Category Archives: Sexual Health

Notes from the Road: Buenos Aires WPATH

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I am in beautiful Buenos Aires at my second World Professional Association for Transgender Health. My first was held in Amsterdam in 2016 when I was a fresh faced, just-finished first year medical student. Now, as a mid-fourth year student I am significantly more exhausted and disillusioned; I also have so much more doubt about choosing this field of medicine as my calling.

I like to tell the story that I returned to medical school to practice transgender health. Specifically, to be able to prescribe transitional hormones and participate in the insurance racket to reach more people. And that is part of the story. The root truth is I have been compelled to be a full scope physician for many reasons and transgender medicine gave me a focus because it was something I could not attain as the Naturopathic Doctor that I was before.

The last session I attended at the WPATH ARGENTINA conference was an incredible and inspired panel of Brazilian intellectuals speaking on depathologizing the transfeminine and deconstructing cisheteronormativity. Fran Demetrio, a transfeminine Brazilian professor was so passionate and eloquent in her discussion of injustice, oppression, systemic violence and the colonization of knowledge imported by biomedicine. She was being translated which made some of the discourse hard to fully comprehend and I wished WPATH had provided a professional translator for her because what she had to say was so profound and important and well thought out. She framed a paradigm that took the personal out of the conversation and raised it to a social construct and human justice level. In rough translation, she explained that not including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the [transgender] patients knowledge. Considering and understanding this is essential to depatholgize the trans experience.

Despite the  multiple disparities that this population faces world wide, there is a slowly increasing body of trans identified physicians and health leaders in the field. However, to date  many of the people making the decisions about gender medicine are not differently-gendered themselves. Surely, this is problematic. The numbers of trans identified health care leaders is increasing by the year, and with groups like the Transgender Professional Association for Transgender Health, they are seeking greater control around the discourse of gender medicine and claiming their place as necessary voices in the didactic.  

The tensions between cis and trans leadership has created a simmering anger within this medical community. A socialist friend of mine shared that in activism in general there is a current trend towards challenging aggressions towards advocacy leaders in many different fields with a similar theme of  – who has the power to speak and represent the cause?

I was personally attacked in this rising conflict this year when I created a transgender health elective as a third year medical student for global medical students to supplement core medical school curriculum. A variety of trans and nonbinary people on social media threatened to create a petition against the course as it does not have a transgender identified course leader and there were multiple flamings on Facebook. I personally received several vitriolic emails from different people about the course, its content, and my leadership. I was privileged to have a team of (cis and transgender) people who have been in the field for a long time holding leadership positions to assist me in creating online and email responses that were balanced, appealed to reason, and illustrated the many ways the course seeks to uphold and respect the “nothing about us without us” principle while promoting evidence based foundational medicine.

I brought up this conflict between cis and trans leadership in the didactic of transgender medicine again at one of the ethics seminars at WPATH, where leadership and authority privilege was being discussed. Unfortunately, I was emotional in my questioning of the ethics behind attacking ally’s and advocates, as I am still deeply shaken by this experience. The response from one of the panelists was that when working as a non trans person with the gender diverse community there is so much anger one must simply expect to be attacked and be ok with that.

I am a person who has been excavating emotional violence in my personal life and creating real boundaries to protect myself for the first time. I don’t think I can intentionally choose a career were the population I am exhausting myself to serve reserves the right to be emotionally violent towards me indiscriminately because of their experience of violence. That is like saying that my mother has the right to be violent towards me in any way she sees fit because of the abuse she and her mother suffered. No.

Again.

“not  including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the patients knowledge. Considering and understanding this is essential to  depatholgize the trans experience. “

Dr. Demetrio’s message ultimately lifted my perspective of the conflict to a healing systems approach. With this in mind, I am still recalibrating my commitment to trans health as a specialized field of medicine, while intentionally making room for the many trans identified health care leaders. As a nontrans woman and a white queer/lesbian, I devote the next phase of my medical education to the foundations of internal medicine as well as lesbian health, vaginal happiness, fertility, community health, and queer health issues like addiction and mental health. My view of women’s health includes trans and cis women, as does my passion for community wellness. I am confident that these past 11 years of studying transgender medicine and advocacy work will continue to inform the communities I serve, if in a less direct way.

I see now that when I claim my leadership vision within a paradigm that matches my own identity I can be stronger and more authentic.

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Gender Affirming Health Care: Top Ten Tips

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This article was written for the American Medical Student Association journal The New Physician October 2017. The original can be found at this link: http://mydigitalpublication.com/publication/?i=445109&utm_source=webtoc&utm_medium=referral&utm_campaign=O17#{“issue_id”:445109,”page”:1}. Volume 66, Number 5.

Picture this: it’s your second day of practice. You graduated medical school, made it into a residency, and now it’s time to be a doctor …. In walks your third patient of the day – medium height, medium build, medium length black hair, charming but shy face and awkward smile and – your quick-fire practiced analysis stops there – frozen, you can’t tell if this person is a girl or a boy. You glance at your paperwork. First Name: Robin. Last Name: Also Unhelpful. The person is talking in a midrange tone, and you aren’t listening because you are frantically scanning their body to figure out what lies underneath the black tee-shirt and dark Levis. You look up at the persons face and see it start to close as they observe you floundering to see past their gender.

Transgender Medicine is a newly emerging subspecialty, but every health care professional is already seeing transgender patients. Trans people have always been a part of every culture worldwide; in the last ten years there has been a public blossoming of gender expression in social media, television, and probably your personal family or friend circle as well. Transgender people have come out as part of our modern society, and as physicians we need to be culturally and medically competent enough to provide good medicine for this community.

As of 2017, there are several epicenters of transgender medicine, research and scholarship worldwide. The Dutch are famous for their longitudinal body of evidence on transgender health, as they have been collecting research and academic scholarship on transition medicine within their socialized health care system for over 30 years. As such, they have a tried and true so-called “Dutch protocol” for male to female (MTF) and female to male (FTM) transitions that has been used as a template for most international Standards of Care.

The US has several gender specialty clinics that conduct research and offer high quality trans health care. These clinics and hospitals are also key players in this rapidly evolving area of medicine, surgery and research. The best known of these include:

  • Fenway Health Center in Boston
  • The Center for Transgender Medicine and Surgery at Mount Sinai in NYC
  • The Mazzoni Center in Philadelphia (which puts on the free Philadelphia Trans Health Conference annually)
  • The Center of Excellence for Transgender Health at UC San Francisco

For future and current physicians interested in Transgender Medicine as a specialty, the key areas for concentrated trans care are Family Medicine, Endocrinology, Psychiatry, Surgery/Urology and Pediatric Endocrinology. There is not yet a fellowship available in Transgender Adult or Pediatric Endocrinology (Coming Soon!) but the first fellowship in Transgender Surgery has been piloted this year at Mount Sinai in New York City.

Whether you want to dive into the depths of the transgender community and learn the intricacy of this rich and diverse community or not, as it was said before every physician will see trans people in their career. Take the time now to become familiar with the basics of transgender health literacy, for your professional integrity and your patients.

TOP 10 TIPS FOR BEING A TRANS FRIENDLY PHYSICIAN

DON’T GET HUNG UP ON IDENTIFYING GENDER IN THE FIRST 3 MINUTES. Gender and Sexuality Identity begin to develop at 2-3 years of age. Your patient has probably been trying to figure out their gender for a whole lot of years before they showed up in your office, so chances are their gender is more complicated than your 10 second evaluation. Once you notice you can’t confirm male or female specifically (spoiler alert: you may be wrong in your assessment) MOVE on with your objective assessment and Listen to what the person is saying.

THEY IS THE NEW SINGULAR PRONOUN: For some people, She doesn’t feel comfortable, but neither does He. Some people live in the space between male and female, and those definitive English pronouns can feel extremely uncomfortable. Being mis-gendered by pronouns is also surprisingly hurtful to trans people. “They” is a neutral pronoun that just feels more comfortable for some people. Why not use it? (Ps. Please don’t use the “it’s just not good grammar” argument because chances are your grammar isn’t perfect otherwise; and, while it may commonly be an English plural pronoun, Latin-based languages have pleural pronouns that can also be used in the formal You/singular.) Again, the use of “They” is really helpful to some people for communication purposes, so embrace it, try it on every day, and get used to it. In fact, it really comes in handy when referring to someone whose gender you can’t figure out, as in saying to your attending “I’m not sure what’s wrong, but they look really terrible, would you come take a look?”)

ACCEPT THAT SOME PEOPLE LIVE OUTSIDE THE LINES: Technically, the term is “non-binary” for people that don’t neatly fit into the sex-gender binary of male / female. This is a complex spectrum of identities that can be any shape or form and have any meaning for an individual. The non-binary space can be intentional with hormone use, or how people are born or mature. For people who have always fit within the binary, it can be hard to remember that other people LIKE THE WAY THEY ARE. It isn’t our job as physicians to try and get them to fit within a specific box. For other people, the non-binary identity may be a stepping point, a transitional space, or something they struggle with. As always it is simply our job as health care providers to create a safe place where people can talk about their health care needs, and help them get these needs met.

STATISTICS DON’T LIE: Not a lot is known about trans health care seeking behavior from an evidence based perspective, but from my community I know that many of my gender minority friends avoid health care due to bad medical experiences being misgendered, disrespected, or worse assaulted/insulted or denied care. From the research that does exist, the statistics are alarming. Dr. Angela Carter, a transgender physician from Portland, Oregon writes “One in 5 transgender people have been turned away from healthcare because of their gender, and an estimated 30% have avoided seeking care due to fear of discrimination. Reports suggest that 50% of transgender people have had to teach their physician how to care for them; 24% of trans people have been verbally harassed while seeking care; and, 2% report an actual physical assault while trying to get care.” Read more of her great Trans Health 101 article here: http://ndnr.com/endocrinology/transgender-healthcare/.

PAPERWORK: What is named, exists. If you have a box for Transgender or better yet Male to Female, Female to Male, and Gender Nonbinary on your intake form or embedded in your EMR next to Male and Female, you can have that helpful self-identifying information at the first encounter. At the same time, this improves the patients visit experience, offering a named identity and acceptance from the first encounter. Make sure your staff are educated in trans cultural competency as well. Include training elements like being compassionate and respectful with patients who may have gender incongruent birth names, insurance navigation, and associated pronoun use.

EMRs – UN/NECESSARY EVILS: It will take a long time and many years of advocacy work before most hospitals EMRs are updated to contain alternate gender identities; however, having staff who are trained in ways to communicate about gender differences can soften the experience for the person who is in an acutely ill and vulnerable state needing medical care. For example, triage personnel (and med students!) could say “”So, I know this may be a difficult question right now but what is your preferred pronoun and what is your is gender designation on your health insurance?” This non-judgemental approach leaves space for the person to give an answer without an explanation and conveys compassion in a business-like open-ended manner.

DON’T JUDGE A BOOK BY ITS COVER: Many trans people “pass” for their chosen gender completely. We need to be mentally and medically prepared for providing effective and competent health care to people who physically inhabit bodies that are hormonally and anatomically complex. Doing this work AND exploring your own personal, moral, or religious complexities of feelings about trans gender and identity needs to be done BEFORE that patient walks in your door needing your professional skills as a doctor, not your human opinions.

KNOW YOUR RESOURCES: The World Professional Health Association (wpath.org) has been the guiding force and academic collective of transgender scholarship for the past 30+ years. WPATH has been at the heart of the conservation and documentation of the protocols used for transitional medicine. There is a published a Standards of Care (version 7.0) that is available online and in print. University of San Francisco also has a superior online learning center with everything you need to know to start basic primary trans care including evidence based protocols. http://transhealth.ucsf.edu/trans?page=guidelines-home. Fenway Health is the east coast online epicenter for trans health resources and reading and has great free training webinars http://fenwayhealth.org/care/medical/transgender-health/. Take an afternoon and familiarize yourself with these sites, bookmark them, and pass them on.

KNOW MORE RESOURCES: No one should have to travel beyond state lines to get competent medical care. As with most kinds of medicine, having a grasp of your local resources is essential, especially for primary care docs who just can’t do everything (contrary to popular belief.) Know who is providing competent transgender primary care and endocrinology for adults and for children in your area, who has experience with transition hormone therapy, where to refer for respectful electrolysis and other cosmetic procedures, and who is offering the basic surgeries like mastectomy in your part of the world is a great way to provide your gender minority patients with access and resources. If there isn’t anyone offering these services, consider taking a WPATH certification course and becoming that person.

DON’T BE AN ASSH**E: The best thing to do when you make a mistake is apologize. I have over 10 years of professional experience with trans health and gender non-conformity has been part of my social circle for 20+ years and I still unfortunately misgender people, use the wrong pronouns, and say awkward things. And then I apologize and learn from my mistakes. Doctor-patient relationships are built on an exchange that requires integrity and some transparency. You don’t have to be the expert in trans medicine- your patient is the expert in what their body (mind spirit) needs. Your job is to help them maintain a safe and consensual medical space where they can address health concerns and work towards their optimal self-expression. This may include transitional hormones and gender affirming surgery for some, or it may be flu shots and cholesterol testing for others. Or oncology. Or labor and delivery. Or sickle cell anemia. Who knows what the person will need, trans people are people and you have one in your office right now. What will you do?

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Balancing with Ayruvedic Medicine – from Womens Power to Heal

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510fafgjdbl-_sx336_bo1204203200_I am doing an Integrative Medicine Scholars program through the AMSA and we have to do a project to explore some aspect of Integrative Health. Ayurveda is a practice of medicine I don’t know much about, so I decided to do a personal practice incorporating lifestyle, nutrition and herbal medicine principles for the month of January. My friend Cathleen Miller helped me to figure out what my Dosha is (constitutional type) and lent me this amazing book, and …. here we go! Below is an outline taken directly from this text for (my) Pitta-Vata type.

Balancing Pitta-Vata Rhythms –

  • Rise with the sun and go to bed by 10 pm – maintain steady eating and sleeping routines
  • Ease yourself out of all stressful activities and maintain only those projects that create ease – allow adequate time to complete projects
  • Take ample rest
  • East wholesome, fresh, moderately warm, moist substantial and calming foods.
  • Avoid bitter, cold, raw, hot, spicy, oily, salty, fermented or stale foods and stimulants.
  • Shield against hot, wet, humid, cold, damp, or stressful environments.
  • Embrace serenity, love, warmth, healthy rituals and calmness.

Nutrition Principles

AVOID: caffeine, refined sweets, alcohol, saturated fats, excess salt, oily and spicy foods, and commercial dairy projects, as well as highly processed junk foods, meats, additives, frozen, canned, commercially grown, bioengineered, transgenic refined salts, sugars, flours and hydrogenated oils.

CHOOSE:

VEGETABLES Broccoli Brussel sprouts cabbage Cauliflower
Artichokes Asparagus Bamboo Bitter greens Black olives
Celery Cucumber Green beans Dark greens Parsnips
Peas Potatoes Sprouts Summer squash Sweet potato
Winter squash yams Watercress Bok choy Carrots
Daikon Beets Leeks

 

FRUITS Apples Apricots Coconuts Dates
Fresh figs Oranges Pears Pomegranate Tangerines
Mango Plums Raisins Quinces Limes
pineapple Avocado Banana Grapefruit Kiwi
Lemon Peaches Tamarind Rhubarb

 

LEGUMES Aduki beans Mung beans Kidney Lima
Lentil Navy Pinto Chickpeas Tofu
Black beans

 

NUTS Coconut Roasted sunflower seeds Roasted pumpkin seeds Poppy seeds
Water chestnuts Macadamia nuts Sesame seeds Pecans Walnuts
Pine nuts Pistachios

 

DAIRY Unsalted butter Cows milk Cottage cheese Sweetened yogurt
Buttermilk Whole cows milk cheese Cream Ghee Sour cream

 

OILS Sunflower Almond Olive Coconut
Dark sesame Light sesame

 

SWEETENERS Maple syrup Dates Sucanat

 

SPICES Coriander Cumin Cardamom Cilantro
Curry leaves Dill Fresh basil Fennel Turmeric
Saffron Peppermint Spearmint Ginger Anise
Mustard seeds Sage Nutmeg Thyme Ginger
Cloves Rosemary Tarragon Oregano parsely

 

Practices

  • New moon journalling with saraswati mantra – Aim Sarasvatyai Namaha
  • Ginger compress one week before the new moon (unless bleeding)

1 gallon water

1 handful grated fresh ginger

1 lg stainless steel pot with cover

2 stainless bowls

  Bring water to a boil, and add ginger secured in a ouch with a drawstring. Squeeze the  pouch to release the ginger juice and drop into the water. Simmer 30 minutes. Let sit 5 minutes before uncovering when taken off the heat. Create a compress towel and apply to lower back for 4-5 minutes or until lukewarm. For full instructions, see text p. 264.

  • Rose Oil Pichu – for headaches, hair loss, pain in the eyes, poor vision, mental fatigue and nose bleeds. Pichu: a powerful lubricating and loving therapy that helps maintain mental calm, emotional equanimity and helps balance the doshas. Best time: waxing moon phase. C/I bleeding. Best time: morning or early evening.

¼ cup dried roses

1 c sesame oil

Bring to boil over low heat and remove from heat, Add rose flower, cover and let steep 4-6 hours. Strain and use.

PICHU instructions: need pottery bowl, 12 “ clean cotton square and cotton hand towel.

  • Wash hair a few hours before
  • Release all stressful thoughts and details from the mind
  • Assemble the supplies on the floor close by
  • Soak the cloth in oil and lie down; place the cloth ear to ear. Press down on the cloth and wipe away excess oil
  • Rest quietly for 30 minutes and rise slowly, use hand towel to wipe away excess oil and maintain a peaceful attitude for the rest of the day.
  • Shakti Mudra – should be daily but 3 times per week seems doable – enhances sense of self, reinforces femininity, self esteem and restores vital energy to the womb.

Sit facing east

Bring palms together and separate slowly

Form the Shakti mudra hand position – see p. 192 text

Breathe deeply into pelvis and breathe out slowly, tracing the exhalation from the base 0f the perineum, circulating through the uterus and belly

Maintain for 15 minutes

Take a deep breath and make a commitment to a life of non-hurting

 

  • Yoni Mudra – 3 days before the new moon and full moon to revise Shakti prana.Not when bleeding.

Sit in meditative practice with palms facing up

Create the yoni mudra hand positions – see p. 155 text

Hold the hand gesture for 5 minutes

Allow breath to flow freely throughout the body, keeping the mind centered

HERBAL MEDICINE

Herbal Teas for PMS – Vata type predominant – take for 3 days of the new moon as well as the 5 days before menses

Helpful herbs: nutmeg, valerian, triphala, ashwaganda, shatavari, cinnamon, turmeric, fennel, dill and wild yam.

CINNAMON, CLOVE AND CARDAMOM DECOCTION (VATA) for PMS

2 c water

2 c organic milk

1 tbsp cloves

1 tsp cinnamon

1 tsp cardamom

½ tsp ginger

1 pinch saffron

 

LAVENDER FENNEL GINGER TEA DECOCTION (PITTA) for PMS

I c water

1 c organic cows milk

1 tso roasted fennel seeds

1 tbsp lavender petals

1 tbsp hops

½ tsp ginger powder

1 pinch saffron

bring water and milk to a boil. Toast the fennel seeds, then add all herbs and spices and simmer on medium for 15 minutes. Remove from heat, add saffron and stand 3-5 min before drinking.

 

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Heartbreak and Heart Failure

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screen-shot-2016-11-06-at-2-48-11-pmSometimes life, work and study all seem  to dovetail and everything makes sense for just a few glorious moments. Cardiology was like that for me, in between the Frank Starling curves.

Last year we had a case study of a woman with congestive heart failure (CHF.)  Her husband had renal failure and needed dialysis, and she worked at a job she didnt love. She slowly developed worsening heart failure over the course of the case, with  shortness of breath, edema, high blood pressure, and poor circulation, eventually dying from it. I was impacted by the apathy she displayed in her efforts to recover – unwilling to eat more grains and greens, decrease salt,  get outside, exercise regularly, investigate psychotherapy, or better her personal life in any way. Instead, she just declined in health, adding a new prescription per year to mange her symptoms until she  – drowned. In her grief. Of heart disease.

This. Story. Happens. Every Day.

And not only in the US, or Canada or Europe. World-Wide.

The multitudes of meta-analysis risk factor evaluations like the Framingham, Whitehall and Rekjavic studeis have concretely illustrated important evidence about the facts of heart disease: atherosclerotic fatty streaks in arteries, high blood sugar, and  inflammation are the undeniable Holy Trinity of heart disease. What is not being avidly reported is the rate of divorce, or mood disorders in these same subjects. The sexual dissatisfaction. The childhood trauma. Socioeconomics and race are sometimes studied, and African Americans and Latinos have higher rates of heart disease. Nobody is surprised. Russia has the highest rate of ischemic heart disease in the world, along with some African nations and Indonesia. These countries also have horrible human rights records, with well documented transphobia, homophobia and police brutality.

screen-shot-2016-11-09-at-9-01-58-pmIf we are going to turn around heart disease, do we not need to acknowledge the humanity of the heart? The same  epidemiological study quoted deep within the content:

“Additional reports from this study have shown inverse associations between fair and respectful treatment at work and CHD [Congestive Heart Disease],and job control with future CHD risk.“

Similarly, hypertension, which is the harbinger of heart disease through its effect on cardiac structure and function,  is hugely mediated by the stress response.

screen-shot-2016-11-09-at-9-11-31-pmI was talking to Dr. Stein, an internist specializing in HIV and also our OMS II course director, about this theory that heart failure is so rampant because we have no real medicine for soul-problems like dissatisfaction, grief, sorrow, envy, loneliness and such. He said the links between depression, elevated cortisol, hypertension and CHF are well documented and clearly evidenced.

He reiterated that it is known that People of Color have higher blood pressures because their lives are more stressful due to systemic and personally experienced racism aka “stress.” It is also well evidenced that African Americans with CHF respond better to different medications than other races – Hydralazine, a vasodilator that decreases resistance,  improves survival with  isosorbide dinitrate rather than the ACE inhibitors and Beta Blockers commonly used. Ha, decreasing [systemic institutionalized] resistance as a keystone in improving survival? I need to know more about the MOA of these drugs to understand why decreasing the catecholamines isnt enough for this population; maybe its because of the deleterious and constant push and pull the sympathetic blockers have on the heart receptors of someone living in the actual adrenergic rut of an unsafe society.

3f0a8388-0078-4c4f-88ef-36078365eae5Our cardiologist professor Dr. Glass stated that the average person with hypertension is on 3.4 medications to manage it. These are usually layers of diuretics to decrease the blood volume and drain edema (decreasing preload), and beta blockers to decrease cardiac work and improve cardiac output,  and/or other meds like diphydropyridines and nitrates. But guess what – it just came out recently that hypertensive medications may be CAUSING depression/ mood disorders while working to decrease blood pressure.  What a double whammy.  This was a big study from a database of a single hospital containing 525,046 patients over 5 years. This 2016 article stated:

“Major depressive and bipolar disorders predispose to atherosclerosis, and there is accruing data from animal model, epidemiological, and genomic studies that commonly used antihypertensive drugs may have a role in the pathogenesis or course of mood disorders.”

  • Patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers had the lowest risk for mood disorder admissions
  • those on β-blockers (hazard ratio=2.11; [95% confidence interval, 1.12–3.98]; P=0.02) and calcium antagonists (2.28 [95% confidence interval, 1.13–4.58]; P=0.02) showed higher risk
  • those on no antihypertensives (1.63 [95% confidence interval, 0.94–2.82]; P=0.08) and thiazide diuretics (1.56 [95% confidence interval, 0.65–3.73]; P=0.32) showed no significant difference.

To summarize the findings,  calcium antagonists and β-blockers may be associated with increased risk, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be associated with a decreased risk of mood disorders. (Hypertension. 2016;68:1132-1138. DOI: 10.1161/HYPERTENSIONA HA.116.08188.)

It appears, the drugs that most directly affect the heart muscle itself are thus linked to more mood disorders, while those that work indirectly and decrease the work for the heart seem to have less impact on mood.

This is such a broad topic and there are so many layers to heart failure – blood pressure, kidney regulation of blood pressure, nutritional effects, blood lipids, blood volume, inflammatory mediators, free radicals and antioxidants, sleep quality and more – but I think that too often we lose sight of some of the most basic truths of happiness and heart health. And we also forget the deeply sensitive creatures that most of us are and fool ourselves that pharmacy could possibly be enough to cure a heart that is systemically broken, or the effects of a chronically hypervigilant nervous system.

imagesWIDJJQD2I am going to need to become proficient at cardiology as an Internal Medicine doc. But without a degree in psychiatry, or soul medicine, or archangel intervention, how can I possibly hope to help people recover their failing hearts when the intersections cut so deep? I am scared of all of those people that have no willingness, or ability, to look deep within and make the simple and profound choices towards life. This is the part of being a physician I most fear. The medical failures; the broken hearts.

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Frequently Asked Questions: Hormone Tx

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Many people have questions about the safety and efficacy of hormone treatments. I provide individualized hormone treatment programs. Every patient undergoes our complete metabolic bloodwork panel; a physical exam including breast exam, and a full 90-minute initial intake to make sure that hormone treatment is safe and recommended for you.

Here are some common questions, asked in our free 30 minute screening consults.

Will I need to stay on hormone treatment forever?

Current evidence shows that estrogen and progesterone bioidentical replacement therapy is safe for up to 15 years. After 15 years the risk of hormonal cancers increases very slightly. I encourage our patients to follow their own instincts around the duration of bHRT. Many women reach a point where they want to try coming off the hormones, to see how they feel. (Many then come back on the hormones for the feelings of well being they provide!) There is no “right answer” for the duration of hormones treatment; instead, your ongoing health and feelings of wellness may be the most important indicator to measure this.

What is a Bioidentical hormone?

Bio –meaning, of the body and Identical meaning, exactly like = hormones that are exactly like those your body naturally produces.

Why use Bioidentical hormones?

Generic and brand name hormones made by pharmaceutical companies all have biochemical additions to the basic hormone structures like pharma-signatures that make the drug patented (and profitable.) Bioidentical hormones are made as liquids, creams, troches, rapid dissolve tablets, injections or suppositories by a compounding pharmacy laboratory like Apothecary by Design to make them exactly like the hormones your body would naturally be producing. Drug companies cannot make money off of this form of hormone because they are universal; therefore their use is discouraged by big pharma. We know that bioidentical hormones are the safest, most effective way to replace hormones in your body. We only use compounded, bioidentical estrogen, progesterone, and testosterone at Age Management Center.

Do hormones cause cancer?

The Women’s Health Initiative study in 2001 did show an increased risk of not only breast cancer, but also heart disease in women taking the medications in the study. What is KEY here is that the hormone medications used in the study were the horse-based estrogen Premarin and a synthetic version of progesterone called progestin, brand name Provera. The study was separated into just Premarin users and Premarin + Provera “Prem-Pro” users. The Provera Rx was clearly indicated as the causative factor for the increased risk of breast cancer in clinical data. In further studies on bioidentical progesterone it has been evidenced that 200 mg of bioidentical progesterone is actually protective against the development of breast cancer.

It was the synthetic pharmaceutical analogue Progestin that is linked to cancer development, not either bioidentical estrogen or progesterone. Having said that, if you already have an estrogen positive cancer growing in your body, additional hormone replacement therapy can feed the tumor growth. We encourage all of our patients to get screening mammograms yearly during menopausal hormone replacement therapy, and actively support anti-cancer nutrition and antioxidant supplementation as part of our treatment protocols.

What about heart disease in women and estrogen use?

One of the most surprising results of the Women’s Heath Initiative was the increased risk of cardiovascular health issues like blood clots resulting from plaque rupture in women using Premarin. Estrogen is in fact protective for the cardiovascular system as it increases elasticity in all systems including the blood vessels. More elastic, flexible arteries means healthier blood flow. However, when combined with risk factors for atherosclerosis (plaques in the arteries) like elevated cholesterol, high blood sugar, smoking and being overweight the benefits and the risks need to be weighed to assess what is best for each woman.

At Age Management Center our complete metabolic blood work panel and 90 minute initial consult is in part to ensure that your body is metabolically able to handle additional bioidentical estrogen, and that you are a good candidate for hormone treatment. Some women need to do additional metabolic and cardiovascular work to reduce risk factors before estrogen-based therapy is indicated. Oral estrogen (taken by mouth) was associated with more risk for plaque rupture than topical estrogen. We start all women on a topical mix of bioidentical estradiol and estriol plus additional progesterone to manage symptoms while navigating risk, ultimately improving metabolic and cardiovascular health for effective anti-aging.

I thought testosterone was only for men?

Want to know a secret? Testosterone is like magic for womens health. It is actually the most abundant hormone across our entire lifetime because our body continues to produce it after menopause (if all goes well.) Testosterone is extremely valuable for women’s health because it is the “vitality” hormone that leads to physical and mental strength, bone health, leadership qualities, sexual appetite, sexual satisfaction, mood stability and more. Testosterone levels naturally start to get lower around 40, but the adrenal glands take over testosterone production when periods stop completely. We see low testosterone in women of all ages; we use testosterone supplementation in most of our menopausal treatments, because it helps you feel great! This hormone has been part of menopausal treatments since 1937. There is not much excitement generated about it in traditional medicine because who wants strong, sexual, healthy, happy, active, passionate postmenopausal women? I do!

Will taking testosterone make me look manly? (Facial hair, lower voice etc)

My job is to replace and optimize hormones to their natural levels. When testosterone levels are optimized for your body, it is unlikely you will have complications like black facial hairs, voice lowering, acne, or other classic side effects. However, this of course depends on your genetics and sensitivity to hormones. We start with the lowest possible dose after our thorough initial exam, an adjust dosages based on your personal experience plus laboratory testing. If you happen to be someone who does have side effects like facial hair or pimples, these are immediately reversible by lowering your dose.

At Age Management Center I also provide transition support for transgender and transsexual individuals. These dosages of hormones are significantly higher than doses used for hormone replacement, and do have permanent and reversible side effects that are usually considered desirable by the people using them.

Do you accept insurance?

Age Management Center is a concierge medical practice. We offer the best of modern regenerative medicine, guided by cutting edge evidence based research, in a relaxed, comprehensive manner. Our hormone programs are simple. Once a month fees include all doctor visits, emails, and phone calls, as well as your administrative support and foundational hormones. We operate outside the insurance system so that we can offer the high touch personalized medicine that our patients have come to rely on. We do not bill insurance companies for our services; however we can give you an itemized “superbill” for your services that you can submit on your own for reimbursement. We invite you to come in for our free 30-minute consultation to learn more about our concierge medical programs and how these might work for you.

Can I use my insurance for the comprehensive metabolic bloodwork?

We prefer that our patients use our cash-based in house laboratory services as it allows for consistent lab results and lab values, speedy results, streamlined workflow and improved coordinated care. We thoroughly research the best prices for lab work, and pass those savings on to our patients. For example, our complete metabolic blood work is priced at $1800 through insurance billing. We offer it at $395, passing on our physician pricing to you. Many of our patients have tried to use their insurance to run the blood work, and with deductibles and co-pays have ended up paying at least $600-800 for the same work.

Furthermore, many insurance companies and PCP’s will not cover some of the hormonal blood work evaluations we consider crucial to accurately understanding your metabolic and hormonal health. By having all of your blood work arrive in time for your initial visit, we are better able to serve you in a timely and effective manner. Laboratory, physician and clinical services can all be claimed as health expenses on your taxes, and can be part of your deductible.th

Can I use my Health Savings Account or Flex Spending Account?

Yes. Age Management Center services are billable through HSA and FSA’s.

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Fertility is the New Holy Grail

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Resolve to know more about the underling factors affecting conception and alternative family possibilities. * This article was originally written for the February 2015 Digital Issue of Essential Living Maine*

I had two stepmothers who were infertile for various reasons, and have an adopted baby brother. Several of my close friends and family member have used IVF to conceive, and I have my eggs cryopreserved. A few of my good friends have fostered and adopted, and others have intentionally chosen childfree lives. As lesbian and gay marriage has normalized, and divorce rates have climbed, more and more alternative families are being created using sperm banks, surrogates, egg donors, known sperm donors and more. The quest for fertility is all around us, and has been for the past 30 years in ever-increasing numbers.

The Internet has an enormous amount of information available on this topic, as the World Wide Web offers an enormous cross cultural support network for women trying to conceive (#TTC.) Infertility is usually a silent disease without any visible disability associated; however, it draws deeply on the mind/body and soul in underground ways that cannot be explained to those who do not have to undergo its trails and tribulations. Thus, the web is a great way to connect, share information, and do research while maintaining public anonymity.

220px-Sangreal-1Integrative Medicine is key to enhancing fertility. Integrative Medicine combines the best of modern medicine (reproductive technology) with time-honored complementary and alternative medicines (botanical therapies, clinical nutrition, homeopathy, acupuncture, and stress management support.) The quest to get pregnant (and stay pregnant!) has been a calling of doctors and midwives since the beginning of time and across all cultures.

After ten years of fertility specialization, here are my Top Ten Integrative Medicine Fertility Fundamentals to know about when mapping your journey:

  1. First, while on oral contraceptive pills, rings, or IUD’s and for at least 6 months coming off them, it is important to supplement with a good quality multivitamin that contains at least 10-20mg of all of the B vitamins, magnesium, vitamin C, and 800mg folic acid. These are depleted by synthetic estrogens, and a deficiency can cause long term fertility issues down the road.
  1. If you have a family hx of miscarriage, have had a miscarriage yourself, or have any anemia or high homocysteine on lab work, you may want to test for a genetic defect called MTHFR that leads to a folic acid absorption issue. http://www.apothecarybydesign.com/blog/archives/332
  1. DHEA is a fat-soluble antioxidant and hormone precursor produced by the adrenal glands. DHEA is also a key player in egg health, showing improved embryo quality and higher live birth rates than controls. Studies have used 75 mg of DHEA daily. 1 DHEA supplementation also evidenced higher rates of spontaneous pregnancies in long-term poor responders to IVF in another study using 25 mg three times per day. 2 DHEA supplementation slows the aging process by preventing lipid oxidation while improving energy and metabolism.
  1. CoQ10 is imperative to egg health. Egg division from 46 to 23 chromosomes requires effective mitochondrial function. 3. It has been suggested that mitochondrial DNA defects that effect metabolic capacity may be a cause of failure in egg maturation, fertilization, or early embryonic development. 4. Aged eggs have decreased mitochondrial energy which can result in deficient energy to divide properly resulting in Downs’s syndrome and other genetic anomalies. All women over 30 who are still considering pregnancy should be on 100mg of ubiquinol daily to maintain efficient mitochondrial activity.
  1. Test your hormones early, and keep testing every few years for an objective measurement of fertility reserves. Follicle Stimulating Hormone (FSH) levels must be tested on day 3 of the menstrual cycle with Anti Mullerian Levels (AMH) levels before beginning fertility protocols. FSH reflects the relationship between the ovaries and pituitary and higher levels indicate perimenopause and poor ovarian function. Therefore, levels of FSH under 10 are best. AMH is also called the “egg timer” as it gives an accurate level of the follicular reserves of the ovaries. AMH levels do not fluctuate throughout a cycle and can be tested at any time. Serum AMH levels decline throughout ones reproductive life cycle, and are undetectable after menopause; therefore, higher levels are more desirable.
  1. Don’t wait too long to consider IVF. If you have been #TTC for more than 9 months and have not become pregnant with regular, timed inseminations, IUI’s or intercourse, make appointments with a fertility clinic and an Integrative fertility specialist. Having a Plan B will decrease stress, and it takes time to consider the financial and medical burdens associated with reproductive technology. However, it is worth it to have that baby in your arms! If IVF is needed, committing to the process earlier in your fertility journey can increase your chances for that #BFP (Big Fat Positive) on your first attempt.
  1. Don’t forget the men! At least 30% of infertility is male factor. Too often one half of the couple is doing everything possible (yoga, clean eating, no caffeine, no alcohol, meditation, support group, acupuncture, etc) while the other half is the root cause of the issue. Getting a sperm analysis is one of the first steps in a fertility evaluation, and can bypass months of angst from non-conception.
  1. Sperm need fertility enhancing supplements too! Omega 3 fats, 15 mg zinc, and stress busting herbs like Maca or Ashwaganda will improve sperm health, tonify libido and boost fertility.
  1. Have your thyroid hormones including TSH, Free T3 and Free T4 and your progesterone levels tested. Low thyroid function leads to low progesterone, which leads to frequent miscarriage in a classic vicious cycle. Some Endocrinologists and Family Docs may have conservative opinions on these levels and may use outdated reference ranges or be unwilling to test for Free T3. Consulting an Integrative Medicine Doc, Naturopathic Doctor or anti-aging Hormone Doctor may give you more information about optimizing your hormone levels rather than operating at a subclinical deficiency.
  1. Consider alternatives to the traditional nuclear family. There are many beautiful babies who want safe, stable, loving homes and need fostering and adoption. I know three amazing families of beautiful fostered babies! There are also women able and willing to carry babies to create families that are not their own. While a biological birth is what we are taught to dream for, this is not the answer for some. Infertility is tragic and real for people who have always assumed they would be able to birth when they are ready. Allow your self to grieve as a couple, but do not close the door on other options even if they seem inconceivable at first.

On another note, childfree living also has many blessings. Our culture is slowly shifting away from the definition of having a (nuclear) family as the ultimate success. Childfree living allows for a more relaxed and abundant lifestyle with more freedom, ability to travel, and heightened romance for a couple. We are an overpopulated planet, and I know from my life, having an auntie that is invested and involved in my life is incredibly valuable. Here are many ways to be a part of a family, and each version needs to be recognized as equally valuable and important!

I could keep typing another ten set of treatments supports, and probably another ten after that,  I am so passionate about fertility! However, as I said earlier the Internet is a rich resource. Some other articles I have written on the topic include:

I wish each of you success on your Holy Grail of Fertility. May your journey connect you to your own Divine nature as you experience one of the great, uncontrollable mysteries of life: Conception!

References

  1. Addition of Dehydroepiandrosterone (DHEA) for poor-responder patients before and during IVF treatment improves the pregnancy rate: a randomized prospective study. Hum Reprod.  2010; 25(10): 2496-500Accessed September 13 2013
  1. Leonidas mamas, Eudoxia Mamas. Dehydroepiandrosterone supplementation in assisted reproduction: rationale and results. Current Opinion in Obstetrics and Gynecology 2009, 21:306-308.
  1. David Meldrum, MD. Aging gonads, glands, and gametes: immutable or partially reversible changes? Fertility and Sterility 2013; 99:1-4.
  1. The use of mitochondrial nutrients to improve the outcome of infertility treatment in older patients. Fertility and Sterility 2010; 93:272-5.

To book an appointment:

http://www.agemanagementcenter.com/contact-amc/  or call 207-774-1356

Clinical Practice:

www.agemanagementcenter.com

www.facebook.com/AgeManagementCenter

For more information about Infertility see:

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LGB Trans HRT ~ New Program, Fresh Vision, New You

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imagesWIDJJQD2The flame of Trans* Health has been burning steadily brighter in my life over the past 3 years. I was keen on the practice while still living and working in Toronto, ON but without a scope of prescribing hormones, my work with the Trans* community was peripheral medicine – acupuncture, restoration of transman fertility, anxiety support etc. I continued to take trainings in the hormone and lab protocols to better understand the medical aspects of transition, without the vision of guiding transition myself.

Once I moved to Maine in 2011, my scope of practice as a ND changed. Naturopathic Doctors have different abilities to prescribe and order diagnostic lab work in each state and province. Most of the west coast states plus British Columbia have full prescribing rights, can do IV therapies, and can act like primary care docs for their patients. In the more conservative middle North America and east coast, Vermont and New Hampshire are the only states/provinces with a full scope of practice. However, for me, from Ontario, the ability to prescribe most hormones and antibiotics was a big change of pace!

I mentored and practice with Dr. Michael Bedecs, an Osteopathic Doctor specializing in hormone therapies for the past  3 years. Under his guidance (plus several conferences on trans health, anti-aging and hormone optimization) I have come to better understand the intricacies of the endocrine system, and how they interrelate through reproductive, thyroid, adrenal, pancreatic and pituitary pathways. All this time, my brain has been making subtle connections in Trans* health, drawing pathways to hormonal optimization the bridges the cultural and gender fluidity required with treating the LGBT community with medical advancements in metabolism, subclinical hypothyroidism, fertility, adrenal exhaustion, cortisol excess, insulin resistance and more.

Dr. Bedecs and I have created a new program called LBGT HRT that includes the dynamic possibilities of gender and hormone variation, bioidentical hormone replacement, transsexual transition and transgender health. We will be offering this through our concierge style practice at Age Management Center in Portland, Maine.

Age Management Center is a cash based practice. We do not accept any insurance plans for visits, medication or laboratory services. Some patients are able to pay for our services through Health Savings Accounts, or get third party reimbursement. Working outside of insurance allows us to provide a standard of care far above  the norm. We offer blood work here in our clinic, at physician pricing. Because we are not limited by the current scope of insurance, we are able to test for and evaluate metabolic parameters that are essential to our complete understanding of hormonal health and wellness.  We spend an average of 90 minutes for first visits, and offer a free 30 minute consult before any commitment is required. Furthermore, within our framework of concierge medicine, each visit is not priced and ticketed; rather, the ongoing support of our doctors, nurses and medical staff is included in the program, allowing you unlimited access for questions, concerns, and follow up until your program is fine tuned and ship shape.

We know this style of medicine is not accessible for all members of the LGB and Trans community. Therefore, I created a monthly sliding scale clinic at Justice in The Body the first Monday of each month from 9am – 12pm to meet the needs of the lower income members of the gender queer and Trans* community here in Portland, Maine, and beyond. This clinic is limited in that a prescribing MD, NP or DO is still required to Rx the Testosterone for FTM and Spironolactone or Cyproterone for MTF; however, I am able to order lab work through insurance in Maine and can work with your prescriber to optimize current hormone protocols and work on supporting the Integrative aspects of general health and wellness that come with transitioning. Many of my patients at the Trans* Health Clinic have been fully transitioned, and we are working on other aspects of preventative medicine and optimized health through the lens of Trans* medicine. I am currently working on expanding the scope of the JITB Trans * Health Clinic by finding a prescriber to work directly with us in house. Stay Tuned!

Follow me on Twitter for Trans* Health @LGBTHRT

Follow me on Facebook for monthly updates about the Trans Health Clinic at JITB

Note: Trans* is a new-ish term. The asterisk denotes that the term is encompassing the entire transgender, transsexual and gender fluid spectrum of individuals without having to write all of that every time.

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Women need Testosterone

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When I say Testosterone, what do you think?

Most people think: men, male. Some people think trans,*  transgender, or FTM. Very few people will think “the most abundant sex hormone across a women’s lifespan and an important sex hormone for all genders.”

All of the above is the correct answer.

Estrogen and Testosterone have been sequestered into gendered boxes, but both are equally important sex hormones for human health. Functional and biologically active androgenic receptors are located throughout the body in both sexes. Testosterone receptors are found in the breasts, heart, blood vessels, digestive tract, lung, brain, spinal cord, nerves, bladder, uterus, ovaries, skin, bone, bone marrow, muscles and fat cells of all women. This wide diversity of receptor locations illustrates the panorama of body systems that rely on adequate levels of testosterone for optimal female  function.

And yet, this important hormone is routinely ignored in women of all ages and especially those in their 30’s and 40’s who are exhibiting signs of testosterone deficiency including: dysphoric mood, muscle loss, cognitive decline, insomnia, breast pain, rheumatic and other pain, incontinence and sexual dysfunction.

Think you might be T deficient? Take our Eve test now! http://www.agemanagementcenter.com/eve-scale/

Around menopause, testosterone and other pro-androgens like DHEA, DHEA-S, and androstenedione become the primary hormones available as estrogen and progesterone levels decline. The ovaries stop becoming the major source of hormonal production, and the adrenal glands take over. As early as 1937, testosterone was used as a successful and important bioidentical hormone replacement option for menopausal women.  Seventy-seven years later, doctors still do not routinely address testosterone deficiency in this population, nor do they even test for it!

Symptoms are not enough to assess hormonal balance. Accurate bloodwork including Total Testosterone, Free Testosterone, Sex Hormone Binding Globulin, Estradiol, Total Estrogen, Progesterone and DHEA-S must be assessed to have a clear picture of hormone health for all genders.

Many endogenous hormones can be converted into other hormones, like Testosterone being aromatized to Estradiol and DHEA-S into Testosterone or Estrogen. Understanding these pathways and monitoring the blood levels over time is the best way to achieve optimized hormone status. No hormone should be ignored based on presenting gender or sex, as it is the delicate interplay of hormones that creates vibrant wellness.

For more information on women and testosterone make an appointment to consult with Dr. Wright now. To schedule bloodwork to assess your testosterone and other hormone levels, call Kristen at 207 774-1356. Free initial consults are available.  www.agemanagementcenter.com

References:

Transdermal testosterone therapy improves wellbeing, mood, and sexual function in premenopausal women. Goldstat, Rebecca MPH1; Briganti, Esther MD2; Tran, Jane MD1;
Wolfe, Rory PhD2; Davis, Susan R. MD, PhD1 Menopause. September 2003 – Volume 10 – Issue 5 – pp 390-398

Testosterone therapy in women: Myths and misconceptions Rebecca Glasera,b,∗, Constantine Dimitrakakisc, Maturitas 74 (2013) 230– 234

Current perspectives on testosterone therapy for women. Susan Davis MB, Bs, FRAC-P, PhD., Sonia Davidson MB, Bs, FRAC-P, PhD.  Menopausal Medicine. Volume 2 0 , No. 2 — Ma y 2 0 1 2

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#TTC Obsession – Confessions

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Getting pregnant is scary and exciting. The process of wanting to conceive and then waiting to find out…. not priceless. I am intimately aware of this as a Naturopathic Doctor with a focus on In/Fertility. I have also been privately preparing for this moment of my late 30’s when I am ready to conceive.  I have treated and supported many women through this process already. And here I am, alone with my OPK stick in the bathroom, discerning the workings of a secret universe. CONCEPTION.

I am amused at my complete immersion in the consuming nature of trying to predict my own ovulation. I cannot believe how often I think of the subject. I am constantly turning the information over in my mind. I read fertility forums online to gather information; I delve into friends’ personal experiences. Medicine looks so different when one is the patient! Suddenly there are a thousand things I do not know… Ovulation Predictor Kits are only the beginning.

And, in the obsession of pregnancy, it becomes everywhere. Books and television remind me that women have been torturing themselves about the ability to get pregnant forever! First, it was conceiving a boy, and whether or not the First Son would be born.  With rampant infertility, the collective obsession has turned to the BFP and away from gender preference.

We want to be able to control this event with every ounce of heart and mind. We are so used to be able to create what we need, if we only put enough effort into the act! It is maddening to have to develop techniques like trust and patience to achieve our highest goal…. and yet that is what it comes down to in the end. Do we hold the ultimate responsibility of whether or not life occurs in our very body?  It is appears to be the hugest responsibility, and yet it is one we cannot. create. on. our. own.  As my friend said yesterday, “We are accomplished and often privileged women! Powerful creations, and yet…” we cannot read what should be the simplest signs of all from our flesh. Are we ovulating today? Are we pregnant? It’s a huge pressure.

For same sex couples and single folks, there is the additional stress of genetic material to procure. The art of conception (often) looks very different for lesbian and gay couples. Not only will the inseminations need to be precisely timed, but the acquisition of said tools of conception must also be arranged. The cost of becoming pregnant begins with the very first try, an additional ingredient in the pressure-cooker of preparation. (In a call-out to women with biologically male partners, I do understand that when women hit the fertility clinics, we are all in the same machine.  The sex or gender of our partner becomes much less relevant although issues of accessibility to and cost of genetic material remains an additional stress.) It’s a wonder any of us become pregnant at all! But we do, in every increasing numbers.

The minute details, test results, and potential scenarios become an endless gerbil wheel of anxiety. It is important to step back from your own fertility and restore some normalcy to your daily routine. I was wound up over the timing of what was only a pre-cycle. Imagine how physically stressed out I could be for the real thing! One of my friends advised me after her first birth – make it fun. Try to relax around it. And she laughed knowing how hard that would be. I suggest distracting yourself as much as possible from thinking the same old anxious thoughts.  HOW? Listen to music that makes you sing. Watch a movie that engages you. Make time for friends or family who you like talking to and who are interesting. Write in a journal so you can get the thoughts out of your head and onto paper. The less time that is spent obsessing about the timing or prediction of said events will be in your best interest overall!

There is no conclusion to the story. The (new brand of) OPK kits wait for next cycle in my bathroom cupboard. I am going to pray for myself, light candles of hope, and continue to make the daily small offerings I do towards pregnancy – high quality prenatal vitamins, DHA essential fats, green tea, and other things appropriate for my personal care. My sweetheart and I also have a plan B, and C in place to rely on. When I get in the hamster mind of prediction anxiety again, please remind me of this post. Stress inhibits Ovulation!

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Improving Libido with Naturopathic Medicine

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Sex, sex drive and inherent libido are all very complex subjects in modern culture, affected by our extremely long TO DO lists tagged onto the ends of busy days. Here is an article I wrote for QueeriesMag.com February 2013 on Naturopathic Medicine to increase sex drive.Let me know what you think!

http://queeriesmag.com/index.php/2013/02/14/on-the-kitchen-table/

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