Medications: too little science, too much art

February 24, 2020

What dose should I take? That has never had a clear answer for me.

As a kid in severe pain, the doctors told me to take 3 ibuprofen. They said they wanted me to take 4, but held back because of my size. I was probably around 14 years old then, and under 100 pounds. The thing is, size isn’t the only way to dose a medication. Oops.

As an adult, something slowly became clear: I need small doses of everything. I’m still not a huge person, but I’m certainly well over 100 pounds, and I react strongly to everything.

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A typical starting dose of melatonin is 1-3 mg. I take 75 mcg! I have empty pill capsules which I use to split capsules that, even at their lowest dose, are too strong for me. I open them up and carefully pour the contents into the empty capsules, dividing each pill into 2 or 3 doses. It’s a pain in the butt, but necessary.

Now I’m taking a compounded hycrocortisone (HC). Since it’s a compound, it’s easy to get any dose I need. You know what isn’t easy? Knowing which dose I need!

A book I trust insists that women should start at 25 mg. Patient groups I trust also say to start at 25-30 mg. My doctor says that 15 mg is the right dose. I started at 15 mg and quickly ramped up to 25 mg. I felt much better. After several months, though, I suddenly gained a lot of weight all at once. My doctor felt it was due to the HC and wants me to lower the dose. Given the way I gained the weight (the timing and location) I have to admit that he’s probably right. I had a few other symptoms, too, which could be related. Still, I was hesitant. I felt good, after all. And while for some medications, blood or other tests will give answers as to a medication’s efficacy and impact, HC messes with adrenal tests and makes the results unreliable. Dosing is based only on symptoms. Oy!

If only there was some way to know what the right dose is!

I decided to lower my dose a bit at least. I went down to 22.5 mg. In less than a week I got my period for the first time in months. I don’t think that was a coincidence. There’s been no change in my weight, but I know from experience that steroidal weight gain is a bitch to reverse, so I’m not expecting it to magically disappear on its own.

I’ve had some other good effects, though. I seem to be sleeping better, and I’m waking up feeling more alert and less fatigued. Hmm. That’s appealing.

The question now is: what do I do next? Do I lower the dose a bit more? Hold it at 22.5 mg because it’s working? Change the timing of the pills? I wish I knew!

Unfortunately, there’s no choice but to experiment. This week I will lower my dose again, down to 20 mg, and see what happens. It might be great. I might feel even better. On the other hand, I could feel a whole lot worse. Unfortunately, there’s absolutely no way to know in advance. I just have to try it.


The help I didn’t know I needed

January 29, 2020

The last week and a half have been really rough. But I’m trying to learn from it.

First there was a minor injury. I’m still not sure how it happened, I just know the pain was intense and different than what I typically experience. That lead to a visit to the doctor followed by an MRI later that day. I was out of the house, in pain, rushing around, for 8 hours. Not surprisingly, between that rough day and the pain, that lead to increased adrenal fatigue.

Here’s where I made my mistake: I didn’t take an extra dose of my adrenal medication on that day when I was in the most intense pain. I didn’t take it on the day of the doctor visit and MRI, either. Nor did I take it in the days following. I kept thinking that if I got some rest, I would be ok. I was wrong. Finally, I took that extra dose two days ago and I am finally feeling like my old self again. I’m still in a lot of pain, but at least the fatigue isn’t dragging me down to the point where I can barely function. I am once again able to answer emails, run small errands, and write this blog post.

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So now it’s time to learn from my mistake. You see, I thought about taking that pill last week, but I dismissed the idea. The fatigue gave me brain fog, and I couldn’t think clearly enough to realize that it was what I needed most. I told myself that I would be ok with some rest even though I should have known from past experience that it wouldn’t suffice.

Meanwhile, I saw my mother twice that week. The second time she commented on how much better I looked. I know I didn’t look that good, so I must have looked truly horrible the first time. Friends who don’t usually check on me were texting daily to ask how I was feeling. Other people knew I was struggling, even if I didn’t see it myself.

So this morning I sent a text message to a few select people: my parents, several friends who are my chosen family, and a couple of other close friends. These are the people I feel are most likely to know when I’m suffering from adrenal fatigue. It started with, “Hey folks, I want to ask a favor.” I went on to explain my mistake in not taking my adrenal medication sooner and why it happened: fatigue leading to brain fog which affects my judgement. Then I continued, “So the favor is simply, when I say that I am struggling with adrenal fatigue, please remind me to consider taking some extra of the medication.”

Ideally, I would make myself a note and leave it someplace that I would see it, but the truth is, when I feel this bad, I won’t see the note. Or I will see it and ignore it. I spent two days doing little except watch tv. I could barely get dressed. In that state, I can’t trust myself to be the only one to look out for me. That is why I ended the message with, “At the end of the day, of course this is my responsibility. But since you are the folks I am most likely to talk to about ongoing symptoms, I wanted to reach out because sometimes I need a bit of help. Thanks for being awesome and supportive in general!”

I think this is something we can, and possibly should, all do. It is especially important for those of us who live alone, or who live with others who are not supportive. Find one or more people in your life who you can trust, and simply ask them to remind you to do a couple of specific things when they see you struggling. Maybe you want to give them a short list, and ask them to send it to you. Maybe, like me, you only want to ask them to remind you of one thing. This isn’t the kind of thing you will ask of everyone you know, but of just a select few who know you well, who support you, and whom you trust.

Part of self-care is asking for help. Today, I took that step. What about you?


Gaslighting’s toll

December 17, 2019

If you had asked me a few weeks ago if I had ever been the victim of gaslighting by doctors, I would have said no. Which is sort of funny, because this blog is full of examples, written over the past 8 years. Somehow, I didn’t see it.

Sure, I knew that doctors had told me that it was all in my head. Or that I was making it up in order to get attention. But that’s not the same thing. Except as it turns out, it is.

My therapist used the word last week as we discussed this topic. As soon as she said “gaslighting” it clicked that yes, that’s what had been happening. A few days later, someone used the word again as they talked about medical professionals. And it all fell into place.

I have dealt with gaslighting by doctors for almost 30 years, so no wonder I get nervous about appointments. No wonder I have an inherent distrust of doctors. It makes sense that on dating apps, I avoid doctors and other medical professionals. It all fits.

The problem is, I still need doctors. I need them to order tests and to write prescriptions. Sometimes, I even need them to help me figure things out. The problem is, I don’t trust them. That’s why I was so surprised by a simple suggestion several weeks ago. I was debating whether or not to take a prescription. My symptoms had gone away before I had been able to start it, and I didn’t want to take it unnecessarily. Talking to my therapist about this conundrum, she suggested that I ask the prescribing doctor for his advice. Wow, I hadn’t thought of that! She wasn’t surprised. I learned a long time ago not to trust doctors. I figure things out for myself as much as possible. Still, in this case it made sense to ask, and I’m glad that I did.

I know there are good doctors out there. Some have them have been incredibly helpful. Not all of them subjected me to gaslighting. But just like I clearly remember the time I backed into a telephone poll while parking last month but have completely forgotten the dozen other times I parked in that same spot without hitting the poll, it’s the doctors who treated me badly who stand out most in my mind. They are the ones that scare me, that put me on edge, even when I know I still never see them again.

Sadly, I am not alone. There are many of us who have been subjected to this horrible treatment. It is no wonder so many of us distrust doctors and the overall medical system. I am now working on this with my therapist. I will never undo the damage that was done to me physically by ignoring my symptoms, but maybe one day I will have just a bit more trust in medical professionals? Maybe. Until then, if you have been, or are currently being, gaslit by your doctor, know that you’re not alone. And if you can, find someone better.


How my doctors’ office lost their phlebotomy lab

November 29, 2019

I emailed my doctor a reminder that I needed to have some blood tests repeated. When I first started going to that office, I lived less than a mile away. On days that I felt well enough, I walked there. Now I live a 30 minute drive from there, so it’s harder to get blood work done. That’s why I figured this was good timing; I had an appointment the next day with another practitioner in the office. I wasn’t prepared for my doctor’s response. It basically said, the order is in the system but they no longer have a phlebotomy lab, and it listed some other places I could get my blood draw.

WTF?

The next day, I saw the other practitioner and I asked about the loss of the phlebotomy lab. Was it temporary? Why on earth would a medical facility no longer have the ability to draw blood?

Her answer was simple and terrible: it was not considered cost effective by the hospital that was now in charge.

Several years ago, this independent facility became part of a local hospital system. This happens a lot in my area. For me this was good in some ways, because now they took my insurance, while they had not previously. On the other hand, the doctors lost some of their independence. Where before they referred patients to the best doctors they knew of, now there was pressure for all referrals to be within the hospital network. Not exactly putting patients first, were they?

This year, that hospital joined another hospital network. The hospitals are now separate, but connected. The new hospital network is bigger, though, and has more power. And the new network says that the phlebotomy lab is not cost effective. It’s not worth the money, even though it’s important for the care of the patients. How does that make sense? Isn’t the entire point of this building to provide care to patients? Apparently not.

My doctor had giving me a list of alternate places to get my blood drawn. Unfortunately, it was an additional two weeks before I was able to get to any of them. I have a car and am often mobile. Several years ago when I could barely leave the house more than two or three times each week, this would have cost me more. Some people don’t have cars, which will make many of these locations harder to access. For some, it will be impossible. What will happen to them? What will happen to all of us, as hospitals continue to make decisions that favor the bottom line over patients?

Because that wasn’t the only bad news. My practitioner also told me that the hospital is considering moving the entire staff of that building. The new location would be nearby, but due to traffic, it would be much harder for me to access. Due to less public transportation access, it would be impossible for others to access. The reason they are considering this is because it’s cheaper. The office has occupied this building for many years. However, it is now considered prime real estate, and the hospital would rather get more money by moving everyone. Maybe this will work out ok, but I do wonder what will happen to the many patients who rely on these excellent doctors and who can not get to the new place. Have they been taken into consideration at all?

This situation isn’t unique to this one office. We are seeing it more and more. There are cutbacks in all kinds of areas. What will be next? And what kind of impact will it have?

Have you experienced medical facilities prioritizing money over patients? Please share it in the comments.


Was it all Celiac to begin with?

November 16, 2019

The earliest potential Celiac symptoms I remember began when I was 12. The first time a doctor suggested that I go gluten-free I was 32. Hmm. A bit of a problem there?

I went to the doctor for the extreme constipation I had as a child. I drank a lot of disgusting prune juice and still had rare, difficult, painful poops. Eventually that seemed to resolve itself. End of discussion.

A year or so later I had unexplained joint pain. I was told it was tendonitis for a long time but even the doctors had to admit that didn’t seem to fit the type of pain I had. I was told to wear braces on my wrists. The pain came and went. They didn’t know what else to do. I spent many years trying to figure out this pain but as far as they were concerned, the discussion was over.

As a teen I had horrible stomach pains, nausea, and diarrhea but had no idea how abnormal this was and told no one for several years. Eventually I did talk to a doctor. I asked to be tested for lactose intolerance. I was told there was no such test (a lie!) Instead, the doctor told me to keep a food and symptom journal. After a few weeks I gave him my notes. He told me that he showed it to a nutritionist and that it wasn’t lactose intolerance. End of discussion. No further examination of my obvious problems. A few years after that I was diagnosed with irritable bowel syndrome. I did some research and saw that my symptoms didn’t quite align with IBS, but it was the only diagnosis I was given, so I went with it.

Later in my teens I was far too thin. I occasionally skipped dinner. I was diagnosed with anorexia despite the fact that I ate breakfast, lunch, and snacks every day, I only skipped dinner 2-3 times per week at most, I had digestive problems, and I was so alarmed by my own weight loss that was the one who went to my parents with a concern that something was wrong and asked to see a doctor. The doctor put me on a high calorie diet. I eventually gained a little weight. End of discussion.

Around this time I was diagnosed with depression. I was sent to therapy that did nothing. I was put on anti-depressants with horrible side effects. After less than a year I was taken off of the medications. The depression was magically gone. End of discussion.

And lest anyone think that my medical history fell through the cracks, all of this occurred at one medical facility, where all of the doctors could see all of my records. How did they all miss this?!?

Was this necessarily Celiac disease? No, of course not. But when a child has constipation, diarrhea, weight loss (I was down to 89 pounds! I’m short, but I should never have lost that much weight – I should have been at least 100-105 at that point), joint pain, depression, nausea, stomach pain, and more, how did they not at least consider this possibility?!? This was the 1990s and while Celiac wasn’t as well known then as it is today, there was plenty of awareness. The doctors should have known.

An interesting thing has happened in recent weeks. After some time on hydrocortisone, my brain fog has been lifting and I am thinking more clearly. I have less fatigue. With that layer of haze lifted, I can better feel and understand what is happening with my body. I can think it through more clearly. And I wonder if maybe all of my problems actually stem from Celiac disease.

As regular readers of this blog know, I have a long list of diagnoses. But the thing is, a lot of them are comorbidities with Celiac. Many others are known to be secondary or tertiary issues. For example, I have polycystic ovary syndrome, but after many years of struggling with PCOS symptoms, they finally went away once I was on a proper dose of the right thyroid medication and fully gluten free. I now get my period at least every other month and I rarely have super heavy bleeding. I was recently diagnosed with SIBO, but it’s known that small intestinal bacterial overgrowth is more common in folks with Celiac. My digestive issues, aside from some SIBO symptoms, have all completely resolved now that I am 100% gluten free. I still have constant joint pain, but it has improved greatly thanks to treatments and, I suspect, being gluten free. My adrenal fatigue, one of my most disabling conditions, was caused by long term chronic illness. My Hashimoto’s thyroiditis is a comorbidity with Celiac.

All of this makes me wonder, what if I had been diagnosed with Celiac at age 12 (or younger)? If I had gone gluten free back then, could this have been avoided? Maybe the joint pain would have resolved. Maybe Hashimoto’s would never have developed? Mostly likely, if the Celiac and Hashimoto’s (if I even had it) had been treated properly to begin with, adrenal fatigue would have never begun. That means I would have never become too disabled to work.

That’s hard to think about. This was avoidable. Somewhat. I would still have had problems, of course. I would still have had to avoid gluten, which would have probably been a lot harder as a child in the 1990s than as an adult in the 2010s. I would have still gotten glutened and had to deal with the fallout. I would still have had autoimmune disease and would likely have had some fallout from that; some folks with Celiac feel fine, but others don’t. My health would not have necessarily been perfect. But it would have been a lot better.

This is only speculation of course. I can’t be sure that all of my health issues stem from Celiac. Over the years I have had several other theories about how my health issues all connect. Each one has felt closer to the truth, and this one does as well. I don’t know if I’m right, but I suspect that I’m at least close.

We need better screening here in the U.S. and around the world. Estimates of folks with undiagnosed Celiac are high, as much as 90%. I don’t want to see others live with what I have had to live with if it can be avoided. And I’m one of the lucky ones; some folks die from undiagnosed or late diagnosis of Celiac. If you or someone you know has several of the 300+ Celiac symptoms, please consider testing. You can see a shorter list here, but it is missing a lot of categories. And if you have experienced something similar to what I have described, please comment below. It is important to gather these stories in order  to highlight the need for more testing and awareness.


Would it be different if I weren’t a woman?

August 21, 2019

I started a new medication. My doctor and I had discussed beforehand that the dose I wanted based on my research was higher than what he suggested. We agreed I would start at his level, then go up only if needed.

For the first two days I felt absolutely horrible. I increased the dose and felt less bad. I increased more and felt better. So I stayed at the higher dose for a bit. It still wasn’t having the effect I had hoped for, but I needed more time, and the higher dose meant my prescription would run out early. I messaged my doctor to get a new prescription.

My doctor said he didn’t remember discussing the higher dose and thought I should be on a lower one. We went back and forth several times in email. I was anxious: challenging doctors can be problematic. I don’t want to be considered a “difficult” patient. I want my doctor to like me so he’ll help me more. Many doctors dislike being questions. Many people dislike being questioned in general, of course, but doctors often have big egos, and are treated like they know it all.

As I talked to my therapist about my anxiety, I discovered two interesting things. First, she helped me connect my anxiety to the way some medical practitioners had treated me in the past. It all made sense when she connected the dots. In fact, it seemed obvious, but I hadn’t seen it.

Second, as I spoke, I said that this wouldn’t be a problem if I were a man. I didn’t even realize I was thinking that; it just popped out of my mouth. And the instant it did, I knew it was true. I had an imagine of the conversation I’d had with my doctor in his office when he prescribed this medication. I thought about how I presented my own research and his reaction to that. He wasn’t entirely dismissive, but he didn’t really consider it, either. And I felt that if I were a man, he would have actually listened to me and considered the merits of what I presented.

Am I right? Who knows. I can’t test this. But here’s what I do know: it is documented that women and men are treated differently by medical professionals. You can read about it here and here, among other places. Sometimes I wonder if this entire journey would be different if I were a man. I’m not saying men have it easy. They are often maligned for “giving in” to symptoms, and they are discouraged from expressing and dealing with the complicated emotions that come from living with chronic illness. Still, I wonder. Would I be taken more seriously? Would I get of the tests I request, less resistance to the treatments I want to try? Would a doctor still have refused to give me a medication in my late 20s because it would cause infertility, even though I told her I was willing to risk it?

Obviously, I have it easier in many ways, too. I am cisgender, petite, white, and well-spoken. That gets me farther in a lot of situations, including medical settings. I am bisexual, but most doctors don’t know that, just as most don’t know that I am Jewish. Still, this question about gender weighs on me.

I am curious, what experiences have you had in medical settings that you think may have been different if you presented as a different gender? I’d love to hear about them.


Acknowledging the pressure

July 23, 2019

“You’re feeling a lot of pressure.” When my therapist said those words, everything clicked into place. Yes! That’s what I was feeling and unable to acknowledge for myself, much less express to her, but she figured it out. And suddenly, it all made sense.

It’s hard enough to feel ill all of the time, but I also feel responsible for how I address my illnesses. I go to 5 different doctors and get 6 different opinions. I do my own research and figure out a course of action, but no doctor will order the tests I want or the prescription that I feel will help. I try to sort through all of the possibilities, the research, the unknowns, the assumptions, the inconclusive data. I talk to experts and I ask questions of other patients. I look at as many resources as I can. But at the end of the day, it’s up to me, and me alone, to decide what to do.

That’s a lot of pressure!

I want to feel better. I want to feel as well as possible. I don’t know what that is. Would that mean I was well enough to walk 3 miles? To finally get and care for the dog I’ve always wanted? To attend a wedding without having to leave early? To go out 3 nights in a row without becoming so ill that I can’t function for days afterwards? What is a reasonable goal? I don’t know. No one knows. But still, I aim to feel better, whatever that might be.

And as I aim to feel better, I must make myriad decisions. It’s scary and overwhelming. I have a bit one coming up in a day and a half and yes, I am overwhelmed and scared. I have a lot of research to do between now and then. I worry that my doctor might not agree with the approach I want to take or vice versa. I could be wrong. I won’t know until I try this new medication. This is my health, my one and only body, my life. If I get this wrong, there are no do-overs. The result would be damage that is likely irreversible. On the other hand, doing nothing will also result in irreversible damage, which means I have to do something. And I am the only person who can ultimately decide what that something will be.

So yeah, that’s a shit-ton of pressure. And I hate it. At least now I recognize it for what it is. I am learning to sit with my feelings. Still, the pressure is intense and it’s real. This is my life that I’m deciding about. I hope I make choices that improve it.


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