Ethics of Authorship: What’s So New About the Upcoming Clinical Practice Guidelines for Menopause : They’re Written by Women

June 14, 2015 • By

When I attended the 2015 Endocrine Society meeting in San Diego, I was struck by the sessions about the upcoming clinical practice guideline on menopause (Treatment of Symptoms of the Menopause): they were authored by women. Here’s an interview with Cynthia Stuenkel, MD, Chair of the Menopause Clinical Practice Guidelines Taskforce for the Endocrine Society:

Ethically, does gender really matter when it comes to producing evidence-based practice guidelines on menopause? Yes. It does when it’s about menopause.

When considering beneficent therapies for peri and post-menopausal women, it’s still difficult for male practitioners to understand and appreciate subtle and nuanced qualitative differences in menopause symptoms. The most caring and sensitive male practitioner has still never experienced an ordinary period and cramps, flooding, hot flashes, and bloating. And for many women reaching their career peaks in peri- and post-menopause, it’s difficult for males to imagine these symptoms while chairing a meeting or making a major presentation. Several professional women in this phase of life pack plenty of red clothing (pant suits, dresses, or skirts) when traveling because of the unpredictable nature of their menses.

From a medical sociological perspective, women bond over their uterine experiences. Transgendered females (who transitioned from males) have noted the differences in intimacy between female and male friendships, for example: women talk about their bodies. Women who don’t know each other may immediately share information about the state of their uterine health in a public bathroom or private boardroom.

Clinical practice guidelines authored by female experts in menopause hormone therapy may help to ensure that patients’ reported symptoms help to guide goals of treatment. At the same time, patients may begin to place trust in evidence-based guidelines for hormone therapy when they can no longer just brush them off as a “male-dominated industry”.


Mad Men Finale and Type 2 Diabetes: What Happened “When We Bought The World A Coke”?

May 18, 2015 • By

As all Mad Men fans now know, the main character, Don Draper, “found” himself at a wellness retreat — and presumably “taught the world to sing” by creating that iconic “Hilltop” Coca-Cola ad from 1971, which established Coca-Cola as a global brand: .

See the New York Times review of the finale here:

A few things happened when we bought the world a Coke.

In 2005, the Liquid Candy report was released, which tracked soaring obesity rates directly to the marketing of soft drinks:

In 2010, a paper in Diabetes published a direct link to type 2 diabetes: people who consume sugary drinks regularly—1 to 2 cans a day or more—have a 26% greater risk of developing type 2 diabetes than people who rarely have such drinks:

What are the ethics of allowing soft drink companies to continue to promote their products to children, or at sporting events? Should we impose similar advertising bans as we did with Big Tobacco? When the Mayor of New York City tried to impose a ban on Big Soda (as in jumbo size containers), it didn’t go very well:

In 2011, Coca-Cola began its own wellness campaign to offset public opinion:

Unlike Big Tobacco, which is an addictive carcinogen with a direct causal link to lung cancer (as we see in the fate of the character, Betty), Big Soda is not in the same category. It is only one of many factors in the type 2 diabetes delivery system.

Transgender Medicine

He Says/She Says: Ethical Considerations for Transgender Patients

May 11, 2015 • By

Bruce Jenner’s recent interview with Diane Sawyer was essentially a public service to endocrinology, but it may have unintended consequences for Jenner and his family. The interview can be accessed here:

In 2009, The Endocrine Society published the first clinical practice guidelines for hormone therapy in these patients:

Long before the Jenner case became well-known, there have been concerns that endocrinologists are not being properly educated about treatment for transgender patients, as this 2014 press release for a transgender session indicates:

The Jenner case raises several sensitive ethical issues for patients and providers:

  • Confidentiality in transgender patients is often not possible after hormone therapy begins, as the transformation can be dramatic — long before the patient is ready to disclose. In high-profile patients, such as Jenner, patients may be forced to announce their treatments before they are psychosocially prepared. Discussions about confidentiality, and its limitations after treatment begins, should be part of the consent process.
  • There are concerns that media coverage of the Jenner case, or other cases, needs to be respectful, as the Center for Journalism Ethics has noted here:
  • Endocrinologists who are treating this patient population may need to work with journalists to ensure accurate information is being reported.
  • Personhood and pronouns. At what point in transition does the He become a She, or vice versa? It may be important to put together a treatment plan that includes “personhood planning”.

Ultimately, what used to be an occult practice in endocrinology is becoming part of mainstream practice. It’s time to create specific ethical standards for this unique subspecialty in endocrinology.

Reproductive Endocrinology

Leggo My Embryo: It’s Not a Frozen Waffle, but a Potential Person

May 11, 2015 • By

Endocrinologists are very familiar with Sofia Vergara, who is the Spokeswoman for a major brand of levothyroxine sodium, after her total thyroidectomy for thyroid cancer:

But her thyroid gland is not the only thing that’s out of her body.  She’s making bigger news in an unusual reproductive ethics case surrounding ownership of frozen embryos she created with her ex-fiancee, Nick Loeb. Recently, the issue aired on the Today Show:

The law is clear that embryos are not legal persons, even when created by celebrities. Personhood occurs at birth. But there is such a thing as “embryo patienthood.” This is a concept that grew out of the “fetal patienthood” framework developed by bioethicist Lawrence McCullough and OBGYN, Frank Chervenak.

So what is the moral status of frozen embryos? It all depends on whether they are patients.  McCullough and Chervenak assert that patienthood status is determined by the parents. If the embryos are intended to be future children, they are patients to which physicians owe beneficent-based obligations. If they are not presented as patients, they do not need to be morally considered.

But what happens when paternal and maternal interests clash? When Dad says the embryos are patients, and Mom says they are not? Reproductive endocrinologists need to ensure their couples have clear Advance Directives before creating potential persons. In the same way that we advocate for Advance Directives for End of Life decisions to avoid family conflicts over dying patients, we need Advance Directives for Beginning of Life decisions, too.


Childhood Obesity and National Security: Widespread Consequences

May 11, 2015 • By

Our young adults are “Not the Very Model of a Major General” because they are too fat. A disturbing report, “Too Fat, Frail, and Out of Breath to Fight”,  prepared by a retired Major General, General and Admiral in the U.S. Military, and funded by the non-profit group, Mission Readiness Minnesota, breaks bad news. It provides us with the stark consequences of the last two decades of the childhood obesity epidemic.  For any pediatric endocrinologist, the medical statistics may be familiar — especially for those who frequently see patients with BMIs over 40. But the epidemic has now created a national security problem for our all-volunteer military.

You can access the report here:

It concludes:

  • Nearly one in three young Americans is too overweight to serve.
  • > 60 percent of non-deployed active duty service members experience a sprain, stress fracture, or other musculoskeletal injury each year due in part to years of low calcium intake, lack of long-term exercise habits and/or excess weight. The military is spending billions treating these injuries among active duty personnel and veterans.
  • In Minnesota alone: 69 percent of young adults cannot serve in the military; 10% of young adults has asthma, which disqualifies them from service, but which is linked to obesity.

Bioethicist, Art Caplan, had this to say about the report:

Given the state of international conflicts, the U.S. Military may need to call upon pediatric endocrinologists, above all others, to serve their country by telling schools, once and for all, what to serve our children. In the meantime, an all-volunteer military appears to be unsustainable if our kids don’t slim down.