Category: TRAINING

It’s happened to so many people who menstruate: you’re going about your life until you realize that you just got your period. The ungainly scramble to find a restroom and the fervent prayer that you packed a menstrual product leaves you feeling anxious, vulnerable, and exposed. This is compounded by the fact that our society stigmatizes menstruation — or really, anything to do with a uterus — and a taboo hangs over these discussions.

This scenario is far worse if you are one of the nearly 22 million women living in poverty in the US who cannot afford menstrual hygiene products, a problem known as period poverty. One study in Obstetrics & Gynecology demonstrated that 64% of women reported ever having difficulty affording menstrual products, such as pads, tampons, or reusable products like menstrual cups. And 21% reported that they were unable to afford these products every month. People who are homeless or incarcerated are at particularly high risk of not having access to adequate menstrual hygiene products.

Why are period products a luxury?

Menstruating is a basic fact of human existence. Menstrual hygiene products are necessities, not luxuries, and should be treated as such. Unfortunately, food stamps and subsidies under the WIC (women, infants, and children) program that help with groceries do not cover menstrual products.

I have had patients tell me that they use toilet paper or paper towels instead of pads or tampons because they cannot afford menstrual products. People with heavy periods requiring frequent changes of these products particularly face financial challenges, as they must buy even more pads or tampons than the average menstruating person. If they try to extend the life of products by using them for multiple hours at a time, they can wind up with vulvar irritation and vaginal discomfort. They may also be at greater risk for toxic shock syndrome, a life-threatening infection.

Why is it important to talk about stigma around periods?

We need to address stigma around menstruation in order to understand and fix the challenges people face around access to menstrual hygiene products. Period poverty is real. Period equity should be real, too. Embarrassment or taboos may prevent people from advocating for themselves, but if that stigma is removed — or even eased by talking through these issues — we as a society can move forward to address the needs of half of our population. There is no equity when half the population bears the financial and physical distress as a consequence of the reproductive cycle needed to ensure human survival.

How can we address period poverty?

There are simple solutions to period poverty. The first is to eliminate the tax on menstrual products. Think about it: just as food, a necessity for all of us, is not taxed, menstrual products should not be taxed. Products that are reusable, such as menstrual cups or underwear, should be subsidized, and their use encouraged, to eliminate excess waste from individually wrapped pads and tampons. If these products are publicized, promoted, and affordable, more women may opt for them. Pads and tampons should be available free of charge in schools and federal buildings (note: automatic download).

Finally, you can take action: write to or call your legislators! There is a fantastic bill, Menstrual Equity For All Act of 2019, sponsored by Representative Grace Meng, that was introduced on March 26, 2019, but never received a vote. There is no good reason why this bill, which would allow homeless people, incarcerated people, students, and federal employees free access to menstrual hygiene products, was never even brought forward for a vote. We live in one of the world’s wealthiest countries, and lack of menstrual hygiene products should never impact someone’s ability to work or go to school. It’s time to stop treating people with a uterus as second-class citizens.

About the Author

Huma Farid, MD, Contributor

Dr. Huma Farid is an obstetrician/gynecologist at Beth Israel Deaconess Medical Center, and an instructor in obstetrics and gynecology at Harvard Medical School. She directs the resident colposcopy clinic and is the associate program director for the obstetrics and … See Full Bio View all posts by Huma Farid, MD

Let’s not kid ourselves: the pandemic is still with us, despite how it may sometimes seem.

Increasingly, people are going back to work in person. Schools reopened this spring. And mask mandates are history in most parts of the US. In many places, case rates are falling and deaths due to COVID-19 have become uncommon. For many, life now closely resembles pre-pandemic normalcy. So, what do you need to know about where we are now?

Not so fast: COVID remains a big problem

The virus is still very much with us, not behind us. According to the CDC, in the US there are nearly 100,000 new cases (likely an underestimate) and around 300 deaths each day due to COVID as of this writing. Despite this, more and more people are paying less and less attention.

That could be a big mistake. With summer travel season here and some dire warnings about fall and winter, it’s worth stepping back, taking a deep breath, and reassessing the situation.

Here are responses to five questions I’ve been hearing lately.

1. I haven’t gotten COVID by now. So, do I still need a vaccine?

Yes, indeed! Vaccination and boosters are the best way to avoid a severe case of COVID-19 infection.

Maybe you’ve been spared infection so far because you’ve been vigilant about physical distancing, masking, and other preventive measures. Or perhaps you’ve inherited genes that make your immune system particularly good at evading the COVID-19 virus. Or maybe you’ve just been lucky.

Regardless of the reason, it’s best not to let your guard down. The SARS-CoV-2 virus that causes COVID is highly contagious, especially the most recent variants. And while some people are at higher risk than others, anyone can be infected and anyone can become seriously ill from this virus. Even if you get a mild or moderate case of COVID-19, remember that some people experience symptoms of long COVID, such as fatigue and brain fog.

2. More and more vaccinated people are getting sick with COVID. And I’ve heard that more COVID-related deaths have occurred since vaccines rolled out than before they were available. So, how much of a difference do vaccines and booster shots really make?

They make a huge difference.

It’s estimated that COVID-19 vaccinations have saved more than two million lives in the US. If vaccination rates had been higher, estimates suggest more than 300,000 additional lives could have been saved.

We know that rates of infection, hospital admission, and death dropped dramatically among vaccinated people soon after vaccines became available. We also know that most severe cases of COVID-19 among the vaccinated occur among people who haven’t had a booster shot. Overall, severe cases and deaths remain much lower among people who are vaccinated and boosted than among people who are not vaccinated.

Is it true that the share of severe COVID cases and deaths occurring among the vaccinated has risen? Yes, but possible explanations for this trend actually show that vaccines continue to protect people from serious illness:

• When rates of infection fall, overall rates of hospital admission and death fall for everyone, vaccinated or not. So, the gap between rates of infection and death between vaccinated and unvaccinated people gets smaller.
• Available vaccines aren’t as effective against new variants of the virus. True, but these vaccines still effectively reduce the risk of severe disease.
• Immunity wanes over time. That’s true for even the best vaccines, which is why boosters are needed. Yet only about a third of the US population has received a COVID booster. That makes it easier for the virus to continue to spread and mutate.
• We’ve now logged more time with vaccines than without them since the pandemic began. Because no vaccine is 100% effective, the numbers of cases and deaths will continue adding up, eventually outnumbering pre-vaccine cases and deaths.

3. First, vaccines were going to solve this. Then we needed one booster shot. Now we need two. What’s happening, and why should I even consider this?

Good questions. The protection provided by most vaccines tends to wane over time. That’s why tetanus shots are recommended every 10 years. We’ve learned that protection against COVID-19 may wane a few months after the initial vaccine doses. A first booster is recommended for everyone who is vaccinated, five months after completing the two-dose Moderna or Pfizer vaccine series or four months after the single-dose J&J vaccine.

Because immunity from the first booster may wane sooner in older adults and people with certain health conditions, another Pfizer or Moderna vaccine dose is now available to those over age 50 and others at particularly high risk.

4. Now that mask mandates are in the rearview mirror and everyone is tired of COVID restrictions, what else helps?

It’s not yet clear that mask mandates should have been lifted as soon as they were, especially when rates of infection were starting to rise again. We’ll only know in retrospect if that was a good idea.

As for other measures, physical distancing, masking up, and other steps still make sense in certain situations. For example, if you’re using public transportation or traveling by air, a well-fitted mask can provide a measure of protection. If you’re regularly exposed to a lot of people and know you will soon be in close contact with someone who is at high risk, mask up and get tested in advance.

5. What’s the bottom line here?

Get vaccinated! If you’re eligible for a booster, get one. It makes no sense to get the initial vaccine and forego boosters. If you’re one of very few people who had a significant reaction to one type of vaccine, ask about getting a different type of vaccine as a booster.

When the pandemic began, few were expecting that more than two years later it would still be causing so much suffering and death. But we shouldn’t pretend it’s over; don’t throw out your masks just yet and do follow public health recommendations. If you’ve decided not to get vaccinated or boosted, think again (and again)!

Yes, we’ve all had it with the pandemic. But I think of it this way: when it looks like rain, throwing out your umbrella and pretending it’s sunny are decisions you’ll probably regret.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

By now, you’ve probably heard that there is a monkeypox outbreak traveling around the globe. Cases have spread far and wide, including in the US, Canada, Europe, and Australia. It’s the largest outbreak ever recorded outside of western and central Africa, where monkeypox is common.

But controlling this outbreak demands preventive measures, such as avoiding close contact with people who have the illness and vaccination. One method of vaccination, called ring vaccination, has worked well in the past to contain smallpox and Ebola outbreaks. It may be effective for monkeypox as well.

How can monkeypox be contained?

According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization, monkeypox is unlikely to become a pandemic. At this time, the threat to the general public is not high. The focus is on identifying possible cases and containing the outbreak as soon as possible.

Three important steps can help stop this outbreak:

1. Recognize early symptoms

• Usually, early symptoms are flulike, including fever, fatigue, headache, and enlarged lymph nodes.
• A rash appears a few days later, changing over a week or two from small flat spots to tiny blisters similar to chickenpox, then to larger, pus-filled blisters.
• The rash often starts on the face and then appears on the palms, arms, legs, and other parts of the body. If monkeypox is spread by sexual contact, the rash may show up first on or near the genitals.

2. Take steps to stop the spread

• Monkeypox spreads through respiratory droplets or by contact with fluid from skin sores.
•  Anyone who has been diagnosed with monkeypox, or who suspects they might have it, should avoid close contact with others. Once the sores scab over, the infected person is no longer contagious.
• Health care workers and other caregivers should wear standard infection control gear, including gloves and a mask.
• In the current outbreak, many cases began with sores in the genital and rectal areas among men who have sex with men, so doctors suspect sexual contact spread the infection. As a result, experts are encouraging abstinence when monkeypox is suspected or confirmed.

3. Use vaccination to help break the chain

• Monkeypox is closely related to smallpox. People who received a smallpox vaccine in the past may have some protection from monkeypox. (The US smallpox vaccination program was discontinued in 1972, and smallpox was declared eradicated worldwide in 1980.)
• Stockpiled smallpox vaccinations and newer vaccines that can be used for monkeypox or smallpox are also available.

Ring vaccination

Monkeypox differs from the virus that causes COVID-19. People with monkeypox usually have symptoms when they’re contagious, and the number of infected persons is usually limited.

This means it’s possible to vaccinate a “ring” of people around them rather than vaccinating an entire population. This selective approach is called ring vaccination.

Ring vaccination has been used successfully to contain smallpox and Ebola outbreaks. It may come in handy for monkeypox as well. Here’s how it works:

• As soon as a case of monkeypox is suspected or confirmed, the patient and their close contacts are interviewed to identify possible exposures.
• Vaccination is offered to all close contacts.
• Vaccination is also offered to those who had close contact with the infected person’s contacts.

Ideally, people should be vaccinated within four days of exposure.

This approach requires widespread awareness of monkeypox, rapid isolation of suspected cases, and an efficient contact tracing system. And of course, vaccines must be available whenever and wherever new cases arise.

Are the vaccines used for monkeypox effective?

According to the CDC, the smallpox vaccine is 85% effective against monkeypox.

While a newer vaccine (JYNNEOS) directed against monkeypox and smallpox has only been tested for effectiveness in animals, it is also expected to be highly effective in humans.

Of course, vaccinations can only work if people are willing to receive them. We’ll learn more about this as more people are offered the option for vaccination.

Are the vaccines used for monkeypox safe?

As with most vaccines, the most common side effects include

• sore or itchy arm at the site of the injection
• mild allergic reactions
• mild fever or fatigue.

Fortunately, more severe side effects, such as significant allergic reactions, are rare.

The bottom line

In light of the current monkeypox outbreak, you may soon be hearing more about ring vaccination. Then again, if appropriate measures are taken to prevent its spread, this outbreak may soon be over. Either way, this won’t be the last time an unusual virus shows up seemingly out of the blue in unexpected places. Climate change, shrinking animal habitats, rising global animal trade, and increasing international travel mean that it’s only a matter of time before this happens again.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, and rates are rising, particularly in adults ages 20 to 49. Unfortunately, approximately 30% of eligible people in the US still have not been screened for CRC.

Colon cancer may be prevented with screening tests that look for cancer or precancerous growths called colon polyps.

When should you start screening?

The United States Preventative Services Task Force recommends starting screening for CRC at age 45 for average-risk patients. These guidelines reflect the most up-to-date research on when risk for colon cancer begins to increase.

Average-risk patients are those with no personal or family history of colon cancer or a genetic condition that increases the risk of developing CRC. For this reason, it is important for patients to share their family history, including all cancer diagnoses in blood relatives, with their primary care doctor, who can help decide the right time to begin colon cancer screening.

High-risk patients are advised to begin screening before age 45. A primary care physician can help determine when and how a patient who is concerned about their risk level should be screened for CRC. Patients who have a history of CRC or polyps; a first-degree family member with CRC or advanced polyps (those that would have gone on to become CRC if they had not been removed); a family history of certain genetic syndromes; or a history of inflammatory bowel disease (like Crohn’s disease or ulcerative colitis) are some examples of high-risk factors.

What are the options for CRC screening?

Colonoscopy: Colonoscopy is the gold standard of screening tests, and identifies approximately 95% of CRC. It is also the only method that allows a gastroenterologist to both detect and remove potentially precancerous colon polyps. Colonoscopies are considered low-risk procedures, but they do have a small risk of bleeding and perforation that increases in older age groups.

Patients need to clean out their colon prior to the procedure by drinking a colonoscopy prep, which washes stool out of the colon so that it can be properly assessed during the procedure. The prescription instructions for the prep are provided by the gastroenterologist’s office.

In most cases, the procedure will be performed under sedation to ensure the patient is as comfortable as possible. It is important to note that patients are not placed under general anesthesia, but most remain sleepy and comfortable throughout their colonoscopy.

During the colonoscopy, a gastroenterologist will insert a flexible tube with a camera at the end, called a colonoscope, into the rectum. The entire colon is then carefully examined. If no polyps are detected and the preparation (cleanout) of the colon is adequate, a repeat a colonoscopy is suggested in 10 years. If polyps are detected, or the patient’s risk level or symptoms change, this interval will be shorter.

FIT testing: The fecal immunochemical test (FIT) is a lab test that looks for hidden blood in the stool. Patients use a kit to collect their stool and then use a probe to scrape the stool, which is then placed into a tube and mailed to the lab. FIT testing is repeated every year. A drawback of FIT testing is that it has a false positive rate of approximately 5%. It can effectively rule out CRC with 79% accuracy. FIT testing is noninvasive, convenient, and cost-effective, making it an acceptable alternative to a colonoscopy for many people. If a stool test is positive, a colonoscopy is needed to evaluate the reason for the positive test.

Flexible sigmoidoscopy: A flexible tube with a camera is used to look at the rectum and the lower part of the colon. The advantages of this procedure are that it is faster than a colonoscopy (only 5 to 15 minutes) and requires less aggressive laxative medications. Typically, patients receive a flexible sigmoidoscopy every five years if no polyps are detected. As this test does not examine the whole colon, it cannot detect cancers or polyps in the unexamined portion. At best, it can detect 70% of cancers and polyps. If an abnormality is detected, a follow-up colonoscopy is needed to look at the entire colon.

CT colonography: A CT scan is used to visualize your rectum and entire colon. Just like with a colonoscopy, patients need to take laxative medications the night before to empty the colon. A small tube is placed in the rectum to expand the colon to get clear pictures. This test may be useful for patients who cannot tolerate anesthesia or have other medical conditions that prevent them from having a colonoscopy. A drawback of CT colonography is radiation exposure, and finding unrelated abnormalities outside the colon that can lead to unnecessary tests. While CT colonography is about 88.7% accurate at finding certain polyps, it is less accurate than colonoscopy overall. If the CT colonography result is abnormal, a colonoscopy is required for full evaluation of the colon.

Cologuard: This is a test where patients collect their stool, scrape it with a probe, insert it into a container with preservative, and mail it to the lab. This test looks for atypical DNA, or traces of blood in the collected stool that may be suggestive of precancerous polyps or CRC. Typically, patients repeat the test every three years. If the Cologuard test is positive, a colonoscopy is necessary for further evaluation. However, Cologuard’s accuracy is still limited; 13% of the time the test indicates the patient may have cancer when they do not. In 2019, a study showed that annual FIT testing or colonoscopy may be more effective and less costly than Cologuard. Further research is ongoing to evaluate how accurate (and thus how useful) this test is at detecting CRC.

Which screening option should you choose?

The most important part of colon cancer screening is to have a screening test performed. For most patients, colonoscopy or FIT testing are the most common ways to screen for colon cancer. However, there are other options to consider if you are unable to undergo or are uncomfortable with colonoscopy or FIT testing. Ultimately, this is an important and personalized decision, and a discussion for a patient to have with their healthcare provider, so that the right test can be done at the right time.

About the Authors

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

In the spring of 2020, the pandemic catapulted many of us into shock and fear — our lives upended, our routines unmoored. Great uncertainty at the onset evolved into hope that, a year later, a semblance of normalcy might return. Yet not only do people continue to face uncertainty, but many of us have also reached a plateau of fatigue, resignation, and grief.

We are living through a time of widespread illness, social and political unrest, economic fractures, and broken safety nets. Whether each of us experiences the ravages of this time close to home or as part of a larger circle, the symptoms of collective trauma are widespread. Many of these symptoms — feeling overwhelmed, anxious, fatigued — may be familiar. One deserves special mention: numbness. As a psychiatrist who has considerable experience treating refugees suffering from trauma, and an author and teacher who works with collective trauma, we have learned a great deal about how numbness affects us all.

Newsfeeds: Friend or foe?

Compounding our challenges are our news viewing habits. During times of uncertainty, we are each, in our own way, experiencing vulnerability. Fears that had lain dormant for years may be activated, causing low-grade stress or full-blown anxiety. These fears are exacerbated by what might be called the “toxic trauma story” churned out by mainstream news channels.

The formula is simple: brutal facts associated with high emotion attract viewers. As the old adage says, “If it bleeds, it leads.” Negative news around vaccine reactions or political unrest provides the ultimate sensational content for viewers. But for most Americans, this daily onslaught of negativity exerts a toll on mind, body, and emotions.

Numbness is one possible response to trauma

When a situation is overwhelming, your body protects itself by entering a “fight, flight, or freeze” mode. Our responses to the pandemic and continuous uncertainty, fueled by doomscrolling and newsfeeds, range from hyperactivation (fight or flight) to numbness (freeze). While the three Fs refer to the body’s stress response in the moment, these reactions can continue long after exposure to trauma.

In medical terms, numbness occurs when nerves are damaged, leading to partial or total loss of sensation in the body. We can also describe numbness related to our psychological well-being: a lack of enthusiasm and interest in life, a sense of apathy and indifference. The spectrum ranges from mild apathy to disassociation to a heavy, weighty lethargy, which is often a symptom of severe depression. “Freeze” refers to a paralyzed or frozen state associated with post-traumatic stress disorder (PTSD) and major depression. We have each worked with thousands of people — some refugees, some not — who have experienced this level of trauma.

The numbness many people are experiencing and describing these days didn’t necessarily begin with the pandemic, nor is a toxic stream of trauma stories the only source feeding it. It may have been there for many years, only to be triggered by recent personal and societal challenges.

This numbness is not just a lack of feeling; its symptoms vary. You might feel a low level of anxiety operating in the background, much like an operating system running our computers silently. You may feel no emotion or a sense of frozenness during the day, followed at night by insomnia or nightmares. Some people who are refugees cannot watch the daily news, since it is a terrifying trigger that floods them with memories of their past traumas.

How does numbness affect us collectively?

Millions of people turn to their phones and devices for daily notifications of traumatic news. These instantaneous alerts offer little space for digestion and reflection. That harmful combination of speed and trauma can strike at our nervous systems, overwhelming us until we are too numb to comprehend the complex range of experiences flooding in over the last days, weeks, and years. What happens to us as a culture, grappling with this cumulative phenomenon?

Where collective trauma now exists, we need to seek ways to facilitate dialogue and restoration. The numbness following traumatization reduces our capacity to witness suffering. We lose our reflective capacity to be self-aware, which reduces empathy and compassion. Indifference and disconnection can contribute to further atrocities, fueling a feedback loop that makes new traumas more likely to occur.

Collective numbness can surface as epidemic substance misuse; food, sex, or entertainment addiction; media overuse; or in other ways. It reveals itself as a collective shutting-down to crisis, which can derail healing.

How can you counter numbness and feeling overwhelmed?

As individuals, we can spend more time practicing self-care, as outlined in the Harvard Program in Refugee Trauma toolkit. For example, take time to reflect on the resources and sources of support you have in your life. Spend quality time with family, and if possible, in nature. Set boundaries on news devices to give your nervous system a chance to relax. Turn off your notifications, leave your phone far from your bedroom at night, and consider periodic news fasts to give your system a full recharge.

Developing a mindfulness practice can help reduce stress, allowing people to digest and integrate hidden emotions or experiences buried under numbness. One option is a practice called 3-sync: imagine a journey of witnessing yourself, moving deliberately as you notice the state of your body first, then your mind, and finally, your emotions. Following this during meditation can help you become aware of imbalances within yourself, as well as areas of strength and vitality. Another practice, global social witnessing, is a conscious process of witnessing the news, and digesting it with our minds, bodies, and emotions fully present.

By working together to be with whatever is present, acknowledging and feeling our discomfort, resistance, and pain, we may move closer to integration and a sense of healing during this time of upheaval.

About the Authors

Richard F. Mollica, MD, Contributor

Dr. Richard F. Mollica is a professor of psychiatry at Harvard Medical School, and director of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital. A pioneer in international research on refugee trauma, he … See Full Bio View all posts by Richard F. Mollica, MD

Thomas Hübl, Guest Contributor

Thomas Hübl is a renowned teacher, and author of Healing Collective Trauma: A Process for Integrating Our Intergenerational and Cultural Wounds. Since 2002, he has led dialogue and restoration processes around collective trauma with more than … See Full Bio View all posts by Thomas Hübl

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

It’s an old line: everyone complains about the weather but no one is doing anything about it.

But if you’re a person with bad allergies or asthma, stormy weather can be more than an annoyance; it can be a serious threat to your health. “Thunderstorm asthma” was first reported in the 1980s in England and Australia, and cases continue to crop up. Just after severe thunderstorms passed through Melbourne, Australia in 2016, more than 9,000 people sought urgent medical care for asthma during one notable event. Medical facilities were overwhelmed and at least eight people died. That’s unusual, but if you do have asthma — or seasonal allergies, as it turns out — understanding this trigger can help you stay well.

What is thunderstorm asthma?

The term describes an attack of asthma that starts or worsens after a thunderstorm. It can occur in anyone with asthma, but it most often affects people with seasonal allergic rhinitis, which many people know as hay fever or allergies. Heralded by a runny nose, sneezing, and itchy eyes, seasonal allergies are often worst in the spring, summer, or early fall.

Rain tends to lower pollen counts by cleansing the air, and many people find that rainy weather tends to reduce asthma symptoms triggered by allergies. But thunderstorms can make asthma worse because of a unique sequence of events:

• Cold downdrafts concentrate air particles, such as pollen and mold
• These air particles are swept up into clouds where humidity is high
• In the clouds, wind, humidity, and lightning break up the particles to a size that can readily enter the nose, sinuses, and lungs
• Wind gusts concentrate these small particles so large amounts can be inhaled.

What raises risk for experiencing thunderstorm asthma?

According to a new study in the Journal of Allergy and Clinical Immunology, a whopping 144 out of 228 people with seasonal allergies reported experiencing thunderstorm asthma — that’s 65%! And many of the asthma attacks set off by thunderstorms weren’t mild. Nearly half of people who had an attack sought emergency hospital treatment.

Among people with seasonal allergies, risk factors for experiencing thunderstorm asthma include having

• poorly controlled asthma symptoms (assessed by a standard asthma questionnaire)
• a low score on a rapid exhalation test (a common breathing test for asthma)
• higher levels of a certain antibody (ryegrass pollen-specific IgE)
• higher numbers of certain blood cells (eosinophils, which tend to increase when people have allergic conditions)
• higher levels of exhaled nitric oxide (one measure of lung inflammation among people with asthma).

Not everyone with these risk factors will develop thunderstorm asthma. And even among those who do, asthma attacks won’t necessarily occur with every storm. But it may be useful to know if you’re among those at risk, especially if you live in an area where thunderstorms are common.

The bottom line

Thunderstorm asthma may seem like more of a curiosity than a serious threat to public health. But when it affects a large population area, emergency rooms can become overwhelmed, as happened during the 2016 Melbourne event. A better understanding of when these events are expected could lead to advanced warning systems, enhanced emergency room preparedness, and even preventive treatment.

In the US, 25 million people have asthma and more than 20 million have seasonal allergies. Odds are good that millions have both, which puts large numbers of people at risk for developing thunderstorm asthma.

If you’re among them, the weather forecast may be much more than just a guide on what to wear or whether to bring an umbrella. Knowing thunderstorms are headed your way may serve as an advance warning to double check that you are taking your asthma medicines properly, have a supply of rescue medicine handy, or simply plan to stay indoors until the storm has passed.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

• Perform aerobic exercise.
• Eat Mediterranean-style meals.
• Avoid alcohol, cannabis, and drugs.
• Sleep well.
• Participate in social activities.
• Pursue novel, cognitively stimulating activities, listen to music, practice mindfulness, and keep a positive mental attitude.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

Polio is a potentially life-threatening or disabling illness that spreads from person to person. Thanks to vaccination, the United States has been polio-free since 1979, and the spread of this highly contagious disease has been interrupted in most countries. Yet on June 22, the United Kingdom Health Security Agency announced that it had detected poliovirus in a most unexpected place: the sewers of London.

Over the past several months, scientists at the agency repeatedly found poliovirus in London sewer water. The viruses were genetically similar, suggesting that they were the result of limited spread within a family or close-knit community. Just how concerned should all of us be about this news?

Health clues found in wastewater

Sampling of wastewater for genetic material from viruses is a powerful tool used by epidemiologists to track outbreaks of polio and other diseases. Surges in the amount of SARS-CoV-2 RNA in Boston wastewater have been highly predictive of COVID outbreaks. Wastewater may also help to detect the spread of influenza and antibiotic-resistant bacteria.

Poliovirus infection was once a common and dreaded disease. Most people with poliovirus either had no symptoms or mild gastroenteritis (stomach flu). But one in 100 people developed paralysis, or poliomyelitis. In half of the affected patients, this paralysis was permanent.

In the UK, wild poliovirus has been eliminated since 1984. Although great progress has been made in many parts of the world, complete eradication of polio has been elusive. Pakistan and Afghanistan have never been free from wild-type polio, and outbreaks have recently taken place in Malawi and Mozambique, countries which had previously eliminated polio.

The reasons for this backsliding are complex. Some contributing factors are diversion of scarce resources toward the COVID-19 pandemic, backlogs in vaccine manufacturing, anti-vaccine agitation, and violence directed at vaccine workers.

Another problem is vaccine-derived poliovirus. In the United States and most other countries, injections containing killed viruses are used. While these vaccines are safe, they are less effective than oral vaccines at breaking the chain of polio transmission. Oral vaccines stimulate long-lived immune responses in the lining of the intestines, where polioviruses replicate. Unfortunately, oral vaccines contain weakened but live viruses, which occasionally revert to a more dangerous form. In fact, the poliovirus found in London was a vaccine-derived strain that the infected individual had likely acquired from travel abroad.

Who is at risk for poliovirus stemming from this source?

Vaccine-derived viruses pose little risk to highly vaccinated populations, but they are able to spread in communities with low polio vaccination rates. In some cases, this can even cause paralytic disease. Because of these risks, steps are being taken to gradually phase out the use of oral polio vaccines.

If you’re concerned about polio, the best protection against this disease is vaccination. Children should receive a full series of four shots of inactivated polio vaccine, given at specific intervals, that helps with developing immunity.

Nationwide, rates of childhood polio vaccination in the United States are still high (nearly 93%). However, some infectious disease experts worry that the weakening of vaccine mandates in some areas has created islands of vulnerability in this sea of immunity. Communities in the US with low childhood vaccination rates have been vulnerable to large measles outbreaks in recent years, and might also be vulnerable to polio outbreaks.

With few exceptions, adults who were fully vaccinated as kids do not need booster shots. These exceptions include travel to a country with active polio transmission, laboratory work with poliovirus, or providing health care to polio patients and their close contacts. A single lifetime booster dose of inactivated polio vaccine is adequate for these high-risk scenarios.

About the Author

John Ross, MD, FIDSA, Contributor

Dr. John Ross is an assistant professor of medicine at Harvard Medical School. He is board certified in internal medicine and infectious diseases, and practices hospital medicine at Brigham and Women’s Hospital. He is the author … See Full Bio View all posts by John Ross, MD, FIDSA