The magical mystery land of community health

I don't make this stuff up!…but I do change identifying information.

Who Knew? January 31, 2010

Filed under: Uncategorized — lesbonurse @ 9:22 pm

One of the things I love about my job is that I am continually learning new and interesting things.  For example, did you know that a traumatic injury to the testicle can lead to the testicle disappearing?  Indeed.  I recently had a patient who had only one testicle on exam.  He explained that he had a traumatic blow to the ‘nads as a kid, but was too embarrassed to tell anyone.  When the swelling went down, one of his testicles was gone, never to reappear again.  After an ultrasound confirmed that the testicle was indeed gone, not just undescended, I put in a call to Urology.  The urologist confirmed that it is possible to kill off your testicle, and then it will necrose and shrivel until there is only the teeniest trace of the tissue left in the seemingly empty sack.  Well, I’ll be damned.

The second thing I learned this week is that it is possible to pop (ok, the medical term is ‘rupture’) your bladder in a traumatic accident.  Apparently the chances are greatest if your bladder is very full and then you take a hit to the abdomen, for example in a car accident.  I had a patient who had just such a situation.  After open abdominal surgery, her bladder was repaired and she had to have an indwelling catheter for more than a month.  Yikes.  Apparently I missed the memo about traumatic bladder rupture, because when I told my co-workers about this case, two of them said “Oh yeah, that’s why mom always said to empty your bladder before you get in the car.”  Huh.  My mom never said that.  I could have ruptured my bladder!

But now I know: don’t get in a car accident with a full bladder.  And if someone smashes you in the ‘nads, tell someone, or else you might not see that testicle again.  Good to know.

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FTMs and endometrial hyperplasia: how to screen? January 24, 2010

Filed under: Uncategorized — lesbonurse @ 10:35 pm

Endometrial hyperplasia is a condition in which the lining of the uterus grows thicker than it should be. In some cases, the thickened endometrium can develop abnormal cells, which might become cancerous and lead to uterine cancer.  Obviously, cancer is a bad thing and we want to avoid it.  There are a few reasons that endometrial hyperplasia a concern for FTMs: excess androgen exposure (ie: testosterone) appears to lead to Polycystic Ovarian Syndrome-like ovaries in FTMs.  It has been found that women with PCOS have a higher rate of endometrial hyperplasia than women without PCOS.  Generalizing this to trans men, we can speculate that PCOS-like ovaries in FTMs on testosterone might also lead to PCOS-like endometrial hyperplasia in FTMs.  Additionally, FTMs that are on testosterone develop amenorrhea (no periods), and while this is generally due to the uterine lining becoming thin and atrophic, there is a small possibility of the lining building up and becoming thicker instead. There was an article published in the 1980’s about a small sample of FTMs who had hysterectomies. The authors reported that the number of the samples that had hyperplasia was higher than normal. This led to concerns about FTMs having undiagnosed hyperplasia, although to my knowledge there has not been any similar follow-up study to confirm or refute this. Finally, trans men may avoid medical care, thus ignoring signs of endometrial hyperplasia (such as vaginal bleeding or spotting while on testosterone) which could lead them to potentially develop undetected/untreated uterine cancer.

So how do we screen for this uncommon but important condition in trans men? The answer is…wait, there’s no answer. At least, not an evidence-based, universally accepted recommendation for screening. Different providers have different recommendations. Some recommend a pelvic ultrasound every 2 years before hysterectomy. Some recommend a pelvic ultrasound about 18 months after initiation of testosterone. Some recommend no screening unless a patient develops vaginal bleeding. Some recommend an annual “progesterone challenge” in which the patient is given 10 days of progesterone to try to induce vaginal bleeding, with the idea that any built-up endometrium will be sloughed off.

The progesterone challenge is my least favorite of the screening ideas. Not only does it seem like an emotionally difficult practice for the patient, but it seems unnecessary. I don’t know how many cases of endometrial hyperplasia are caught this way, but my guess is not many–it seems like a low yield type of screening. Plus, I don’t entirely get what it is looking for. If the patient doesn’t bleed, does that imply that the patient doesn’t have any endometrium to shed?  Because that would be a good thing.  Or does it imply that the endometrium is not shedding and is building up?  Because that would be a bad thing.  If the patient does bleed, does that mean that the patient is safe because their endometrium has sloughed?  Or does it mean that the patient should be evaluated more because they have built up an endometrial lining and they really should have an atrophic lining?  And given all these possible outcomes, what are the next steps after the progesterone?

So…what do I recommend?  At this point, I’m leaning towards a) the pelvic ultrasound at 18 months post-initiation of testosterone or b) no screening unless symptomatic.  As a relatively new and still-nervous provider, I would feel reassured if all of my FTM patients on testosterone had normal uterine ultrasounds.  However, I understand that getting a pelvic ultrasound is not fun, particularly if a patient is uncomfortable with the internal (vaginal) approach, and can also be expensive or hard to access.   So it seems reasonable to me to present the evidence–or lack thereof–to patients and let them decide.  None of my patients have opted for a voluntary pelvic ultrasound yet.  None have opted for a voluntary progesterone challenge, either.  But at least they have the information.

*I’ve put “Do literature search about uterine hyperplasia in FTMs” on my To Do List, just in case I have missed any new or groundbreaking research.  As soon as I have some free time (ha) I’ll get to it.  And if I find anything new, I’ll let you know.

 

Election night haiku January 20, 2010

Filed under: Uncategorized — lesbonurse @ 3:00 am

Why, Massachusetts?

Why go from Ted Kennedy

to republican?

Watching election:

Feel hope for healthcare reform

dying a sad death.

 

Welcome to your new career January 15, 2010

Filed under: Uncategorized — lesbonurse @ 3:42 am

Today was my new NP student’s first day of clinical placement with me–and actually his first NP clinical placement ever. Good thing we started with a community healthtastic marathon. In 6 hours we saw 2 new patients who both had cocaine-induced heart attacks and hypertension, 2 other patients requesting narcotic refills, a patient with severe anxiety who claimed that the paroxetine “almost killed me as soon as I took it” but the xanax from her previous doctor “worked perfectly,” a woman with psychotic tendencies requesting “all my medications, because I just got mad and threw them all in the trash 2 weeks ago,” a man with Hep C, cirrhosis and ascites, and a woman who declined to let the male student observe her pap smear (but ,oddly, let her 5 year old daughter take pictures of her on her cell phone during her breast exam). That’s right, NP student, one day this will all be yours! Get ready for it.

 

Sorry, that’s outside my scope of practice January 13, 2010

Filed under: Uncategorized — lesbonurse @ 2:36 am

Chinese-speaking husband, accompanying non-English speaking wife to annual exam: “I have a question.  What size bra does my wife wear?”

Me: “Excuse me?”

Husband: “Well, I try to buy her some bras and I don’t know what the sizes mean.  Can you tell me what size bra she wears?”

Me, momentarily stunned into silence: “Ummmm…wait, does your wife go to the store to buy her own bras?”

Husband: “No, I buy them.”

Me: “She should go with you to the store, and the women in the bra department will help her find the right size.  They do it with a measuring tape.  They have to measure her here–> (pantomiming measuring around braline)”

Husband: “Doctors don’t do it?”

Me: “No, doctors don’t do it.  Only at the store, where they sell the bras.”

Husband, looking disbelieving: “Well…ok.”

 

Life lessons January 6, 2010

Filed under: Uncategorized — lesbonurse @ 3:40 am
  • When your family sends you a “special” sausage in the mail for Christmas, eating it will give you a terrible case of food poisoning.
  • Poor proof reading will result in your documentation stating that your patient was treated with “vicious lidocaine” (instead of ‘viscous lidocaine’).
  • Inserting a tampon rectally is not a recommended treatment for rectal bleeding–try coming to the clinic instead!
 

Slogans for a new year January 4, 2010

Filed under: Uncategorized — lesbonurse @ 2:05 am

My friend (let’s call her GlobetrottingMidwife) and I like to make up rhyming motivational slogans for each new year.   Here’s some community health slogans for 2010:

Take your meds again in 2010

Feeling Zen, 2010

Come see me again in 2010

Avoid nasty men in 2010

Use your insulin pen in 2010 (please!)