evidence based medicine

Medical Monday: You asked for it… Endometriosis

Women are curious about endometriosis because it is a curiosity. The causes of endometriosis are not precisely understood but we have a good working knowledge.

We do know that it involves endometrial tissue being extruded out of fallopian tubes and into the pelvis. There, in a subset of women, the tissue implants and becomes active. Then, in a subset of these patients, this tissue secretes inflammatory mediators. Finally, some of these women develop autoantibodies. Pain and infertility can result from all of the inflammation and the damage that it causes. Cysts full of liquid can form; scarring can block tubes and distort anatomy. 

Treatments are of two types: medical and surgical. Medical therapy makes good sense because we know that endometriosis is hormonally responsive. Conservative surgical therapy is helpful to drain cysts, cauterize lesions, and release adhesions such as the ones in the photo. Definitive surgical therapy includes removal of the tubes, uterus and ovaries. 

Recently I was asked to review a blog post posted on my Facebook page. (See blog post HERE)  It was by a naturopathic doctor who was proposing a different approach to endometriosis. She was postulating endometriosis as an autoimmune disease. Apparently she had read a speculative literature review article, (Reference HERE) which noted an increased prevalence of inflammatory mediators and auto antibodies in those with endometriosis. Despite anything like a high level of evidence, (See levels of evidence HERE) she drew a causal relationship between these findings in the occurrence of endometriosis.

I think the authors of the study would consider these findings noteworthy associations, but would not feel entitled to draw any further conclusions such as causality.  I myself would say her blog post thesis is a case of confusing eggs with chickens. In other words, endometriosis probably causes inflammatory mediators to arise and fosters the development of autoantibodies, not the other way around as she proposes. Some people are more immunologically reactive than others, and those that are will likely develop more autoimmunity of whatever type. 

It is important to note that the author of the blog post draws a conclusion from this paper from which no conclusion can legitimately be drawn. She goes on to propose therapy, including modifications in diet, i.e. going off dairy and gluten. She then suggests her book which further discusses endometriosis and the "natural immune-modulating treatments" which she offers. 

I see two main differences between legitimate medical websites and others. First, legitimate medical websites are evidence based. This  means that not only must they cite medical research, but that they must cite it correctly, and not draw unfounded or speculative premature conclusions for associations which may be suggested. Secondly, legitimate medical websites are realistic. Others are boundlessly optimistic, offering readers and customers results that invariably surpass conventional treatments. 

I say, follow the money. Also, if it seems too good to be true, then it probably is. Finally, the proof is in the pudding. 

Click HERE for your internet learning toolbox. 

To learn more about endometriosis, check out our straightforward page on this common disease HERE. 

Medical Monday: Another Obstacle to Health Care: Anti-science

What does vagina steaming and the recent measles outbreak having common ? Need a hint ? OK. What can make people on both sides of the political spectrum mad ? You guessed it ! The anti - science movement. 

According to that venerable site rationalwiki.org, anti science 

" refers to persons or organizations that promote their ideology over scientifically-verified evidence,[3] usually either by denying said evidence and/or creating their own." 

Recall that science is advanced through the scientific method, which involves testing hypotheses with experiments, then revising said hypotheses. Experiments should be on done on that which is measurable, done blinded, controlled, and should be reproducible and peer reviewed by the appropriate scientific institution. Science is always undergoing a process of refinement based on observable facts. 

This should be clear. Yet the media and advertising to which we are daily exposed has become a brew of fake science and real science. How is a person to know the difference ? Well you can use your gut feeling of course. ( And I have a bad feeling about vagina steaming.)  Or, you can have a look at my section of this site where I try to give some help on this issue. It is called Information and Learning. I try to give you some tools with which to navigate the information stream coming at you every day. 

Let's look at some hot news topics where anti-science is in play: climate change, genetic engineering, vaccines, juice cleanses, GMO food, stem cell research, and yes vagina steaming. These topics are especially hot in election years, and when money is involved. 

Here is a great article in Scientific American about a science quiz given to presidential candidates 2012. 

Click here to either laugh or cry. 

Here too, is a fair handed look at anti-vaccine sentiment on both sides of the aisle from Slate

Here is fantastic compendium of articles from various writers on the anti-science movement from Huffington Post. 

I would like everyone to take a charitable look at the nature of our national dialog. Feelings are running high, especially in the wake of the recent measles outbreak. In this climate, where there are many voices clamoring to be heard, let us keep the dialog civil and ahem, scientific, whenever possible. 

In that spirit, I will share with you an article about one of my favorite most well intentioned celebrity health gurus, Gwyneth Paltrow. Don't get me wrong, I love Gwyneth. Her site, Goop.com is full of lovely recipes and pretty unaffordable clothes. She has a holistic approach and a lovely positive attitude which really does count for a lot. HOWEVER, I cite this article below to show that sweet well intentioned people can get it wrong. Enjoy, and remember that laughter and affection are the best medicines. 

Three Reasons You Definitely Shouldn't Get Your Vagina Steamed , from Women's Health 

Medical Monday: Evaluating Medical Reports in the Media

Everyone is interested in medical news. It is inherently sensational. But, it is challenging to report, and even journalists with the best of intentions have a hard time getting it right. 

When an intelligent patient comes to the office and spends 15 minutes with her doctor, and the doctor goes through a detailed explanation, under the best of circumstances, only part of that will be correctly remembered. Here are some links if you are interested in reading more about that : 

How Much Can Patients Learn in a 15-Minute Doctor Visit?

New Prescriptions: How Well Do Patients Remember Important Information?

Long term clinical trials: how much information do participants retain from the informed consent process?

The difficulties are on both sides. Doctors have crammed schedules. They aren't always the best of communicators. Sometimes the doctor and the patient have differing agendas for the visit. And the patients are often distressed about what they hear, which impairs understanding and memory. 

Consider classroom learning. I need to hear things and be thinking about them, take notes, see diagrams about the topic, get handouts, look it over,  and repeat it all before it is really ingrained. This type of thing is also what patients need to understand a topic. They know this and so they head for the internet. That's where it gets exciting. 

Since I am in the process of building a website for patients, I have been researching other doctors' websites. They range from the sublime to the ridiculous. Most of the sites have some useful information. However too many of them contain unfounded claims and conflicts of interest by way of selling unproven remedies. In many cases the remedies involve foods or supplements which in limited lower quality studies, showed promise, but were never followed up or proven. 

I will highlight perhaps the most prominent of these internet doctors, Dr. Mehmet Oz. With the most impeccable of academic credentials, and a media empire to boot, he is under serious fire for making unsubstantiated claims and hawking unproven products. The best documentation of this to date is through Vox Media, what I would call the thinking person's news network. Until I read the series of articles at Vox, I had no idea, since I do not have a TV. Check out this entertaining and informative debate here

Meanwhile, if you would like to read more about how to safely navigate the internet, check a  series of pages on my site, starting HERE.  There are lots of internal links so be prepared to click. I really put my heart into these pages since I believe strongly in freedom of information and the patient empowerment movement. I hope they are beneficial for you.