Birth Control Pills and Infertility

Earlier I posted about resistance to chronically high insulin levels in diabetics. There I explained how diabetes is best understood in terms of hormones and hormone resistance. The body may develop resistance to chronically high levels of a circulating hormone, such as insulin (which can occur with high blood sugar levels). But I think this can also occurs with estrogens and progestins.
Some women experience infertility of variable duration (sometimes indefinitely?) after stopping birth control pills. Now, your body increases or decreases its production of estrogens and progestin as your body needs it, so I think we can assume that birth control pills, because it's a constant daily dose, induce an elevation in circulating estrogen and/or progestin at all times. Even the new low-dose versions. Estrogens are also potent hormones. So is this period of infertility due to down-regulation and negative feedback? In other words, in response to a perpetually high level of exogenous estrogens, the adrenal glands and the ovaries compensate by producing less estrogen, and the body's cells compensate by becoming less receptive to them. The body probably thinks that there's a estrogen-producing tumor pushing out more estrogen than the body needs. Therefore, when the pills are stopped, the body is no longer making enough estrogen, and neither is it responding to what little estrogen it makes. This causes the ovulatory cycle to fail to start. Hence, infertility.

I'm not sure about this, but it seems biologically plausible. Any thoughts? Your experience?

The Pinning

Graduation is rapidly approaching, and even though I'm intensely busy with the semester itself (being the most grueling academic and clinical experience I've ever had!), I have to deal with all sorts of other matters such as getting the nursing pin, paying for graduation pictures, how much to contribute to the graduation decorations fund, and which aerodynamic nursing cap I should wear for the school picture. Okay, maybe not the last one.

If you don't know, the pinning ceremony is an old tradition dating back to Florence Nightingale's school. Eventually each newly-founded school developed its own distinct pin. Our school has a pin. However, the cheapest version is like $70, upwards to $250 for 14K gold. And I don't particularly like the design, being something from the 60's with an Egyptian ankh and a dove. If it was an old-school English-looking gothic thing with Latin inscriptions, that might be a different story. So instead I got a cheap RN pin (that's it in the picture) which looks nicer, for all of $7. (A friend joked I should get what looks like an ""I heart blonde nurses" pin from the same site.)

The only thing I regret about not getting it is that I like my school. It's tough, but our new grads are known to hit the ground running. I've worked with a lot of nursing students and new grads, and it can be scary what you come across. I think many schools are lacking in bedside experience, basic med knowledge, basic physiology, and critical thinking. Our school is training us to enter ICUs if we choose to. So I'm pretty darn proud that I'm there. But $70-and-gonna-lose-it-in-my-underwear-drawer proud? I have to feed my kids with that cash.

As far as I know, there will be no lamps and no capping for the ladies. They are trying to figure out music for the pinning ceremony. I have no input, nor do I want it, but I hope to high heaven it's not sappy-drippy-barfy 'you're my hero' pop songs. I don't know what I'd have—the Star Wars imperial march or something. Didn't Tchaikovsky have a slave march? Those would have been good as soundtracks to nursing school itself...but graduation, I have no idea. "I'm Free" by the Violent Femmes.

Thanksgiving

So I'm working Thanksgiving. That's fine, because I'm thankful I have a job, and one that wants to give me hours rather than take them away.

I brought my wife's excellent pumpkin crumb cake, except what with the shortage of canned pumpkin (are we in a war or something?), she made it with fresh sweet potatoes—which I think is even better. With homemade whipped cream. I also brought homemade guacamole, pico de gallo salsa, and roasted red pepper hummus from the local ethnic grocery. There's a free Thanksgiving meal in the cafeteria. AND my wife is going to bring me Thanksgiving from home.

I'm already full just from the dips and cake. I feel a nursing diagnosis coming on...Imbalanced Nutrition: More Than Body Requirements. I knew those nursing diagnoses that were drilled in our heads in school would help me in the real world.

If she gives it to me, I'll attach the crumb cake recipe to this post. (It's still fall, and besides, it would be good for Christmas, right?) One of the nephrologists walked past me in the hallway with her mouth stuffed full, exclaiming how good it was. It's that good.

Dads Prefer Breastfeeding

A woman on a breastfeeding forum my wife's a member of told her husband to make a pie chart of why he prefers breastfeeding over formula feeding. Apparently he goes on and on about how great breastfeeding is. So here's what he came up with:

Image credit: Dan Chancellor

I pretty much concur. Although I'd probably add that breastmilk is free, and formula is expensive. I'd also make the "good for baby" section bigger, or even divide it up between benefits. I mean, that would be nerding it up hardcore, but I really value the fact that breastmilk is full of antibodies—not just any antibodies, but the antibodies which particularly defend mucus membranes (defending against colds and flu) and the gastrointestinal tract (defending against diarrhea, colic, gastroenteritis, rotovirus, and other fun bugs and parasites). The antibodies in milk are also the non-inflammatory kind; every other kind causes inflammation when they attack. I imagine this is why formula fed kids are more prone to asthma. Asthma is essentially a hyper-reactive inflammatory disease, and formula kids are kind of left to their own devices without non-inflammatory IgA from mom.

Breastmilk contains the mom's white blood cells, particularly macrophages, the big bacteria-eating cells of the immune system. They also barf up lysozyme, the same enzyme they use to digest bacteria, which serves to acidify breastmilk and destroy more bacteria. (Please don't stop feeding your infant because there's barf in it.)

The acidity of breastmilk supports healthy intestinal bacteria, like Lactobacillus and Bifidobacterium, and inhibits the growth of diarrhea-causing or colic-inducing bacteria. Formula has a more alkaline pH which pathogenic bacteria thrive in.

Besides having human proteins instead of cow or soybean proteins, it also contains 'active' proteins (e.g. lactoferrin) which bind iron and B12, which deprives bacteria and makes it more bioavailable to the infant. Ironically formula has higher amounts of iron than breastmilk, but this is because it is less bioavailable to the infant—in other words, it has to make up for the difference. (The same principle works with comparing leafy green vegetables versus iron supplements; you get most of the leafy green iron, whereas 95% of the iron in iron supplements just pass through and make your stools black.)

If none of that mattered, it boggles my mind that breastmilk contains growth hormones that babies need. That would be the biggest of the "good for baby" part of the pie chart. Epidermal growth factor is a biggie; it makes the infant intestine 'seal up' faster. Otherwise it tends to leak substances into the blood in an uncontrolled fashion, e.g. cow's milk proteins in formula, which then meet the baby's immune system, initiate an inflammatory reaction, and lead to a milk allergy.  But it also contains sex hormones, thyroid stimulating hormone, and other stuff. I don't think you desperately need these hormones (obviously not all formula babies are hypothyroid...although come to think of it, their average weight is lower!), but it seems like they can't do anything but help.

So those are some of the main reasons why I, as a dad, prefer breastfeeding. And I didn't even say anything about boobs!

(Thanks to all the people sharing this on Facebook! If you haven't, feel free to and educate people.)

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See my other post about Hospitalized Infants and Breastmilk.

See also How Breastmilk Protects Newborns and The Constituents of Breastmilk for even more of the science behind breastfeeding.

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Why I Like Open ICUs

Recently I was visiting someone in the ICU of another hospital. There were four of us, and the guard informed us that only two at a time could visit. For various reasons (well, the other people were nervous, and it was late in the evening) everyone followed me in. There were already three visitors in the room, so that brought the grand total up to an unforgivable seven. A nurse at the desk, the only one around, reading a magazine, muttered something about how many people there were.

Now, this isn't to justify the atrocious rudeness of what we did. I mean, really, we should've obeyed the visiting rules, but I wasn't going to make a scene about it with the people I was with. But what the heck? It was irritating to me, as an ICU worker myself, knowing how to behave myself; but the people with me were nice, unobtrusive, and would've scattered at the slightest peep from the nurse; the patient we were visiting was not unstable; and nothing was happening in the unit itself. What gives?

I know the arguments for restrictions. It's critical care. We do things differently. We're doing critical and often sterile procedures like chest tubes and whatnot. Besides, the operating room gets to exclude people; so should we. But I don't think it has to be this way.

We have an open ICU. We allow any number of visitors (okay, within reason—usually we're not hosting family reunions or anything), all day long, or all night if they're family. The family members do not often get in the way, and if they are, or we need to perform critical/sterile/ugly procedures (or even just turn the patient), a quick word from the nurse or myself usually gets the family right out of the room instantaneously. Most family are respectful of us, and even the ones that aren't still comply with our wishes promptly. And of course this is all up to the discretion of the nurse and medical staff; if you're disruptive or stressing the patient, you're out. So I don't think that this policy has obstructed our care of the critically ill. So I don't think one-size-fits-all visiting rules are appropriate for the ICU.

I will admit that we have built a new hospital with extra-large ICU rooms. I assume they were built with an open ICU in mind; whereas old-fashioned ICUs have cubical-sized rooms, probably with strict visitor restrictions in mind. Most of our rooms can accomodate several chairs or a sleeping family member.

At any rate, I hate to say it, but I think visiting restrictions are not made for the patient as much as they are for the staff.

Photo by lexrex

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15% off all scrub tops with code "mantops"

Chest Hair and Scrubs

say you're in the hospital and a nurse comes in to take your vitals.
say it's a male nurse.
say he's totally got chest hair sticking out the v-neck of his scrub top. what do you think of this? unprofessional? supersexy? don't think anything either way?

So goes a pertinent question on a Livejournal forum. I'm not a girl, so I don't know what to say. But I am a boy and I wear scrubs. For now, I am undershirt-free. I'm not exactly Wolfman or anything, but I most likely have some chest hair showing much of the time. I wear scrubs that fit me, not big baggy things, so undershirt sleeves poke out of the arms of my scrub tops. I don't like how that looks. No one has mentioned the chest hair, which is saying something—I work with critical care nurses who unabashedly proclaim their judgments on any subject, personal or professional, regardless of audience or professional propriety, including my personal appearance, on a daily basis. I think they would zero in on that if they thought it was ridiculous.

But I'm beginning to doubt myself. I'm beginning to doubt the chest hair.

There's an epic debate about male nurses and chest hair on the forums at allnurses. At FIVE YEARS running with 28 pages of comments, it's clearly one of the most pressing intellectual controversies not just in nursing, but in all of human experience. There is no consensus at all, but there are definite parties or camps. Women are divided between those who think it's unprofessional have chest hair showing (but admit they hate chest hair), and those who think it's silly to worry about it. Men are divided between those who always cover it, and those who describe their voluminous body hair in exquisite detail and dare anyone to mention when they expose it. ("Excuse me, but I believe you've lost your pen in your, er, uh, hirsutic growth.")

What do you think? Should I keep on keepin' on, or should I find an alternative—say, sleeveless undershirts, or simply wearing t-shirts as some men do in lieu of scrub tops?

Getting All Hormonal: Type 2 Diabetes

Call me crazy, but I really like endocrinology. Hormones are up there with neurons in the category of weird, esoteric, but cool body systems. I picked up on it in Anatomy II and I've been studying it here and there ever since. I even doodle hormone maps when I'm bored in class: hypothalamus → TRH → anterior pituitary → TSH → thyroid → T4 → T3 = boosted metabolic rate.

I have a lot of ideas and theories about hormones which are (hopefully) not that esoteric and pertain directly to a lot of people with certain health conditions. I want to record them before I forget 'em.

My first idea is about diabetes, and has a lot to do with the concepts of down-regulation and negative feedback. First, hormones are extremely potent, causing big effects despite being present in extremely low quantities in serum. Hence, in the presence of dangerously elevated hormone levels, cells will decrease the number of receptors to that hormone on their exterior surfaces, so they become less responsive to the hormone. That's down-regulation. And in the presence of high levels of circulating hormone, the body will tend to produce less of that hormone. That's negative feedback. These are both healthy, normal compensatory mechanisms.

I think diabetes is better understood in light of these two concepts. If humans eat only when they're hungry, their blood sugar levels rise and fall periodically throughout the day. Following that, insulin levels rise and fall. But continual overingestion of starches and sugars can lead to a constantly high glucose level—and therefore a constantly high insulin level. Now, insulin is a potent hormone. It pushes serum sugar into cells (and shifts potassium too, right?). You can inadvertantly kill someone with insulin. So people with diabetes undergo a usually healthy compensatory response by making less insulin and becoming more resistant to insulin. In other words, they've down-regulated (reduced the number of insulin receptors) and have undergone negative feedback (reduced their production of insulin). The cells don't care if blood sugar levels are high, as long as they protect themselves from the high levels of circulating insulin and glucose.

This is why diet and exercise are so effective at relieving diabetes if it is not too far progressed. I remember thinking all diabetics had to inject insulin three times a day; that's not true at all. Many diabetics have up-regulated their insulin receptors and decreased that negative feedback response by diet and exercise (albiet often with the help of oral antidiabetic meds which boost insulin production or decrease glucose production).

When diabetes becomes extreme, it will down-regulate receptors and reduce insulin production so much that even in the presence of extreme hyperglycemia (high blood sugar), the body will enter a starving response, metabolizing the body's own proteins and fatty acids just to stay alive, producing potentially lethal amounts of acidic by-products in the blood (diabetic ketoacidosis).

In the hospital, and in acute cases, we inject exogenous insulin to push all that sugar into the cells regardless of whether the cells want it. My question is, does this do anything bad to the cells? I assume the cells have down-regulated for a reason. If they had the capacity to bring a 400 or 600 glucose level down to 100 just by storing infinite amounts of glucose, they would already do it, and we wouldn't have to force it with insulin. So what does this do to the various cells of the body? Anything? I'm not saying, of course, that we should avoid giving insulin for acute high blood sugar or brittle (unresponsive) diabetes; we have clear evidence of the harm that would cause. But I'm curious if research will eventually show any evidence of intracellular damage: i.e. DNA alteration, malignancy, etc.

Insulin image by Isaac Yonemoto.