Menopause Symptoms And Quality of Life

Women who have reached menopause often feel as though they’ve traded one problem for another.  Sure, you don’t have to deal with the hassle of menstrual periods and worry about pregnancy anymore.  The hot flushes, night sweats, sleep problems, mood swings and vaginal dryness are not much improvement though.

Ask women who have menopause symptoms what their least favorite part is.  They will say the hot flushes and sweats at random times of the day and night.  They will tell you about the poor sleep and emotional roller-coaster.  They often WON’T tell you they have vaginal dryness and intolerable itching and loss of urinary control.  They usually won’t tell you they can’t tolerate intercourse with their partner anymore.

A lot of times they don’t tell ME that either.  I ask every woman at her physical about these symptoms if she is heading into menopause.  Women are embarrassed to discuss those parts of their bodies, even with their doctor.

There was a research study published recently in Menopause that asked women with menopause symptoms specifically about vaginal, vulvar and urinary symptoms.  Women who had had no menstrual period for at least a year were asked to fill out a questionnaire, and then had a gynecological exam.

Over 90% of the women were found to have vulvovaginal atrophy.  After the ovaries stop making estrogen at menopause, the skin and other tissues around the vagina and urethra become thinner, dryer and more fragile.  This is called atrophy and is often responsible for the itching, irritation and pain with sex that many women experience.

Many women know about hormone replacement therapy for menopausal symptoms and often refuse to take it.  Not as many women know that there are safer alternatives for vulvovaginal atrophy.  I usually recommend women try over-the-counter DHEA cream which they can get at the health food store or online.  One of my patients told me she tried Julva cream which she bought online and it helped a lot.  (Not an affiliate and I have no personal experience with it, just passing along a report from a happy patient.)

Topical estrogen cream is also very effective and is safe to use even in women who have had estrogen-sensitive breast cancer.  This is a prescription and usually requires an exam to make sure the diagnosis is right.  Many things other than vulvovaginal atrophy cause itching in pain (including infections and some skin conditions).

If you or a woman you love is suffering with itching, pain and/or urinary symptoms after menopause please don’t suffer in silence.  See the doctor and discuss your symptoms so you can get treatment.  Treatment works!

QUESTION:  Have you had problems with menopausal vaginal symptoms?  How has it affected your life?

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What Is Acute Flaccid Myelitis?

It’s a parent’s nightmare.  Your perfectly healthy child comes down with a bad cold.  While they’re miserable for a few days they get better as expected.  Then shortly after the cough and snot are gone, your child gets sick again.  Suddenly your child loses the ability to walk because their legs become very weak.

Since 2014 there has been a new, rare and severe neurological condition reported mostly in children called acute flaccid myelitis (AFM).  This illness can result in permanent paralysis and the cause is not known.

Acute flaccid myelitis behaves almost exactly like polio but it is NOT caused by the poliovirus.  Doctors have checked and none of the patients have had poliovirus in their bodies.  However, almost all of the patients have had a fever or mild respiratory illness before the weakness started.  Most of the cases occur in the late summer and early fall, when the class of viruses that includes polio, enteroviruses, are most common.

AFM causes the sudden onset of weakness in one or more limbs.  Usually one side of the body is more seriously affected than the other.  There is usually no numbness or loss of sensation in the limb(s) although there may be associated pain.

Patients may also have trouble swallowing, weakness or drooping on one side of the face, double vision, problems speaking, and in severe cases trouble breathing.  If you or your child develops these sort of symptoms it is important to get care right away because treatment can be lifesaving.  Even though the cause isn’t known, prompt diagnosis and treatment are critical.

Other illnesses can behave like acute flaccid myelitis.  A stroke, West Nile Virus, Guillain-Barre syndrome and some other infections are on the list.

It’s estimated that one to two in a million children in the US will get AFM per year.  That’s REALLY rare, but very serious.  Parents need to know that if their child seems lethargic or has any weakness at all, they should seek care immediately.

QUESTION: Have you heard of acute flaccid myelitis?

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Eating Out With Food Allergies

As someone who has multiple food allergies/intolerances, I know from personal experience that restaurants can be tricky.  When you have to avoid a number of common ingredients, eating out makes one anxious

Parents of children with food allergies are understandably more comfortable eating their meals at home.  When they control the ingredients they can be sure their kids are safe.  However, there are a number of strategies that can make eating out safer for both children and adults with food allergies.

There was a poster presented at the American College of Allergy, Asthma and Immunology annual meeting this week in Washington State.  Researchers at University Hospitals Rainbow Babies’ and Children’s Hospital explored strategies used to avoid allergic reactions in restaurants.

They found that those who had never had a reaction used more safety strategies than those who had had reactions.  Once a person had an allergic reaction, they tended to increase their use of safety strategies.  This makes sense, right?  Anyone who has had an allergic reaction is pretty motivated to avoid another one!

The allergens people reported included the most common ones like peanuts, tree nuts, dairy, wheat, eggs and soy.  85% of the participants were children, they were split evenly male-female, and most were white.

Safety strategies varied widely.  The most common strategies included

  • Talking to wait staff, manager and chef about allergies
  • Checking menus and ingredients on the restaurant website, if possible
  • Choosing restaurants that are allergy-friendly or have a low chance of contamination
  • Ordering meals with simple ingredients
  • Double checking with wait staff after food arrives

The researchers found that the more different strategies were used, the less likely reactions were.  They also advised that whenever eating out, those who have food allergies should always bring an EpiPen or similar treatment with them in case of a reaction.

I know from my own experience that eating out with food allergies can be tough.  However, if you or your family member has food allergies, you don’t have to give up restaurant foods.  Simple strategies can make eating at restaurants safer and more enjoyable!

QUESTION:  Do you or a family member have a food allergy?  What strategies do you use to make eating out safer?

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Weight Loss Reduces Breast Cancer Risk

Are you tired of me talking about weight loss yet?  LOL!  I just came across yet another reason for women to lose and maintain their weight after menopause.  Weight loss reduces breast cancer risk!

There was an study recently published in Cancer that looked at breast cancer risk in women who gained weight, maintained their weight and lost weight after menopause.  The authors found that weight loss of at least 5% body weight after menopause did significantly decrease the risk of breast cancer over the 11 year follow up period.

In this study, women lost an average of 19 pounds.  While not a small amount of weight, it isn’t a crazy amount either.  They were able to maintain their weight loss for the most part too.

We know that breast cancer risk is higher in women who are overweight and obese.  Since over 1/3 of women in the United States are obese, this is a significant risk factor for breast cancer in this country.  According to NHANES survey data from 2013-2014, 40.4% of women in the US are obese.

Let’s do some math.  Approximately how many American women are obese?  In 2010 (according to census data) there were just under 157 million female Americans.  53.2 million were over 50, and 40.4% are obese.  That’s 21.5 million obese female Americans over age 50.  (Since we’re talking about breast cancer I want to focus on the population most at risk, and the study focused on women after menopause.)

In the study just published in Cancer, they found that 5.09% of women who maintained their weight got breast cancer, and 4.27% of the women who lost at least 5% of their body weight got breast cancer.  That’s an absolute risk reduction (ARR) of 0.82%.  This translates to a Number Needed to Treat (NNT) of 122.  (Remember that NNT = 1 / ARR)  This also assumes that the breast cancer risk reduction was caused by the weight loss.

If 122 obese women have to lose at least 5% of their body weight (and maintain that loss) to prevent one case of breast cancer…

That is over 176,000 women that could be spared breast cancer over approximately a 10-year time frame.  With about 266,000 women diagnosed every year with breast cancer, that’s a 7% reduction.

Will you be one of the women who suffers a potentially preventable case of breast cancer?  Now that you know weight loss reduces breast cancer risk, will you make sure to lose weight and get closer to your ideal body weight?  Your heart, your liver, your brain, your pancreas, your joints, your back, and even your breasts will thank you!

QUESTION: Do the numbers in this article surprise you?

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Surgery Type Matters In Cervical Cancer

Cervical cancer screening is a routine part of women’s health care.  I do Pap tests and HPV screens every week to check for this problem.  Luckily I rarely make a cancer diagnosis (although abnormal Pap tests are fairly common).

Cervical cancer is one of the most common cancers in women worldwide, with over half a million cases diagnosed per year.  About 13,000 new cases are expected to be diagnosed in the US in 2018.  Approximately 4000 American women will die of cervical cancer this year, according to the American Cancer Society.  Women are most commonly diagnosed in their 30s and 40s, but it can happen in women over age 65 as well.

It’s important to realize that this disease is more common in black and Hispanic women, but much less likely to occur in women who get regular screening.  Cervical cancer is preventable with vaccination, regular screening and treatment of abnormal cells found on Pap tests.

Once a diagnosis of cervical cancer is made, surgery is the most effective treatment.  Hysterectomy and removal of lymph nodes in the pelvis is necessary.  What hasn’t been understood until recently is whether the TYPE of hysterectomy mattered.

In this country, most surgery that CAN be done in a minimally invasive way IS done in that fashion.  Laparoscopic and robot-assisted surgeries are associated with less pain, shorter recovery, less blood loss and less risk of infection.  However, recently it has been found that these minimally invasive surgical techniques are actually associated with a HIGHER death rate from cervical cancer.

Two articles (1, 2) published in the New England Journal of Medicine this week showed that open abdominal hysterectomy was much better as far as survival goes than laparoscopic or robot-assisted hysterectomy for cervical cancer.  The number needed to harm in one study was 19 which is really low.  This means for every 19 patients who were treated with a minimally invasive rather than open procedure, one went on to die of cervical cancer who would have survived with the open procedure. In the other study the number needed to harm was 26.

I have two take-home points from this frankly shocking finding.  First, if you know anyone with cervical cancer make sure they know a “keyhole surgery” approach is not as safe as an open procedure.  We can’t assume that an operation that’s right for one condition (like gallbladder removal and appendectomy) is the best for all problems.

The second point is that there needs to be more research done on minimally invasive surgery in cancer patients.  There must be some reason for the difference.  Neither of these studies really addressed WHY there is such a difference between open and minimally invasive operations for cervical cancer.  There are any number of possibilities.  Minimally invasive surgery is as safe for uterine cancer as an open procedure, for instance.

Could it be because cervical cancer is caused by a viral infection?  Or because affected  lymph nodes in cervical cancer are smaller or more subtle or harder to see through the laparoscope?  I really don’t know, and clearly no one else does either.

But with less pain, shorter recovery time, less bleeding and less risk of infection, minimally-invasive surgery is best IF scientists can figure out how to make it safer for cervical cancer patients.  That would be the best result of all.

QUESTION: Do you know anyone who has or had cervical cancer?  What was their experience like?

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Reduce Your Breast Cancer Risk

October is breast cancer awareness month!  My mother, aunt and grandmother all had breast cancer, so reducing MY breast cancer risk is of pretty high interest to me.

Lots of women don’t think about their breast cancer risk except when they get their yearly mammogram.  Early detection makes treatment easier and more successful, so it’s definitely important, but getting your mammogram will not reduce your risk of getting breast cancer.

So what WILL reduce a woman’s breast cancer risk?

Exercise

Even 30 minutes of walking will reduce your risk.  In fact, 30 minutes of brisk walking 4 days per week reduced breast cancer risk by 30-50%.  That’s a huge reduction from just a little effort!

Maintain your weight

Obesity significantly increases a woman’s risk of all cancers including breast cancer.  There is an enzyme called aromatase that is present in fat cells.  It changes male hormones into female hormones.  Even after menopause women’s adrenal glands still make male hormones.  The more fat cells you have, the more aromatase and the more estrogens.

Breast cancer cells are often responsive to estrogens, and so obesity increases the stimulation and growth of these estrogen-sensitive breast cancer cells.  Achieving and maintaining a healthy weight decreases breast cancer risk.

Alcohol

Increasing alcohol intake raises the risk of breast cancer.  Even 3-4 glasses of wine per week has been shown to raise the risk.  The more you drink the higher the risk, but there is no evidence of a “safe” level of alcohol intake.

The most important risk factors for breast cancer are, of course, age and gender.  Women get breast cancer 100 times more often than men, and the risk goes up as we get older.  There are inherited genetic risk factors as well, and there are links to how early menstrual periods started, how many children you’ve had and how late menopause occurred.  Breastfeeding also decreases the risk.  Some of these, like age, are things we can’t control.

But there ARE risks that we can control!  Don’t smoke or drink, exercise regularly and maintain a healthy weight and you will be doing a lot to control your breast cancer risk.

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ER Visit Denials

Imagine you just flew home from a dream trip to Europe and after getting a good night’s sleep in your own bed, you wake up with chest pain and trouble breathing.  Now you’re a young woman so heart attacks really aren’t on the top of your list of worries, but you’re really uncomfortable and a little scared.  A quick call to your doctor’s office and, once informed of your recent airplane flight and the fact that you take birth control pills, you are told to head to the ER.

The ER staff and doctor are very kind and you get an exam, some labs and a scan of your chest which show your pain is from a rib that’s out of place and NOT from a blood clot.  That’s a relief!  Sleeping in funny positions on trains and planes isn’t good for you!

Anti-inflammatories, heat and rest are just the trick to settle the pain and you’re feeling better in just a few days.  However, a different kind of pain starts about 6 weeks later when you get the bill for your ER visit.  Your insurance company has denied the claim, stating that they won’t pay for you going to the ER for a “non-emergent” visit.

Turns out insurance companies like Anthem are trying to control costs by denying claims for ER visits for what they consider non-emergency reasons.  A report published in JAMA recently analyzed what percentage of visits would not be covered and how that relates to the symptoms patients are experiencing.

The researchers found that about 15% of ER visits would be denied with the retrospective review policy.  The problem is that these denied claims had the same symptoms (chest pain, abdominal pain, etc.) as claims that were not denied.  The insurance companies expect patients to distinguish between different types of chest pain and abdominal pain without the benefit of medical training.

This is a mistake.  The researchers in this study noted that patients are going to be hurt by this policy.  If patients with chest pain are afraid their ER visit isn’t going to be covered if it turns out to NOT be a blood clot or heart attack, they will be less likely to get checked out in a timely fashion for problems that could be very serious.

I have a hard enough time getting patients (especially women) to go to ER for chest pain or stroke symptoms.  If insurance companies start denying claims for chest pain that turns out to be bad reflux, or stroke-like symptoms that turn out to be from migraine, people are going to be more likely to ignore their symptoms until it’s too late.

People should NOT go to ER for problems that aren’t emergencies.  Someone who goes to the ER for a sore throat (unless they are directed to go there by their primary care doctor) should have the option of an urgent-care level of care.  Too many non-emergency visits to the ER slows down care for those who have a true emergency.

It’s often hard for us with medical training to be sure someone isn’t having a serious problem.  I send folks to the ER all the time to be evaluated when I can’t reassure them in the office that nothing life-threatening is wrong.  Asking patients without medical training to make those decisions is going to lead to people being hurt.

QUESTION: Have you been to the ER for something that seemed serious but turned out not to be?  What do you think of this new policy?

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The Danger Of Adulterated Supplements

When swimmer Jessica Hardy set two world records in 2008 and was getting ready to compete in the Olympics in Beijing, she had no idea her world was about to come crashing down.  She tested positive for a banned substance right before the Olympics.

Turns out she had taken adulterated supplements that contained the banned substance, undisclosed by the supplement company.  Because she was able to prove the supplement she took contained the substance, her suspension was reduced to one year instead of two.  Still, she missed the Beijing Olympics.

Given the danger of adulteration, why would ANYONE risk taking supplements?  In the United States the supplement industry is only lightly regulated so companies are free to make all sorts of outlandish claims about their products.  My personal feeling is that people are so desperate for a “quick fix” they’re susceptible to too-good-to-be-true product claims for weight loss and other problems.

A report was recently published in JAMA about adulterated supplements.  Turns out almost 800 supplements have been found to have drugs in them, including sildenafil (Viagra), sibutramine (Meridia) and anabolic steroids.  The adulterated supplements are most often marketed for – unsurprisingly – sexual enhancement, weight loss and muscle building.  You can access the database yourself here at the FDA website.

Whether you’re an Olympic swimmer like Jessica Hardy, a world-class wrestler like Narsingh Yadav or Vinod Kumar, or a runner looking to PR your next half marathon, SHOULD you use nutritional supplements?  Which ones should you choose?

If you’ve been following my blog for awhile you probably know my answers to these questions 😉  Good nutrition improves athletic performance, that much is very clear.  And supplements are an efficient way to make sure the body’s nutritional needs (for vitamins, minerals, electrolytes, carbohydrates and protein) are optimally met.

So given this information, taking supplements make sense.  But before choosing a nutritional supplement, you have to ask yourself some questions.  If you have access to a representative for the company (especially if it’s a direct sales company) here are some good questions to get answered.

  • Does the company sponsor Olympic athletes?  How many medals have the sponsored athletes won?  If there are no Olympic athletes, do they sponsor athletes competing in “clean” events – i.e. subject to drug testing?  If not, steer clear.  Many sports supplements have disclaimers in the product literature stating they are not meant for athletes subject to drug testing.  Don’t take those!
  • What research has been done with the company’s products?  Ask to see the publications.  Are they peer reviewed?  You can search in the NIH’s research database to see if it’s a “legit” research article or not.
  • What are the company’s quality procedures?  Is there a money-back guarantee?  How are recalls handled?  Who do you call with a problem?

Ultimately, with supplements the reality in the United States is “let the buyer beware.”  Customers are responsible for doing their own research because the industry isn’t well regulated.  If the product is advertised to produce results that seem too good to be true, they probably are.  Do NOT buy products advertised to improve sexual performance.  No supplement has ever been shown effective for that problem – only pharmaceuticals work.

If you aren’t aware of the company I chose to partner with, I have easy and transparent answers to these questions.

  • Yes, Shaklee sponsors Olympic athletes.  We have nearly 100 athletes and a total of 144 medals to our team’s credit.  That’s a lot of hard work (and a lot of supplements)!  Learn more about the Shaklee Pure Performance Team at this link.  No athlete ever has, or ever will, fail a drug test due to a Shaklee product.
  • Over 100 publications is a LOT of science to Shaklee’s credit.  Published in respected journals like Nutrition, Journal of Clinical Endocrinology and Metabolism, and Journal of Gastroenterology.  You can check out research Shaklee has sponsored about athletic performance, weight management, blood sugar support and other topics at this link.
  • Every lot of raw materials is tested for 350 different contaminants like pesticides, molds, heavy metals and other toxins before it is accepted to make Shaklee products.  Shaklee is BETTER than organic, since organic products can still become contaminated in many ways.  In addition, over 100,000 quality tests are done every year on finished products before they head out to customers.  Shaklee has never had a recall.  They don’t need to!  And if you have a problem, everything is guaranteed, even if you just don’t like a flavor.  You call me, or your distributor if it’s not me, and it gets fixed.  Period.

Again and again, we see in the news reports that supplements aren’t safe, that supplements don’t work, that supplements are at best a waste of money or at worst dangerous to your health.  This isn’t true.  Nutritional supplements are a vital part of supporting health and optimizing outcomes for athletes as well as for the rest of us.  It’s just important to make sure you know what you’re buying!

QUESTION:  Do you take supplements?  Why or why not?  Is this information surprising to you?

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The Power of Optimism

Do you know anybody who seems to walk around under a black cloud of doom?  Everything is always horrible, nothing good ever happens, and worse, nothing good ever WILL happen.

Are you one of those people?  Do you find yourself assuming there will be a bad outcome?

It turns out that ASSUMING there will be a bad outcome tends to lead to HAVING a bad outcome, in terms of health.  There is a lot of new research that shows pessimism is associated with negative health outcomes.  Studies on such different problems as unplanned C-section, cardiovascular health, quality of life after stroke, and sleep quality in children show an association between health and optimism/pessimism.

So what is optimism?  The dictionary defines optimism as “hopefulness and confidence about the future or the successful outcome of something.”  It is the tendency to look on the bright side, to assume things will work out for the best.

Some people are natural optimists, they seem to have a sunny disposition from childhood.  However, most of us have to consciously choose to look for the silver lining.

Are you a pessimist?  Do you tend to imagine terrible things, to assume things will turn out badly?  If so, you are probably not only living with anxiety and depression but you may also be hurting your health.

How does someone overcome their tendency to be a pessimist?  Is it possible to change?  Turns out the answer is yes!

Shawn Achor, a researcher at Harvard, has devoted his career to the study of happiness and optimism.  His book The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work talks about how optimism leads to success.  More importantly, it also details HOW TO BECOME AN OPTIMIST.

Not only is optimism helpful at work, it improves your life in many other ways.  Most importantly, as shown in Dan Buettner’s book The Blue Zones, Second Edition: 9 Lessons for Living Longer From the People Who’ve Lived the Longest, optimism is one determinant of long life.

Being healthy, living longer and being successful are goals that most of us have.  Optimism helps make achieving these goals more likely.  Get and read these two books, I promise you will be glad you did!

You are important to me, and I want you to be happy, healthy and successful.  Optimism is a choice, a skill that anyone can learn.  Make the choice to learn it, practice it and make it YOUR happiness advantage!

QUESTION:  Are you an optimist or a pessimist?  Why do you say that?

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Is Marijuana Use Bad For Your Health?

Over the last few weeks I have had several young patients (and some older patients too) admit freely to smoking marijuana regularly.  When asked if they have considered stopping, they answer “No, why would I stop?”

Ohio has recently legalized medical use of marijuana, and this morning I had some education on the controversy and realities of marijuana use for medical purposes.  It was easier for us doctors when it was illegal, LOL!

Does marijuana have good effects?  Yes, there are therapeutic reasons to use marijuana, which is the basis for legalizing the medical use.  However, it’s important to realize that the medical marijuana law does NOT allow smoking pot.  Legal forms include vaping, edibles, tinctures, oils and patches.

Marijuana helps patients with seizures, anxiety, post-traumatic stress disorder, chronic pain, nausea and vomiting from cancer therapy, fibromyalgia, inflammatory bowel disease, multiple sclerosis, and a host of other medical problems.  Ohio’s medical marijuana program should be deployed later this year (there have been logistical problems).

Doctors have to undergo education before they can be certified to recommend medical marijuana.  Marijuana can NOT be prescribed – it is a schedule I narcotic and if doctors prescribe it they will lose their DEA certification.  Doctors who are certified to recommend medical marijuana use can sponsor patients to get a card which will allow them to buy marijuana at a dispensary.

We have been informed that our medical malpractice insurance carrier will not cover us if we recommend marijuana.  All three large health systems in Cleveland and most (if not all) of the health systems in Ohio are in the same situation.  There are almost 300 physicians in Ohio (as of today) who do have certificates to recommend.  You can find the up-to-date list at this link.

What are the health risks if you do choose to use marijuana?  Smoking a joint increases the heart rate and slows coordination, interferes with thinking and remembering and increases appetite.  States with legal recreational marijuana use have recorded an increase in car accidents attributable to people driving while stoned.  I’ve seen a number of young women who smoke marijuana regularly and complain about weight gain.  (Go figure!)

Marijuana IS addictive.  It is the most commonly used drug of abuse in the United States.  Research has shown that 9% adult habitual users of marijuana  and 17% of teenage users will become addicted.  Signs of addiction include inability to stop using marijuana, continued use in spite of negative social and health consequences and difficulty maintaining relationships with others that don’t smoke pot.

Marijuana causes changes in the brain, specifically in areas related to learning and memory.  It’s worse when teenagers smoke pot, because their brains are still developing.  Pregnant women who use marijuana have children with higher rates of attention, learning and behavior problems.  Secondhand marijuana smoke also contains THC so parents who smoke pot around their children are exposing them to an addictive substance that affects their growth and development.

While it’s not proven that marijuana use causes lung cancer, it definitely causes problems with the lungs, including cough and phlegm production and an increased risk of bronchitis.  Also, most people who use marijuana also smoke tobacco, with all the risks tobacco smoking brings.

Even though use of small amounts of marijuana (the equivalent of one or two “hits” on a marijuana cigarette) can alleviate anxiety, using more actually can worsen anxiety.  Marijuana users are also much more likely to develop mental disorders like schizophrenia.  Teens in particular are more likely to have depression, anxiety and suicidal thoughts if they smoke pot.  It’s not clear whether this is a causative relationship (i.e. do they smoke pot because they’re depressed and anxious, or the other way around).

There is also a risk of poisoning with edible marijuana products.  Absorption through the GI tract is unpredictable and it can take 30 minutes to 2 hours to take effect.  It is easy to over-indulge if it takes that long for the drug to make itself felt.  Also, children can easily overdose if they get into marijuana edibles.  In states where marijuana is legal, ER visits for accidental overdoses in children have gone up significantly.

Marijuana use is on the rise.  Both adults and teens are using marijuana and have the mistaken impression that because it has been legalized for recreational and medicinal use that means it is safe.  Marijuana use is NOT safe, it has real and significant health and social consequences.

QUESTION: Do you think marijuana use should be legal?  Why or why not?

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