertise with this particular tumor, and a wonderful reputation in the acoustic neuroma world. (see anausa.org.)

after speaking with neuro-otologist, Rick Friedman, MD, PhD, I felt extremely comfortable that they had the most experience with complete resection of these tumors. as luck would have it, ryan felt an immediate bond to dr. friedman and never worried again, once they agreed on their plan.

it was a harrowing few weeks as a parent, but i think we did our best to be "cool" for ryan's sake.

now that we are "on the other side": he's had his surgery, we're back on east coast time, and he's back in school and sports, it'd amazing to see ryan return to the happy, confident, (?cocky) young man that he was before this all started.

we were blessed by many friends, family, neighbors and kind strangers who prayed for our son during his treatment and recovery, including some of my colleagues in haiti. (if that isn't humbling, i don't know what is.)

i want to thank you, my patients, for hanging in there when i was gone with ryan, for praying for him while we were gone, and for putting up with my occasional tears even now, as i relive the trauma my young son endured so bravely. sometimes, i wonder if i am here to heal you, or you to heal me. there is often overlap, and for this, i will be eternally grateful.

love, sue malley

Walking to Prevent Teen Suicides

10/05/2011 23:38:00

This summer my oldest son lost a close friend to depression, the day before he was to begin his junior year in high school. All of the high school felt the loss. I was really affected by the numbers of overwhelmed sixteen year-olds present at the funeral: boys and girls, raw and defenseless against their grief.

His close friends knew he was being treated for depression, he didn't hide the medication he took to help control it. They respected him for his candor and took it in stride. Truth told, he was a great kid; funny, kind and well-liked. His humor may have hidden his struggle with unrelenting depression.

Teen depression is strongly linked to teen suicide. But the fact is that suicide is complicated. Underlying depression may be exacerbated by life stressors, such as death, divorce or trauma in the family, traumatic romantic breakups, school failures or being victimized by bullying, etc ... Every case is individual.

Teen suicide is a major cause of death among teens - in adolescents, suicide is the 3rd most common cause of death, after accident and cancer. Luckily, most most suicide attempts are unsuccessful. For every adolescent who kills him or herself there are 8 others who tried and failed (and lived.)

I am proud of my son and his friends - good kids reeling from a terrible tragedy. They organized to do something positive with their grief. A group of friends are planning a community walk in his memory to raise money to try to prevent future suicides with education and increased awareness. Walking in the Out of the DarknessCommunity Walk, this October 22 will benefit the American Foundation for Suicide Prevention (AFSP).

Their group, Team Zack, will be walking with thousands of people nationwide to raise money for AFSP's research and education programs to prevent suicide and save lives, increase national awareness about depression and suicide, advocate for mental health issues, and assist survivors of suicide loss.

If you would like more information about the organization, see: outofthedarkness.org.

If you want to contribute to this cause, please follow link:

http://afsp.donordrive.com/index.cfm?fuseaction=donorDrive.participant&eventID=1514&participantID=230236

I hope that if you are a teenager, you will keep talking to your parents about the things that worry you and bother you. If you're a parent, I hope that you acknowlege how common teen depression is in our adolescents. And, noting the connection between depression and suicide, that you will continue to talk with your teens about signs of depression, and if present in your own home, get help from your physician as well as a therapist. Remember: 1 in 5 high school students consider suicide at some time. Typically in times of difficulty, often with underlying depression and anxiety.

If depression hits your home, recognize it, and use everything at your disposal to intervene. Teen depression is not avoidable. Teen suicide may be.

Where does the money raised go?

2011_Walk_Flyer.doc (DOC — 1 MB)

Getting ready for Haiti

06/18/2011 18:52:00

I won't lie, i am a little scared of what to expect when we get to Haiti. I am not afraid of typhoid, rabies, cholera, malaria, dengue fever, etc... despite the shots i have just received. I am, however, really apprehensive about witnessing the extreme poverty and difficulties of the Haitian citizens. I am afraid of the pain and hunger i will see. I have always been too empathetic.

To combat my fear i am arming myself with a plan to help. Once I signed on for the trip a few months ago, I started to research where i could be of most use. Our group, handsupforhaiti.org,is not quite a year old, and the physician-led teams to date have been focused on pediatric concerns. As the first gynecologist of the group, i have been deeply affected by what i have learned about the lives of Haitian women.

From a gynecologist's standpoint, they have the highest rate of cervical cancer in the world. (This is a preventable disease with even reasonable access to medical care.) With sparse infrastructure, few caregivers, rare pathologists, lack of transportation, unreliable refrigeration and electricity, (things that we take for granted)... like the dreaded Pap smear, are not possible in low-resource settings. Many wonderful physicians and researchers have struggled with this, such as Paul Farmer (pih.org) from Harvard and David Walmer from Duke (familyhm.org), establishing networks where before there were none, introducing prevention of disease and recognition of precursor lesions, overcoming many barriers as they struggled to work toward reduction of risks for this dramatically underserved third world country.

We can never thank them enough for their forward-thinking, brilliance and generosity, so instead, my hope is to carry their torch with them, in some small way. Monday, my pre-med student, Heather and I fly to Raleigh-Durham, to meet the unbelievably down-to-earth David Walmer, MD, PhD, chief of gynecology at Duke Medical Center. While he has a fellowship in reproductive endocrinology and infertility he recognized the need for cervical cancer prevention when visiting Haiti 18 years ago. For the past decade he has been a pioneer in this goal in southern Haiti, even inventing a battery-operated colposcope, "cerviscope", for areas lacking electricity. With a team he organized, Dr. Walmer has been organizing groups from Duke to collect data and care for Haitian women, build health care facilities, while identifying needs, prioritizing and fundraising on their behalf.

When I meet him Monday, after the effusive gratitude, I hope to ask him how to get the most done with each trip. Knowing I cannot afford to leave my Westchester practice and move to Haiti, I hope to learn from him how to engage the local caregivers, to partner with the community leaders to bring the women to me, and to earn their trust. Ultimately, I hope to train local providers in the "screen and treat" protocols currently recommended by the alliance for cervical cancer prevention (http://www.alliance-cxca.org/) The future for screening is likely with rapid DNA testing, as soon as it is available. Until then, we will utilize the proven "VIA": visualization with acetic acid. (It is faulted for excess false positives, requiring potentially unnecessary treatment. I can live with overtreatment, knowing that with no treatment and with absolutely no raditation facilities in Haiti, i will be protecting some women from an inevitably painful death from cervical cancer.)

For now, I am listening to Creole CDs in the new car (totalled the Volvo last week after a long day at work, hit a Hummer who stopped short - airbag felt like a cannon to my chest - question why tanks like Hummers are on regular roads...), and starting to focus on the ways i can learn to help the women of Haiti. I believe that by caring for Haitian women, i will be caring for the children and fathers, too, because, as we know, women are the heart of the community.

As the liberation theologian Juan Segundo put it: "The world that is so comfortable for us is the same one that is so unbearable for billions of others." On a more positive note, Dr. Walmer, when meeting with the Haitian Ob/Gyn society last month, said: "Haiti can be a leader in the development of protocols for cervical cancer screening in low resource countries.” I hope to be a very small part of this very important goal.

National Women's Heart Month Hit Home - Hard

02/18/2011 00:46:00

National Women’s Heart Month Hit Home – Hard

As gynecologists, we often double as a woman’s primary care practitioner, until she gets sick or we find ourselves needing the depth of our internist colleagues. But in terms of preventive medicine, many of us enjoy the education that goes with primary care and are trained to obtain age-appropriate studies and only refer for abnormalities (like elevated cholesterol, for example. I know she’ll need to cut down on trans-fats, exercise more, but I like the internists or cardiologists to decide when a patient with “borderline” results should be started on cholesterol-reducing medications; it’s very individualized, and she'll need long-term follow-up.)

Fortunately, I have colleagues at WH that care a lot about preventing women’s heart disease, the number one killer of women in the United States. George Berk, MD, an extraordinary cardiologist and friend, is developing a program for individualized cardiac prevention as we speak.

This entire month our office has rededicated ourselves to discussing risk factor reduction with each and every patient, and referring her to the American Heart Association’s site for more details. Ironically, one of our key staff members smiling brightly in her red sweater on February 4th’s photo op for our “Go Red For Women” contest was found to have elevated blood pressure: 170/100, that very afternoon. Her headache and overall malaise didn’t compute until then.

She had last had it checked a year ago, and it was apparently fine. She was whisked over to a favorite internist who took her under his wing, and is managing her future, extending her life. What if it wasn’t checked this year? She could have had a stroke, a heart attack or worse.

Last night, I got a call from my older sister to let me know our mother was in the hospital with chest pain. My 81 year-old mother is the strongest woman I know. She bore seven rambunctious, curious and always hungry children, and volunteered her ‘spare time’ teaching exceptional children to read in the public schools. She survived breast cancer almost 20 years ago, and several scares since, but is otherwise as healthy as they come. She drives my Dad and their neighbors to their physician appointments, she herself hasn’t complained much.

When I called her in the E.R. in her local hospital last night I could hear that she was scared. It struck me then, that she is NEVER scared. This was possibly the second time I can remember that tone from her. It worried me, and I called in the troops. (I have many siblings, and they descended upon that poor E.R.), because I was far away and had a surgery last evening.

This morning her cardiologist called to say that things had changed, and she was being transferred to a bigger hospital for a cardiac catheterization. I asked him to tell me if I needed to come, (meaning cancelling a fulIy booked day of very nice women who have spent the previous evening dreading their gyn appointment), something I hate to do. He said to come. I called my mom in the new ICU, and she sounded quieter, still scared. I went into the office to see a few patients and to give the team time to reschedule and shuffle, and with everyone's support (that's why I love my job), I jumped in my car.

I arrived just as they were wheeling her back for the procedure. Several siblings (and my husband!) beat me there, but I got to go in with her. Choking back fear, I summoned the confidence beaten into me during residency, and convinced the technicians to allow me to go along with them, as a physician. They were wonderful. I learned so much in my hour with these gentlemen: Aurelio and Bernie, as well as the invasive cardiologist, Dr. Lee; more than I learned in a whole month of cardio as a med student 20 years ago.

Watching the procedure, with Bernie pointing out each vessel and describing them for me in real time, I felt a growing sense of calm. Each vessel was found to be wide open, a little curly, perhaps, suggesting high blood pressure, but despite open coronary arteries, there was evidence of left heart disease. Her diagnosis: ironic in this cool, relatively unemotional matriarch: “Broken-Heart Syndrome”, a stress-induced cardiomyopathy that reduced the function of her left ventricle by half.

The good news: no angioplasty or open-heart surgery; medications often effectively treat this unusual entity, found almost exclusively in women. In 4-6 weeks, her physician said, she will likely be back to our mother: intelligent, bossy and loving. I can only hope.

Painful Sex and Vaginal Dryness

02/15/2011 23:28:00

Painful Sex? Vaginal Dryness?

Recently, I have seen several peri-postmenopausal patients with similar complaints. Starting after age 40, either the desire for sex wanes, or the desire is there, but sex is painful. Painful sex ultimately leads to avoidance, and there begins a vicious cycle. These are women in happy relationships, without depression or significant anxiety influencing the situation. (I have excluded the others for our purposes today.)

While there is no magic answer to the problem there are several ways to approach this situation that may help. If you are also experiencing hot flashes, night sweats or insomnia, it is reasonable to "blame" your libido problems on several possibly compounding factors. The exhaustion that follows poor sleep, or following the daily multi-tasking of today's woman, familiarity of a loved partner, or new hormonal changes. Specifically the drop in estrogen we experience at several times in our womanhood.

Post-partum women have low sex drive due to breastfeeding. The elevated prolactin level to maintain your milk supply necessarily causes low estrogen. Other times of low estrogen include following surgical removal of the ovaries, chemotherapy or radiation of the pelvis for cancer.

The most common decrease, however, is noted in the year or two leading up to menopause. Low estrogen equals vaginal dryness. Vaginal dryness leads to painful sex. Even with an excellent lubricant (such as Astroglide), or daily use of a vaginal moisturizer (such as Replens) without your own lubrication and preparedness, sex can be uncomfortable and unsatisfying.

What can we do about it?

Vaginal estrogen therapy is a very reasonable treatment for most women. The dose is very low, so as not to be thought to increase your risk for breast or uterine cancer, therefore, no progestins need to be added, as little or no estrogen is absorbed into the bloodstream. In conjunction with oncologists, we often use local (vaginal) estrogen preparations in breast cancer survivors to allow for comfortable intercourse, and improve their quality of life. Local estrogen is not thought to increase one's risk for breast cancer or stroke as can systemic preparations.

An additional benefit, I have learned, from my esteemed urology colleague, Dr. Sheldon Axelrod/mkmg.com, is the decrease in recurrent bladder infections and post-coital bleeding. (Since the posterior wall of the bladder anatomically sits on the anterior wall of the vagina, an increase of blood flow to one benefits the other.)

There are currently three forms of vaginal estrogen preparations available, all used in a similar fashion. Vagifem, my current preference, is a small tablet (resembles a birth control pill on a little stick) that you insert vaginally at bedtime. Within the past year the dose has been further reduced from 25 mcg/night to 10 mcg/night, based on the randomized study showing evidence of similar response. This is used nightly, 14 nights in a row as a "priming dose", then 2 evenings/week for long-term maintenance.

Estring, probably the lowest dose, is a plastic ring placed intravaginally that stays in place for 3 months and slowly releases local estrogen. It does not need to be removed for intercourse; is not thought to be felt by one's partner. You can replace it every 12 weeks on your own.

Lastly, you can choose a vaginal cream: Estrace or Premarin cream; the dose is one gram ("one knuckle's worth") every night for 14 nights, then 2x/week for maintenance. Patients and physicians have their preferences, but, in my opinion the pill is least messy, therefore best tolerated.

Whether you choose to try lubricant, increased vacation time, and/or adding a local vaginal estrogen when you notice vaginal dryness affecting your desire and comfort during sex, we can help. You can continue to be sexually active during treatment, (including masturbation), as this may help the vaginal tissues by keeping them soft and stretchable. preventing the tissues from shrinking.

Sometimes, just discussing the problem, and hearing that you are in good company, can help.