Inspiration Amidst Tragedies

She is a fierce, strong woman. She may come off intimidating, especially at work, but she just means business and patient’s convenience and comfort; nothing personal. She is respected by her colleagues as she is a no non-sense persona. Yet behind this demeanor is a great story… a story of pain… a story of survival… a story of inspiration.

I did not ask permission from her to write this story but as a tribute to her, I am still writing this to share and inspire others out there who are on the brink of losing hope…

She was married (yes, WAS…), had 3 kids (again, yes, HAD). Her husband was diagnosed to have a rare form of diabetes apparently, which unfortunately was passed on to her two sons as well, at an early age.

Few years ago, husband died from complications of his diabetes. That was painful enough. Who would she be with as she goes on through life? But wait… few months after the husband’s death, one of the son died as well, seems from the same problem as the father did…

As I have read from someone before, one of the hardest pain one experiences in life is to bury one’s own child. She wasn’t over mourning the loss of her husband and yet her son immediately followed. What pain could be worse than that?

But just as when she was able to move on, tragedy struck her after another. Her next son became ill. It was an agonizing scene… and despite expert intervention by everyone, he succumbed and died. I know she hasn’t completely healed with her previous loss, and still, this happened.

Just as you thought it was over…

Few months after the son was buried, and while still mourning, she was diagnosed with breast cancer. Yes, the pain at its worse/worst. Luckily though, it was stage 1. She underwent chemotherapy and seems to be in complete remission. I hope it will not recur. She has gone through a lot for recurrence now.

Being diagnosed with cancer is already devastating. The cancer in itself as well is very painful, and the pain is so severe no words would be able to describe it. But she collected these pains up her shoulder and shrugged them off. Aside from these pain and melancholy brought about by cancer, she had other reasons to be depressed, enough to commit suicide. But she didn’t yield.

Her struggle through all these is what I find truly inspiring. While others boast of problems upon problems, here is a woman who endured the worst kind of pain I could ever think of. She didn’t give up. She fought through, coped up and shook off and kept moving on with her life. She didn’t let one tragedy pull her down, despair as if her life no longer matters. She endured. She is my model for strenght, resilience, hope and optimism.

If you think your breast cancer is the worst news you ever had in your entire life, read this story and be reminded that someone else had worse struggles than you did or is having right now.

 

Why Single Women, And Yes, Nuns, Ought To Take Contraceptive Hormones

Birth Control Pills (Image courtesy of © iStockPhoto / Ceneri)

When I once said that nuns and single women who do not intend to get pregnant would benefit from taking contraceptive pills, one anti-RH Bill reacted saying “that is hysterical!” I didn’t think HYSTERICAL was even the appropriate word to say, even if she wanted to express disgust based on her knackered beliefs.

Let us put it that a woman has her first menstruation (called menarche) at age 15 years of age, and menopauses at 45 years of age. Granting she has a regular monthly menstrual cycle, that would make her mens 12 times a year. If she will have 30 years of reproductive age, then that would mean, she will have 360 menses in her lifetime. (Although realistically, nowadays, some girls already start menstruating at 9 years of age. To give you an idea when to expect the girl will mens for the first time, note at how old she is when her breasts start to enlarge — termed medically as thelarche. Approximately two years after that, she will now start her menstruation.)

During a woman’s menstruation, there is interplay between estrogen and progesterone. During the first day until day 14 of a woman’s menstrual cycle, ESTROGEN predominates especially on the day just before ovulation. The latter is responsible to prepare the uterus for an incoming pregnancy as well as ovulation in concert with other hormones; it’s level declines once the ovary has released an ovum. Once ovulation occurs, the corpus luteum (the cells surrounding the ovum in the ovary) release PROGESTERONE. The latter on the other hand ensures that the reproductive organs are optimum for a pregnancy to proceed.

PREGNANCY AND ITS EFFECT ON ESTROGEN ELEVATION

I have emphasized in my other blogs the role of progesterone as the hormone responsible for keeping the pregnancy intact. While estrogen may still be produced during pregnancy (as estriol), its potency is a lot weaker than the estrogen produced during non-pregnancy state (estradiol).

If woman gets pregnant for 9 months, the effect of progesterone is greater than the effect of estrogen. Even if estrogen is also produced during pregnancy as estriol, its effect to other organs such as ovary and uterus is dampened to nil. Thus, in cases where the woman is able to carry her pregnancy to full term, that would save her 9 months from the potent effects of estradiol to her body. If she will exclusively breastfeed (no breastmilk substitute whatsoever is given to the baby) after giving birth as well, this will have the effect of LACTATION-INDUCED AMENORRHEA (woman’s menstrual cycle remain arrested as effect of exclusively breastfeeding her baby) for about 6 months. Thus, one pregnancy will save the woman at least 15 months free from effects of elevated estrogen (estradiol) level. If in her lifetime, a woman will bear 4 children, all of which were term pregnancies, then she will have a total of (15 x 4) 60 menstruation free months in her lifetime. This means, she is on the advantage of 300 months exposure only, compared to women who never got pregnant, who are exposed to the potent effects of estradiol for 360 months.

EFFECT OF UNOPPOSED ESTROGEN ELEVATION

What effect does estrogen have to a woman? Most commonly discussed effects of unopposed estrogen elevation would range from benign (leiomyoma, or myoma of the uterus) to malignant such as cancer of the uterus, ovary, and breast, among other else.

Cancer

It has been established that most cancers are mainly genetic (meaning, inheritance of cancer genes from either side of the parents). But aside from the genes for expression of cancers, there are also genes for cancer suppression that comes along with its inheritance. Whichever of these genes predominates, that is  what is manifested clinically or physically or biochemically or physiologically by the person involved. If a person has breast cancer gene, and the gene for its suppression is muted or ineffective, then the person will have breast cancer manifestations. On the other hand, if the person has breast cancer genes, but his cancer suppression genes are enhanced and working effectively, then the person will not show signs of breast cancer, but still at risk and will readily convert once those cancer suppression genes are skewed. (Confused? hahaha). These cancer suppression/expression genes are regulated by the environmental factors to which the person is exposed to. In the case of breast cancer, one environmental factor is elevated estrogen (estradiol) level.

Estrogen naturally exists in 3 forms in women. The ovary produces (1) estradiol, the most potent form of estrogen, and this is the form usually seen elevated among nonpregnant women during the reproductive age group. This is believed to be the most potent of the three forms. Another form of estrogen is produced during pregnancy is (2) estriol; this has been noted to be the a lot weaker in comparison to potency of estradiol. Another form of estrogen is found among menopausal women, (3) estrone. During the reproductive age group, estrogen is produced by complex enzymatic process at the ovary. Postmenopausally, estrone is converted peripherally at the liver, adrenal glands, breast and fat tissues.

If a person has inherited the breast cancer genes, and keeps on being exposed to elevated estradiol, then she can develop breast cancer, especially if her breast tissue also has the hormone receptors for estrogen. These receptors will bind with the circulating estrogen and thus bring about the genesis of cancer. Between non-pregnant woman (who has 360 times of exposure) and a woman who got pregnant for four times (who only has 300 times of exposure), it is the former who is more susceptible. This only goes to show that even if the woman never took exogenous sources of estrogen (such as oral contraceptive pills), they can still have breast cancer. (I previously blogged a colleague who was single and died at the age of 42 from breast cancer. She too was not taking contraceptive pills — The Pain She Should Never Have.

DO CONTRACEPTIVES OFFER ANTI-CANCER BENEFIT TO WOMEN?

Contraceptive pills contain synthetic progesterone alone or in combination with estrogen. Among its many benefits, the effect in focus is its role in suppressing ovulation. With a sustained elevated level of progesterone from religious intake of contraceptive pills or injectable hormones, this suppresses elevation of estradiol (which leads to ovulation). With lesser if not complete non-exposure of the reproductive organs to estradiol, nothing will stimulate the cancer expression genes and therefore no cancer formation. Of course this is NOT always absolute and there are always exceptions, but these exceptions are often minimal compared to those who will benefit from the treatment.

A meta-analysis on the effect of oral contraceptive pills among women who had genetic mutations (BRCA1/2) for expression of ovarian cancers have shown that oral contraceptives reduce the risk for ovarian cancers, proportional to the length of use. The same meta-analysis also stated that OC formulations used before 1975 were associated with a significant increased risk of breast cancer (SRR: 1.47; 95% 1.06, 2.04), but no evidence of a significant association was found with use of more recent formulations (SRR: 1.17; 95% 0.74, 1.86). (highlights were mine). (Reference: Oral contraceptive use and breast or ovarian cancer risk in BRCA1/2 carriers: A meta-analysis.S. Iodice, M. Barile, N. Rotmensz, I. Feroce, B. Bonanni, P. Radice, L. Bernard, P. Maisonneuve, S. Gandini. European Journal of Cancer, Volume 46, Issue 12, August 2010, Pages 2275-2284).

Do women ought to take contraceptive pills, even if they are not married? 

 

The Pain She Should Never Have

The Pain She Should Never Had.

 

The Pain She Should Never Have

(Photo courtesy of http://www.stage4cancers.info/article/breast-cancer-survival-rate-stage-four-breast-cancer-2/)

How painful is the pain experienced by patients with cancer? I can never imagine…

A lady was diagnosed to have breast cancer. She underwent removal of the breast (mastectomy), followed by chemotherapy. Initially, there was remission, but then it recurred, spreading to other organs. This time, there seems to be no remission. She was in pain, severe pain. I may not understand nor completely know how much pain she, they feel. They usually are given analgesics, but I know it’s not enough to suppress it. This person I knew seems to have been dragged and eaten by the pain she was suffering from; I didn’t recognize her when I went to her wake. I thought I went to a wrong wake, but when her mother spoke of her name, that’s the only time I was convinced it was her. Her last few days was an agonizing one. She tried to fight it, but her bravery was nil. Finally, she went ahead, at peace.

She was single, never been married — at least, no kids nor husband to be left behind… In line with this, again I emphasize the role of hormones and family history in the genesis of breast cancer. She has never been married, she did not avail of any contraceptive method to plan a family size. No contraceptive pill caused her breast cancer. She had breast cancer, she has a family history. In fact, one of the persons who I talked to during the wake is also a breast cancer survivor, her cousin.

If she had family history only as a risk factor, how come she developed breast cancer? The only explanation is that, she is single. It means, she had regular menstruation. With every menstruation, there is a rise of estrogen in her system. In contrast, if she were married and had pregnancy, the estrogen level would have been opposed by this 9-months duration of progesterone predominance. Her breast tissue had hormone receptors responsive to estrogen, and this led to the genesis of the cancer. (This case example again debunks these “prolifers” who claim that people who take contraceptive pills are the one who will develop breast cancer; it happens, with or without contraceptives).

What I cannot fathom is, why do cancers have to cause severe pain… Isn’t it enough that cancers are incurable already, why still the pain…

 

Breast Cancer or the Pregnancy: Which Should Prevail?

(Photo courtesy: http://www.pregnancyandbaby.com)

The tweet exchanges yesterday made me remember one very controversial case I ever encountered during my medical student days, I was a rotator in pediatrics then. It was that of a married woman who was diagnosed to have breast cancer, but it was too late already as she was stage 4. Meaning, the cancer has already spread to distant organs (brain, lungs) from the breasts. Because of this, the oncologist became aggressive with the treatment in an attempt to reverse the condition, if not prolong the life of the patient. But in doing so, the oncologist forgot one important patient data: that SHE IS MARRIED, she forgot to ask when was the last menstruation nor do pregnancy test. So what makes this case controversial after all?

The patient was PREGNANT at the time she was diagnosed to have breast cancer, but neither the patient nor the oncologist have known it that time. Chemotherapy was already started and it was only after the first dose of chemotherapy when the pregnancy was discovered. Also, this happened during the first trimester of the pregnancy! What is dangerous about this is that, chemotherapeutic agents are known to stop the multiplication of cells whether normal or abnormal cells. During the first trimester of human pregnancy, many organs of the fetus are just beginning to form. Rational thinking thus will make you understand that all organs of the developing fetus could be affected by the chemotherapeutic agents the mother has consumed. If the baby will survive, she might be born with several congenital anomalies. I couldn’t imagine the guilt and anguish the oncologist was having at that time. I wouldn’t want to be in her shoes.

The mother decided to keep the pregnancy, she decided not to have further chemotherapies to avoid unnecessary exposure of the baby. This meant her breast cancer will worsen further, considering that it was already stage 4 at the time of diagnosis. Around 25 weeks gestation or barely 6 months, she fell into coma. As it was irreversible, relatives have accepted her fate… but the baby, she’s too premature at that time to be delivered (and there was still no neonatologist available to take care of the baby). Remedy then was to keep the mother alive and her body will serve as baby’s “incubator” until such date when baby would be “safe” to deliver. As they were service case and couldn’t afford sophisticated intensive care intervention, mother remained in the ward, slowly agonizing in pain (a pain not even pain relievers would afford to stop). Unfortunately, on the 28th week of gestation (barely 6 1/2 months), mother succumbed. Immediate cesarean section delivery was then performed bedside (yes, she was no longer brought to the operating room) to deliver the baby. It was a healthy baby girl (female preterm babies have a better survival chance than male). She was then brought immediately to the neonatal ICU at that time and we were just so lucky she did not have the complications of being a premature baby. Also, no visible effects of chemotherapy was observed in the baby, how lucky. The mother on the other hand, after the cesarean section, lifeless, was brought to the morgue.

There are several questions, including ethical ones, surrounding this case. For one, would abortion be an option so mother can continue her treatment? In regions where abortion is legal and allowed, that wouldn’t be a question. But in the Philippines where it remains illegal, this poses dilemma. The argument there would be, the mother and the baby was exposed to chemotherapeutic agent at the point where rapid mitosis and organ formation is ongoing, and where teratogenic would usually exert its effect. Since the developing fetus was already potentially harmed, why allow such pregnancy to continue when you expect the baby to be abnormal in the end? So, abort it (not). Another question would be, shouldn’t the mother have gone cesarean section immediately when she was already in coma so that at least, chemotherapy would have been resumed and might have averted the mother’s condition, right? The problem there is, there’s no better place for the baby to grow but the mother’s womb. Also, chemotherapy wouldn’t have done the mother any good. After all, it was late stage when she was diagnosed for the first time. Prolonging her life would just be prolonging her pain and agony, and there’s no assurance that she can survive the cancer so she could eventually take care of her baby. If baby were delivered earlier, baby might not have survived from prematurity as at that time, surfactant, is deficient from her lungs, and the drug is not readily available in the locality at that time yet (it had to be purchased from centers in Manila, and the drug transport is not that easy). This decision-making indeed may not be conventional but pushed against limits, they’re being done in the field of medicine. Choosing between two evils, and the more beneficial and less controversial option may be the only choice.