Randi Hutter Epstein M.D. M.P.H.

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Hungry: Could it Be Your Hormones

For many of us, the fourth of July means fireworks and food. But here’s the thing: unlike colder weather festivals, such as Thanksgiving, it’s harder to cover up our bulging bellies. Can’t we just have a little self-control?

Well, maybe not. Emerging evidence reveals that our drive to eat may be controlled by our hormones.

People with glitches in the hormone, leptin, for instance—or in the way the body responds to it, are voraciously hungry all the time. Left to their own desires, they become morbidly obese and suffer from all of the consequences that go along with that. Scientists have developed leptin shots that help many people with this rare disorder, allowing them to enjoy hunger and fullness for the first time in their lives. But some folks with a leptin defect have enough of the hormone, but their bodies do not respond to the “I-feel-full” signals. That means that all the leptin in the world won’t stop their cravings. Scientists are beginning to understand their chemical dysfunction. There are a few drugs in the pipeline but no cure yet.

What about the rest of us? Do these exciting clues mean that we can tweak our appetite hormones so we can feel fuller sooner and shed those extra pounds? Can we pop a pill before the weekend barbeque and control the urge to go for seconds?

To be sure, there are self-help books and supplements galore with all sorts of dubious claims to boost your leptin hormone. But here’s the thing: Leptin has been in the spotlight ever since it was discovered in 1994, yet there are so many other chemical signals that control how much we eat, how we burn calories, and what we choose to pile on our plates.

We are a complicated stew of chemicals. When it comes to hunger and satiety, there’s neuropeptide Y, agouti-related peptide, melanocyte-stimulating hormone, ghrelin, insulin-like peptide and the list goes on and on.

So sure, blame your hormones for driving you to the dessert table. But don’t try to “cure” your urges with some dubious supplement.

And sometimes, well, we eat even when we don’t feel those hormonally driven hunger pangs. Sometimes we eat when we’re not hungry because we are, after all, human.

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Why Can’t We Talk About Pain

When my husband was wheeled into the recovery room after a hernia operation, the nurse leaned over and asked him to give his pain a number between one and 10. I could see him woozy and wincing so I whispered (rather loudly), “Ten! Just say ten!” I wanted him to get much-needed painkillers.

“Miss,” the nurse huffed at me, “he can speak for himself.”

Well that’s the problem. Few of us can express our aches and hurts accurately, particularly when we are in the throes of them.

Last week, I wrote a review of Abby Norman’s memoir Ask Me About My Uterus. It’s about endometriosis, a chronic and debilitating illness triggered by uterine-like cells growing outside of the womb. Women with the disorder have heavy, agonizing periods along with a litany of other symptoms depending on where the rogue cells lurk: bowel and urinary tract disorders, leg pains, and on rare occasions breathing problems if endometriosis lands in the lung.

Lena Dunham, Whoopi Goldberg and Padma Lakshmi are among a slew of celebrities who have gone public with their stories about suffering from this illness that typically gets ignored or dismissed for years.

What struck me reading Norman’s book was more than the information about endometriosis. Yes, this disease needs more attention and more research that will, I hope, lead to better treatments.

But the broader message is about communicating pain. Our language for letting doctors know how we really feel is so limited. Stabbing? Throbbing? A two? A ten? To be sure, the smiley faces can help young children communicate the level of their discomfort—pointing to sad face or cheery one may be easier than talking to a grown-up.

David Biro, in Listening to Pain: Finding Words, Compassion and Relief elaborated on this issue. (Biro, by the way, has got an M.D. and did his Ph.D. studying the language of pain.) All of us have had something hurt at some point—some of us worse than others—but without explicit words it’s often hard not only to let our loved ones know how we feel but most importantly it’s nearly impossible to convey these crucial clues to our doctors.

The big push in medical schools these days is learning to listen to patient’s full story (as opposed to simply jotting down lab findings). What we truly need to help doctors and patients understand each other are better ways to express what we are feeling inside. We need to devise a better system so people in pain do not need to rely on their loudmouth wives yelling “Ten! He’s a Ten!”

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For Women’s History Month, Here’s a Woman to Remember

Told to be a Scientist, she Became a Nobel Laureate Instead

In 1941, Rosalyn Yalow, a graduate of Hunter College with honors, told her teachers she wanted to be a scientist. They suggested she become a secretary to one.

Yalow persisted and 36 years after that discouraging conversation, she was in Stockholm, Sweden receiving the Nobel Prize in Medicine or Physiology.

Quite a leap for the daughter of Eastern European immigrants who never finished high school.

The award was for a technique that revolutionized twentieth century medicine. Yalow, along with her partner, Solomon Berson, created radioimmunoassay, or RIA for short. Before RIA, in the late 1950s, endocrinology was guesswork; doctors evaluated and treated patients for hormone deficiencies without knowing how deficient they really were. After its creation, doctors could measure hormones down to a billionth of a gram.

The same tool was used to measure all sorts of things that had been considered too scarce to measure—germs (including the HIV virus leading to the AIDS test), other hormones (helping to spawn the fertility business) and drugs (monitoring drug dosages to avoid dangerous interactions).

I’ve written about Dr. Yalow before—and write a chapter about her in my forthcoming book, Aroused: The History of Hormones and How They Control Just Everything. But hers is a story that deserves to be told again during Women’s History Month.

Rosalyn Sussman Yalow was born July 19, 1921 in New York City. She got into University of Illinois’s College of Engineering graduate program only because so men were fighting in World War II. The school reluctantly admitted a few a women. “They had to have a war so I could get a PhD and a job in physics,” Yalow would say years later.

Her Nobel Prize winning work was accomplished in a lab at the Bronx Veterans Administration. She turned what had been a janitor’s closet into a laboratory. Hardly any female scientists got hired at the V.A., and the few who did had to quit if they got pregnant. “I was too important to be fired,” she told her biographer. She kept her job through two pregnancies.

The kernels of the idea that led to radioimmunoassay began with basic endocrinology studies. Yalow, along with her partner Solomon Berson, proved that hormones can elicit an immune response—something that went against scientific dogma. Despite a scrupulous study, their research was rejected by several prestigious scientific publications. Eventually—after battling with editors, it was published in 1956 in the The Journal of Clinical Investigation. Their findings were quickly confirmed by other labs, and led them to their revolutionary technique.

Yalow lectured all over the world. One of her last talks was to a third grade class in a New York City Public School. She told the students, “Initially new ideas are rejected. Later they become dogma, if you’re right. And if you’re really lucky, you can publish your rejections as part of your Nobel presentation.”

My favorite Yalow story is this one: In her laboratory, she had this sign:

“To be considered half as good as a man, a woman must work twice as hard and be twice as good.” That’s a common feminist maxim.

But Yalow added the punch line: “Fortunately, that is not difficult.”

In honor of Women’s History Month 2018, let’s hope that from now on, women who are excited about science and eager to pursue a career can be nurtured and mentored and encouraged so the journey to success can be just as exciting and stimulating as the goals achieved.

For further reading: Rosalyn Yalow: Nobel Laureate: Her Life and Work in Medicine, by Eugene Straus (Basic Books: 2000)

 

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Predicting Criminal Behavior

In 1924, two rich teenagers from the suburbs of Chicago murdered a kid in their neighborhood. They were caught right away and the trial became known as the crime of the century. The gruesome story of Richard Loeb and Nathan Leopold became fodder for national newspapers and would inspire four films, several books and one play.

During the trial, the killers’ parents hired doctors who tried to convince the judge that the boys weren’t responsible for their own actions. Their faulty hormones made them do it. One doctor, using state-of-the-art tools of the time said he spotted a defective pineal (a gland in the brain) that triggered a lack of inhibition. Today we know the pineal gland emits bursts of melatonin that control our circadian rhythm, our internal clock. In other words, it has nothing to do with compelling someone to kill. In Leopold and Loeb’s time, it was connected ever-so-tentatively to sex and intellect. The doctor explained that because of Leopold’s hard pineal, he had too much libido, even for a 19-year-old boy, and not enough inhibition.

The judge said he was intrigued by this new field of endocrinology (the study of hormones), but these insights were not going to keep two murderers out of jail. The boys were each sentenced to life in prison.

For nearly a century, we have tried to use all kinds of tests to predict human behavior. Around the same time as the trial, Dr. Louis Berman, a New York City doctor, claimed he could look at people and figure out which of their many hormone-spewing glands controlled them. He labeled people “thyroid types” or “adrenal types” based on some dubious assessment. He also said he could forecast their future—whether, based on their hormones, they’d become leaders or movie stars, or criminals. Berman’s ambitions were lofty: he wanted to use his “skills” to evaluate school children and predict their futures. If a kid were destined for a wayward life, he’d prescribe preventive hormone therapy. He wrote books that the public adored and his colleagues loathed. Still, like many ideas based on conjure rather than data, his theory faded away.

We’ve tried for nearly a century to figure out ways to predict who is likely to be a killer, and then take extra cautions with those people. Last week, during a news conference about the flu epidemic, Alex M. Azar, the U.S. Department of Health and Human Services Secretary began by addressing the recent Florida massacre saying the administration needs to be “laser-focused on getting Americans with mental illness the help they need.”

That’s a nice idea. Those with mental health issues should get the therapy they deserve. We don’t need to stigmatize mental illness even further by assuming that anyone suffering from mental illness is a potential murderer. In a scientific article in 2105 published in the American Journal of Public Health, the authors write that the mentally ill are “far more likely to be assaulted by others or shot by the police than to commit violent crimes themselves.”

I’ve spent the past seven years exploring the history of hormones and the science of hormones and behavior. We’ve made great strides. We have more insight into the ways that hormones can make us moody or hungry or tired. We have hormone medicines that can help people with dysfunctional glands. But our notions of predicting a “killer instinct” are, at best, wishy-washy.

We are kidding ourselves if we think we can predict the next killer with tests based on hormones or surveys or any kind of chemical assessments. Politicians and others may look to these studies because they provide a good sound bite, but we need to reread the history of medicine and the recent history of killing sprees to appreciate that it’s highly unlikely we are going to find the sure-fire predictive test and then provide all of the best preventive care necessary to prevent the next massacre.

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Transitioning: The Power of Fiction

For those of who read the New York Times “Modern Love,” column, we know that every now and then, there’s one that resonates but not because of a shared experience. In fact, it’s just the opposite. It rings so close to the heart because we may not have shared the journey but we shared the emotions.

That’s how I felt when I read Laurie Frankel’s essay last fall about her six- year-old son transitioning from identifying as male to female. She wrote so honestly about wanting to cater both to her son’s happiness but also wanting to protect him from the potentially harsh ramifications, potential bullying.

As a mother of four children, I know there are the abstract conversations (“this is what I would do, if…” ) as we role-play perfect parenting. And then there’s the reality of what we do when we are in the thick of it, when we say the wrong thing, when we are not sure what to do to help our kids immediately making sure it’s best for the long term.

I read Frankel’s essay and was so impressed with her as a writer and as a  parent, that when I read in her byline just released the novel This is How it Always is, I clicked on my Amazon app and got it the next day.

After writing and researching medical and emotional issues of those who identify as transgender for my forthcoming book (digging into historical archives, reading memoirs, scouring a trove of scientific articles, interviewing those who identify as transgender, interviewing parents of children who identify as transgender, along with doctors) I was intrigued to see what a novel would offer that I hadn’t gleaned from non-fiction.

A lot.

Frankel intentionally sets up a situation including a family with five kids. She is the mother of one child. She wanted to make the point that identifying as transgender is one thing that complicates growing up, but it’s certainly not the only thing. The other children have their own adolescent issues, too. She also wanted the family to have to cope with the responses not just by parents and the community but by siblings too.

Midway through the book, the mother expresses her willingness to go along with her child’s wishes to transition but expresses her fears of the hormone medication and concerns about the permanence of it all.

“You think Poppy will be the only kid to feel betrayed by her body when it goes through puberty? All teenagers feel betrayed by their bodies when they go through puberty. You think Poppy will be the only woman to hate the way she looks?…..The drugs, other drugs, yet more drugs, a lifetime of drugs, the surgeries, the stuff that can’t be made whole regardless of surgery, these things are huge. These things are scary. These things are mysteries, unpredictable, uncertain….There are hard decisions she’s not old enough to make. There are decisions that just shouldn’t be made for you by your parents. If she is a girl, if deep inside this is her truth, if she needs this, if she wants this, if she must, if she’s sure, then yes, of course yes, thank God yes, we will support her and help and do all all we can and much we can’t yet but will have to figure out, as we have already , as we do for all of our children…”

I spoke to Frankel recently, and I thought she answered two of my questions so well, I wanted to share her answers rather than paraphrase:

RHE: Why Fiction and not memoir?

LF: You know the nice thing about fiction is that parts of it can be true and taken from your own life, but it doesn’t have to be. My hopes and fears drove this whole book. This is probably true of all novels. Also, we are really lucky to live in a community where it was just an easy supported transition in really every way—school, friends, community. It was exactly the way you would want your kid’s life to go. That would have been a short and boring memoir. I also remain keen to protect my kid’s privacy. Everyone knows it was a very public transition. But ten years from now when, who knows who she will be and what she will want other people to know. That would have been impossible in memoir form.

RHE: How do you think your book relates to all children, not just those who are considering transitioning?

LF: I think my story serves as a metaphor. The child you thought you knew turns out one morning to be someone else. That’s what parenthood is like and that’s what childhood is like. And kids change in ways you very frequently don’t know what do to about. You kind of think, here’s the thing: I obviously still love you but I have to think about what to do about it and I have to do the best I can.

RHE: Your book incorporates stories within stories, including a fairytale, and mothers sharing stories. How does the power of storytelling influence transgender rights?

LF: Everything is about story telling. Everyone is reporting and putting their story out, Snapchatting, instagramming. How do you tell your story well and honestly? I teach a college course in literature and we always start with fairytales. They are so problematic for trans kids, for all kids, because what comes first is the whole story. The transformations are instantaneous and painless and permanent and always forward looking and not backward looking. This isn’t a great model for kids with whom the transformation is everything and protracted. They may want to wipe out everything but their parents have no desire to wipe out the past. I’ve been talking to parents and trans kids about how to honor the past, making it part of the story.

This is How it Always is speaks not only to the transgender community, but to any of us who have questioned who we are and who we want to become.