Monthly Archives: October 2019

Popular drugs with surprising side effects

Featured Articles in Internal Medicine In the News

Popular drugs with surprising side effects

John Murphy, MDLinx | August 14, 2019

For many drugs, typical side effects include upset stomach, dry mouth, and drowsiness. But, for some drugs—common medicines that millions of Americans take daily—the side effects may be more unusual. Indifference to other people’s feelings? Yes. Visual hallucinations? Yup. Hypomania? Certainly. Waking up naked in your backyard? It happens.


Some very common drugs—such as acetaminophen, steroids, and anticholinergics—can play surprising tricks on your mind.

Fortunately, these strange side effects don’t all occur with one drug. Here are some of the most common drugs in which they do occur.

Acetaminophen(Paracetamol): Lack of empathy

Acetaminophen—marketed as Tylenol, and available generically—is the most popular pain reliever on the drugstore shelf. But it can have a surprising side effect: lack of empathy for another’s pain.

In two randomized, double-blind trials, researchers tested 80 young adults—half who took placebo and half who took 1,000 mg acetaminophen—and found that those who took acetaminophen felt less empathy and distress in response to both hypothetical and actual scenarios of another person’s physical and social pain.

“Quite literally, acetaminophen reduces one’s ability to feel another’s pain,” the authors concluded.

In a similar placebo-controlled trial by the same investigators, people who took 1,000 mg of acetaminophen felt less positive empathy in response to uplifting scenarios of other people, even though they cognitively understood the positive impact of the other person’s experiences.

The researchers speculated that pain may share a deep neuronal connection with empathy—and they also warned of the large-scale social consequences due to such widespread use of acetaminophen.

Levofloxacin: Delirium

Levofloxacin is a broad-spectrum, third-generation fluoroquinolone used as a first-line treatment for urinary tract infections as well as for sinusitis, bronchitis, and pneumonia. It’s a potent antibiotic for serious infections—and it can cause equally serious side effects such as tendon problems, nerve damage, serious mood or behavior changes, and low blood sugar.

Recently, reports have surfaced about rare cases of delirium in patients on levofloxacin. In one case, a 76-year-old man, who was admitted for acute bronchitis and given levofloxacin, developed symptoms of confusion, disorientation, limited attention, and visual hallucinations. Once the levofloxacin was discontinued, his delirium abated.

Although only nine rare cases like this have been reported, the authors of this study say many more cases might be out there.

“It seems likely that this severe and potentially fatal adverse effect of levofloxacin is much more common than previously reported,” they wrote. “It also reflects the extreme under-recognition and under-diagnosis of drug-induced delirium generally, and levofloxacin-induced delirium specifically by physicians world-wide.”

Steroids: Psychiatric disturbances

Corticosteroids are often the “go-to” drugs for treating inflammatory conditions. Despite their popularity, they have a problematic side effect (actually, a group of side effects) that isn’t so well popularized: corticosteroid-induced psychosis.

Adverse psychiatric effects occur in an estimated 5% to 18% of patients treated with corticosteroids, with increased risk in patients taking higher doses (eg, 40 mg or more of prednisone daily) and in those on long-acting steroid therapy.

Corticosteroid-induced psychosis manifests with a wide range of symptoms, from euphoria and hypomania to mood swings and severe depression. It often occurs within a week of starting the steroid but can happen at any time—even after steroid therapy is completed. In fact, effects can persist well after discontinuing the drug; delirium can go on for another few days, mania for 3 weeks, and depressive symptoms for about 4 weeks.

Older adults are at higher risk for delirium or confusion. They’re also vulnerable to misdiagnosis—corticosteroid-induced dementia can be mistaken for early Alzheimer disease, for instance.

Tapering the corticosteroid often relieves most adverse psychotic effects. However, if steroid therapy can’t be discontinued or if psychiatric symptoms are severe, the patient can be prescribed a low-dose atypical antipsychotic.

Anticholinergics: Dementia

Anticholinergic medications are a broad class of drugs used to treat a variety of conditions, such as chronic obstructive pulmonary disease, overactive bladder, urinary incontinence, allergies, gastrointestinal disorders, and the involuntary muscle movements of Parkinson disease.

Short-term confusion and memory loss are among the drugs’ known side effects. Now, in a new article in JAMA Internal Medicine, investigators found that patients age 55 and older who were on potent anticholinergics for 3 years or more had nearly a 50% increase in their risk for dementia.

The researchers found significantly increased risks for dementia specifically with anticholinergic antidepressants, antiparkinson drugs, antipsychotics, antiepileptic drugs, and antimuscarinics for overactive bladder. The researchers found no increased risks for other types of anticholinergics, such as antihistamines and gastrointestinal drugs.

“We found greater increases in risk associated with people diagnosed with dementia before the age of 80, which indicates that anticholinergic drugs should be prescribed with caution in middle-aged and older people,” the authors concluded.

Insomnia drugs: Serious injury

The dangerous side effects of three popular insomnia drugs—zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata)—are now very well known (even sensationalized), yet they’re still surprising.

The drugs belong to a class categorized as sedative-hypnotics. After taking these insomnia medications, people have reported walking, driving, cooking, having sex, and many other potentially dangerous activities—all while still asleep, so they usually don’t remember what occurred.

In late April, the FDA required that these three drugs carry black box warnings after a total of 66 serious injuries and deaths were reported. The incidents were results of “complex sleep behaviors” that occurred after patients took these medications.

“The 20 deaths reported were from carbon monoxide poisoning, drowning, fatal falls, hypothermia, fatal motor vehicle collisions with the patient driving, and apparent suicide,” according to a statement from the FDA. “The 46 reports of non-fatal serious injuries included accidental overdoses, falls, burns, near-drowning, exposure to extreme cold temperatures leading to loss of limb or near death, self-injuries such as gunshot wounds, and apparent suicide attempts.”

An internet meme has even appeared that gives a name to such events, dubbed the Ambien Walrus. People lay blame on the Ambien Walrus for leading them, while asleep, into some dangerous and some not-so-dangerous activities after taking one of the insomnia meds—such as online shopping, gambling, texting and Tweeting, binge eating, making crafts, housekeeping, going naked in public, etc.

Magic health numbers: Physicians analyze new research and offer advice

Top News in Internal Medicine

Magic health numbers: Physicians analyze new research and offer advice

Newswise | October 08, 2019

We’ve all heard them—those popular “magic” numbers that serve as goals to help us manage our health and achieve optimal wellness. But is it really important to walk 10,000 steps and drink eight glasses of water each day? Will cutting 300 calories a day promote weight loss and improve overall health? And how much coffee is too much?

Three Western Connecticut Medical Group (WCMG) physicians—Dr. Maura Conway, Newtown Primary Care, Dr. Nick Florio, Ridgefield Primary Care, and Dr. Mojisola Ukabi, Brookfield Primary Care—summarized research and the “why” behind several popular health numbers. Here’s their analysis, as well as some recommendations based on their extensive experience advising patients on all aspects of health and wellness.

Is 10,000 steps a meaningful number?

For many years, walking 10,000 steps per day has been considered the “magic” number for optimal health. The Journal of the American Medical Association (JAMA) Internal Medicine recently published results from an observational Women’s Health Study focused on whether increased steps per day are associated with lower mortality rates among older women.

The study found that participants who walked as few as 4,400 steps per day experienced lower mortality rates when compared to participants who walked 2,700 steps per day. And, the more steps participants took per day, the more their mortality rates dropped. However, the study showed that mortality rates leveled off at 7,500 steps, meaning that study participants who walked more did not have significantly lower mortality rates.

WCMG physicians agree that although the key takeaway point from the research is accurate—being active during the day can have health benefits—walking 10,000 steps is not a magic number for everybody, especially because 10,000 steps is not a scientifically-derived number.

“10,000 steps was established because it’s almost five miles, and walking five miles a day is good,” said Dr. Conway.

According to WCMG physicians, finding the right type of activity for your lifestyle and fitness/mobility level—as well as setting goals that motivate you to gradually move more—are the best steps you can take toward improving your health.

“Activity level needs to be patient-centered. For someone who is very active, 10,000 steps won’t be impactful. And for someone who is not very active, a goal of 10,000 steps a day might be discouraging and lead them to give up,” said Dr. Conway.

“People shouldn’t be discouraged if they get a wearable tracker and they don’t reach 10,000 steps per day. If a patient can’t walk or can’t meet 10,000 steps, they should talk with their doctor about other activities they can do,” said Dr. Florio.

Dr. Florio said that keeping track of the length and intensity of your exercise sessions is also an effective alternative to counting steps and can result in health gains.

“I follow the American Heart Association guidelines, which state that most people should engage in at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity spread throughout the week. In addition to physical activity, people should add resistance or weight training at least two days per week,” said Dr. Florio. “Examples of moderate-intensity activity include a brisk walk, slow bicycling, gardening, dancing, or water aerobics.”

Bottom line: Although popular fitness trackers and health guidelines promote walking 10,000 steps, daily activity goals should be personalized and reflect your fitness/mobility level, lifestyle, preferences, and abilities.

Can you improve your overall health by cutting 300 calories a day?

Study results recently published in The Lancet Diabetes & Endocrinology found that participants lost an average of 16 pounds during a two-year period when they cut their daily calorie intake by about 300 calories. In addition to weight loss, researchers also observed that participants who restricted their daily calorie intake showed decreased inflammation and improvements in cholesterol levels, blood pressure, and blood sugar control (which reduces the risk of developing type 2 diabetes).

“The research results make sense because eating fewer calories will help people lose weight over time. Maintaining a healthy weight contributes to overall better health and improved mobility,” said Dr. Conway. “Establishing a target number of calories to cut per day can make it easier for some people who are working on losing weight. However, weight loss should be patient-centered because the number of daily calories each person needs to cut to lose weight will vary.”

Dr. Florio said that it is often difficult for people to significantly reduce their caloric intake. In this study, for example, researchers wanted participants to cut their caloric intake by 25%. However, participants were only able to reduce the number of calories they consumed by 12%.

Dr. Florio said that some people might also have trouble cutting a certain number of calories or following a specific diet.

“I talk to patients about not dieting, but instead making sustainable, healthy, and long-term changes to their eating habits,” said Dr. Florio.

Dr. Ukabi agrees that there is some truth to this research, but it’s not specific to cutting 300 calories per day. She recommends an “everything-in-moderation” approach to weight loss.

“It’s good to cut calories if you want to get to or maintain a healthy weight, but don’t cut calories by depriving yourself of what you enjoy,” said Dr. Ukabi. “Most people tend to ‘cheat’ when they deprive themselves of certain foods. So if you love bacon, eat one piece instead of the four pieces you might normally eat. That way, you still get the taste, but with fewer calories.”

Bottom line: Reducing your calorie intake over time may help you lose weight and improve your overall health, but the number of calories each person needs to cut to achieve health gains will vary. As an alternative to counting calories, you can also reduce your calorie intake by making sustainable, long-term changes to your eating habits and portion sizes.

How much coffee is really okay?

There is a lot of conflicting research out there about how much coffee is too much, and whether coffee is good or bad for your health. For example, a study conducted by researchers at Queen Mary University of London, United Kingdom suggested that drinking up to 25 cups of coffee per day is safe for heart health. However, another study in The American Journal of Clinical Nutrition suggested that drinking more than six cups of coffee per day is associated with a moderate increase in the risk of cardiovascular disease.

“Coffee intake research is conflicting,” said Dr. Conway. “Although some research suggests that too much coffee can be harmful, other studies suggest that drinking coffee could lower the risk of developing certain health conditions, such as heart disease.”

Drs. Conway, Florio, and Ukabi said that they advise most patients to drink coffee in moderation. However, patients with certain health conditions may need to be aware of how coffee affects their body.

For example, Dr. Ukabi said that if you experience heart palpitations after drinking coffee, you should talk to your doctor—you may be drinking too much.

“I usually only talk to patients about caffeine intake if it might be related to another health condition, such as bladder irritation, heart disease, or insomnia,” said Dr. Florio. “In general, two-to-four eight-ounce cups of coffee per day are a normal, healthy amount for people who do not have an underlying health condition.”

Also, Dr. Florio said it’s important to know what researchers consider to be a “cup” of coffee.

“What you buy in the store is usually much more than one cup. It’s also important to know how much caffeine is in the coffee, as different types of coffee have varying amounts of caffeine,” said Dr. Florio.

WCMG physicians also advise patients to be conscious of what they are adding to their coffee and the effect it may have on calorie intake.

“Black coffee is best because you can avoid added calories and sugar from cream and sweeteners,” said Dr. Ukabi.

Bottom line: A few cups of coffee per day are safe for most people who do not have other health conditions. However, you should pay attention to the amount of caffeine the coffee contains and the size of the coffee—as well as how drinking coffee affects your body—to make sure you aren’t drinking too much. You should also be aware of how added sweeteners or cream may impact your calorie intake.

Do you really need to drink eight glasses of water a day?

There are many different recommendations and formulas for figuring out how much water you should drink each day. Although there’s no question that your body needs adequate hydration to function at its best, WCMG physicians agree that water intake needs vary from person to person and should be based on diet, activity level, urine output, and health conditions.

For example, if people are breathing heavily, sweating a lot, or are dealing with diarrhea or another acute illness, they should increase their water intake to make up for water loss.

“Eight glasses of water a day isn’t one-size-fits-all. One person may need eight glasses of water per day, and another may need just two or three,” said Dr. Florio.

Drs. Conway, Florio, and Ukabi said that monitoring water intake becomes more important for people who have medical conditions such as congestive heart failure or kidney disease because these conditions cause problems with regulating fluid in the body.

Dr. Florio said that paying attention to your body’s thirst signals is also an excellent way to make sure you stay adequately hydrated.

“The body is smart and does a good job regulating hydration in healthy people. You feel thirsty when you need more water and feel satisfied when you’ve had enough,” said Dr. Florio. “You don’t necessarily need to drink a specific number of glasses, but you should listen to your body.”

“In general, urinating every two-to-four hours means that your hydration levels are good. If you haven’t urinated in two-to-four hours, you may be dehydrated and should drink water,” said Dr. Ukabi.

Bottom line: Unless you have a health conditions that affects your body’s ability to regulate fluids, drinking water when you feel thirsty is usually enough to help you stay hydrated. Paying attention to your urine output and activity level can also give you clues about your hydration needs.

Although following these popular “magic” health numbers may help some people achieve their health goals, they aren’t a “one-size-fits-all” solution for everyone. The best way to achieve optimal wellness is through a personalized diet and activity plan that reflects your unique needs.

Breast cancer risk.

One in five breast cancers linked to alcohol

New analysis shows impact of booze on cancer understated

New Cancer Council analysis published in the Medical Journal of Australia shows the level of cancer incidence caused by alcohol in Australia is higher than previously thought, with more than 5000 new cases each year linked to long-term drinking.

Applying the latest international data to Australia, the analysis estimated that 22 per cent of the nation’s breast cancer cases were linked to alcohol consumption. It also factored in new evidence linking alcohol to bowel cancer in men.

Cancer Council Australia CEO and a co-author of the analysis, Professor Ian Olver, said community awareness of the links between alcohol and cancer should be raised so people could make more informed lifestyle choices to help minimise their cancer risk.

?We have known for some time that alcohol is a major risk factor for breast cancer, but only by applying international data to Australian drinking patterns were we able to estimate that more than one in five cases here are linked to alcohol,? Professor Olver said.

?Factor in the new evidence on bowel cancer in men and the established links to cancers of the mouth, pharynx, larynx, oesophagus and liver, and alcohol is clearly one of the most carcinogenic products in common use.?

Professor Olver said the impact on breast cancer was a particular concern, as there were few other steps women could take to minimise their risk.

?A lot of effort goes into raising breast cancer awareness, but how many Australian women are aware that reducing alcohol consumption is one of the best ways to reduce their breast cancer risk?? he said.

Professor Olver said the dose-response relationship meant the risk of alcohol-related cancer increased with every drink consumed.

?The more alcohol you consume over time, the higher your risk of developing an alcohol-related cancer.

?So if individuals do choose to drink, our advice is to do so in accordance with the National Health and Medical Research Council guidelines, which recommend no more than two standard drinks a day.

Download Cancer Council Australia’s position statement on alcohol and cancer. 

Research consistently shows that drinking alcoholic beverages — beer, wine, and liquor — increases a woman’s risk of hormone-receptor-positive breast cancer. Alcohol can increase levels of estrogen and other hormones associated with hormone-receptor-positive breast cancer. Alcohol also may increase breast cancer risk by damaging DNA in cells.

Compared to women who don’t drink at all, women who have three alcoholic drinks per week have a 15% higher risk of breast cancer. Experts estimate that the risk of breast cancer goes up another 10% for each additional drink women regularly have each day.

What is perimenopause and how does it affect women’s health in midlife?

Perimenopause lasts months for some women, and years for others. from

What is perimenopause and how does it affect women’s health in midlife?

October 18, 2019 6.07am AEDT


  1. Gita Mishra Professor of Life Course Epidemiology, Faculty of Medicine, The University of Queensland
  2. Hsin-Fang Chung Research Fellow, School of Public Health, The University of Queensland

Disclosure statement

Gita Mishra is supported by the National Health and Medical Research Principal Research Fellowship

Hsin-Fang Chung does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


University of Queensland

University of Queensland provides funding as a member of The Conversation AU.

All women know to expect the time in life when their periods finish and they reach menopause. Many might even look forward to it. What many women don’t know, however, is they will also experience symptoms in the time leading up to menopause. This is known as perimenopause.

On average perimenopause lasts for three to four years, usually starting in the mid to late 40s. Some women may experience it for only a few months, but for others it can be as long as a decade and can start as early as the mid-30s. During perimenopause a woman’s menstrual cycle will become irregular, they may experience lighter or heavier than normal bleeding, and intermittent spotting.

Women who have never given birth, and those with early puberty, or short menstrual cycles are more likely to experience earlier perimenopause.

What’s happening to my hormones?

The ovaries produce the female hormones oestrogen and progesterone, which control menstruation and ovulation (when an egg is released from the ovary).

From a woman’s late-30s, the number of eggs left in the ovaries decreases more quickly. Leading up to menopausal transition, the level of oestrogen changes, dropping rapidly around two years prior to menopause and stabilising around two years afterwards.

Progesterone also decreases towards menopause as it is produced only if an egg is released. Lack of progesterone can result in irregular, heavier, and prolonged menstrual periods during perimenopause.

Read more: Chemical messengers: how hormones change through menopause

Common symptoms

Women can experience a range of symptoms during perimenopause including:

• hot flushes (a sudden feeling of warmth or intense heat that spreads over the face and upper body)

• night/cold sweats

• anxiety, depressed mood, or mood swings

• sleep disturbance and fatigue

• vaginal dryness; discomfort during sexual intercourse

• frequent or urgent urination.

In the last one to two years of perimenopause, women are more likely to complain of low-oestrogen-associated symptoms, in particular vasomotor symptoms (hot flushes and night sweats) and vaginal dryness.

Some groups of women are also more likely to experience menopausal symptoms, including those who are: overweight or obese, smokers, of low socioeconomic status, and those with anxiety, depressive symptoms, or who feel stressed.

Weight gain

A recent US study found the menopausal transition is accompanied by accelerated gains in fat mass and simultaneous losses in lean mass, and these changes in body composition continue until two years after menopause. It was found weight gain began in premenopause and increased steadily during perimenopause (around 0.4 kg per year).

A lack of exercise, unhealthy eating, lower levels of education, insufficient sleep, the number of births a woman has had, and a family history of obesity may substantially contribute to weight gain in midlife.

Menopause causes weight gain, and extra weight worsens the symptoms of menopause. So maintaining a healthy diet and exercise regimen in midlife is important for women. from


For women who seek medical advice for their symptoms, menopausal hormone therapy (MHT, also known as hormone replacement therapy) is the most commonly prescribed treatment. Hormone therapy can help to relieve symptoms by replacing oestrogen levels that fall naturally during perimenopause.

GPs should discuss the short-term (up to five years) and long-term benefits and risks, before women decide to use hormone therapy, according to the college of obstetricians and gynaecologists.

If hormone therapy is not suitable, there are other non-hormonal treatments that can be discussed with the GP. This includes changing lifestyle factors such as improvements in diet, regular physical activity, optimal weight management, and quitting smoking.

Read more: We don’t know menopausal hormone therapy causes breast cancer, but the evidence continues to suggest a link

Perimenopause in the workplace

For some women, menopausal symptoms such as vasomotor symptoms and fatigue can impact their performance at work. The Australasian Menopause Society recommends the following improvements to working conditions for women going through menopause which are based on the guidelines produced by the European Menopause and Andropause Society:

• raise awareness

• allow disclosure of troublesome symptoms

• review workplace temperature and ventilation

• reduce work-related stress

• allow flexible working arrangements

• provide easy access to cold drinking water and toilets.

Read more: How to make work menopause-friendly: don’t think of it as a problem to be managed

Contraception during perimenopause

Women still experience menstrual cycles during perimenopause and can fall pregnant, so contraception remains important. Contraception is required for two years after the last menstrual period in women aged under 50 years and one year in those over 50.

The use of combined hormonal contraceptives (such as pills, patches, or vaginal rings) until the age of 50 is acceptable if women are not at risk of heart disease or thrombosis. Risk factors include smoking, being overweight or obese, or having high blood pressure.

Hormonal contraceptives should not be used alongside hormonal treatments for menopause. Instead barrier methods (condoms or caps) or other methods (spermicides, implant or intrauterine devices).

Can sex improve your health? Yes. Yes! YES!

Featured Articles in Obstetrics & Gynecology In the News

Can sex improve your health? Yes. Yes! YES!

Naveed Saleh, MD, MS, for MDLinx | October 16, 2019

Sex binds humanity; people from all walks of life do it. Recently, researchers have taken a bigger interest in the benefits of sex in terms of quality of life and health. More research on the subject is emerging.


Sexual activity may offer some welcome health benefits.

Although research is limited because of the personal nature of the subject, the health implications of sex have been studied in the past. In now-classic research, William H. Masters, MD, and Virginia E. Johnson looked at physiological responses to sex in a laboratory setting in 1966. They found that during sex, respiratory rates increased up to 40 respirations per minute, systolic blood pressure levels rose from 30 mmHg to 80 mmHg, and heart rate increased to 110-180 beats per minute.

Let’s take a look at five health benefits of sex, according to scientific research.

Energy expenditure

Calories burned during sex has been a topic of debate for quite some time. Although not a lot by marathon standards, it seems that having sex does burn off some energy.

In a low-powered study published in PLoS One, young couples (mean age: 22.6 years) were monitored for energy expenditure during sex via wearable technology (armband). In total, participants burned about 85 kCal at moderate intensity. Specifically, men burned an average of 101 kCal total or 4.2 kCal/min, while women burned about 69 kCal total or 3.1 kcal/min.

In the study, participants also performed 30-minute endurance tests on a treadmill at moderate intensity. In men, average energy expenditure was 276 kCal on the treadmill, and in women, 213 kCal. Curiously, a few male participants managed to burn more calories while having sex vs using the treadmill, which begs the question of what exactly it is they do in the bedroom.

“These results suggest that sexual activity may potentially be considered, at times, as a significant exercise,” the authors concluded.

Increased immunity

Researchers of one study showed that in 112 college students stratified by sex frequency with a partner—none, infrequent (less than once a week), frequent (one to two times per week), and very frequent (three or more times per week)—those who had sex “frequently” had higher levels of salivary immunoglobulin A (SIgA) independent of sexual satisfaction or length of relationships. In other words, having more sex could do the trick in terms of boosting SIgA—an antibody that has been shown to play a pivotal role in protecting vulnerable areas (eg, oral cavity, lungs, and gut) from invading pathogens.

Then again, other investigators have demonstrated mixed results regarding the effects of sex on immune status. For instance, according to the results from one dyad of studies that included both community and undergraduate cohorts, higher levels of partnered sex was linked to lower immunity in women with depressive symptoms in contrast to men with depressive symptoms, who actually demonstrated higher immunity.

Importantly, these studies employed SIgA as a proxy for immunity. Obviously, immunity is much more complex than one biomarker and depends on other elements of the immune system, including inflammation and white blood cell counts.

Reduced risk of prostate cancer

Some researchers have shown a link between increased total ejaculations—sexual intercourse, nocturnal emissions, and masturbation combined—and decreased rates of prostate cancer. In the high-powered Health Professionals Follow-Up Study, men who ejaculated ≥ 21 times a month had a 31% lower risk of prostate cancer vs those who ejaculated 4-7 times a month.

Reduced depressive symptoms

Some experts have suggested an association between increased amounts of sex and decreased levels of depression. In fact, Stuart Brody, PhD, stirred up controversy in sexology circles when he wrote the following in a review:

“It is likely that only unfettered, real [penile-vaginal intercourse (PVI)] has important mood-enhancing benefits. A study of young women in the United States found that not only did Beck Depression Inventory scores worsen with increasing time since last PVI (ie, lower [frequency of PVI] is associated with more depression), but the use of condoms obliterated the apparent antidepressant effects of PVI.”

Obviously, lots of pleasurable and healthy sexual activities do not involve “unfettered, real” PVI, ergo the controversy.

However, there’s no controversy that sexual activity releases endorphins, neurochemicals, and hormones—like dopamine, oxytocin, and prolactin—that elevate mood and feelings of satisfaction and pleasure.


“Yes, sex can actually make it easier to fall asleep,” according to the National Sleep Foundation. “This is mostly because of the hormones that are released during the act. Sex boosts oxytocin (a hormone that makes you feel connected to your partner) and lowers cortisol (a stress-related hormone). Plus, having an orgasm releases a hormone called prolactin, which makes you feel relaxed and sleepy. All of that leads up to a nice, drowsy state that’s perfect for cuddling up and falling asleep.”

Bottom Line

On balance, sex may very well have some health benefits. At least it makes sense that sex could boost quality of life. However, research has been done on this very personal subject is limited, and studies are ripe for bias. So many other factors obfuscate any causal associations. Furthermore, studies are also often done in small populations of college students, so infer what you will.

From peaceful coexistence to potential peril: the bacteria that live in and on us

From peaceful coexistence to potential peril: the bacteria that live in and on us

Hand washing is an effective way to help prevent the spread of bacteria. rawpixel/unsplash

Much like Pig Pen in the comic strip Peanuts, we actually carry around a cloud of bacteria in the air surrounding us.

Bacteria are found in soil, in food, and on surfaces we touch all the time – our mobile phones, for example, are teeming with them.

Bacteria can be good. Our gut is full of bacteria, which help digest food. Fermented foods such as sauerkraut and yoghurt are made with, and contain, millions of bacteria.

But bacteria can be bad, too. They may infiltrate our skin and other defences and get into the wrong places, causing infection. There are several possible reasons for this, and they depend on the nature of the bacteria themselves, the types of entry points bacteria have available to them, and other factors.

How do our bodies fight bacteria?

Our bodies are normally very good at keeping bacteria where they generally don’t cause damage – on skin surfaces and in the digestive tract – and away from areas that should be “sterile” – such as the urinary tract or blood. Mostly this is done by using barriers that physically prevent the entry of bacteria.

But every so often bacteria make it through. The body then relies on a variety of internal defences to identify, isolate and deactivate the invading bacteria. Bacterial infections occur when one of these mechanisms is breached.

Physical damage to the skin, such as cuts and scrapes, or surgery, can allow bacteria ready access to the inside of the body, potentially introducing more bacteria than the body’s defence systems can handle.

Bacterial infections may occur when one of the body’s protective mechanisms is compromised. From

Alternatively, when the internal defence systems are damaged, such as for patients with weaker immune systems (those undergoing chemotherapy, or those with immune system disorders), bacteria can become established in places they are not meant to be.

Both cases are more likely when the bacteria are particularly opportunistic at invading and growing. These types of bacteria are called pathogenic. This is why we have infections caused by certain types of bacteria, such as Staphylococcus aureus or Escherichia coli, and not others, such as Lactobacillus bulgaricus and Streptococcus thermophilus (the bacteria in yoghurt).

The ability of bacteria and humans to peacefully live with each other explains why “superbugs” – bacteria that have become resistant to being killed by antibiotics – can be present, but not immediately dangerous.

Antibiotic-resistant bacteria on our skin

The prototypical drug-resistant bacteria – methicillin-resistant S. aureus (MRSA, or golden staph) – has been around for decades. Almost everyone has S. aureus on their skin, usually around the nose, but (depending on the country and study), anywhere from 1 in 50 to around 1 in 5 people carry a version of S. aureus that has acquired resistance to some types of antibiotics.

As long as it stays on the skin, resistant S. aureus doesn’t cause a problem, and people generally don’t know they carry it. But if it manages to breach the body’s barriers and cause an infection, it can lead to harm if the right type of antibiotic is not used to treat it. It’s usually at this point, during attempts to treat an infection, that it becomes identified as a resistant bacteria.

Read more: We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?

In a similar manner, a recent report found that another common skin bacteria found on everyone, Staphylococcus epidermidis, also has high levels of resistance. The researchers looked at patients with S. epidermidis infections predominantly acquired in a hospital setting. What is not known is how widespread the resistant bacteria are, as there has never been systematic testing for resistance in healthy individuals.

As with S. aureus, the resistant S. epidermidis only becomes a real threat when it has started an infection in the body that needs to be treated with antibiotics.

A more general threat posed by both of these resistant strains is that, as they are on the surface of the skin, they can be readily transferred between people, so the overall presence of resistant bacteria can increase.

Cuts and scrapes can allow bacteria to get inside the body. From

There is significant fear about another class of bacteria that have acquired resistance to almost all antibiotics, resulting in high levels of death in infected patients. These are Gram-negative bacteria, a type of bacteria that already has an additional protective outer layer that makes it more difficult to kill with antibiotics – even before becoming resistant.

The highly resistant species of concern include E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetebacter baumannii, and Neisseria gonorrhoeae. For example, death rates for patients with invasive infections caused by one specific type of resistant Gram-negative bacteria, carbapenem-resistant Enterobacteriaceae (CRE), are estimated to be over 40%. The CRE bacteria are resistant to one of the newer and more powerful classes of antibiotics we have – carbapenems – and are usually also resistant to most other antibiotics.

Read more: Five of the scariest antibiotic-resistant bacteria in the past five years

More than 20 patients died from CRE in Florida during 2008-12, while 6 out of 17 patients infected with a K. pneumoniae superbug died in a US hospital outbreak in 2011. Fortunately these cases are still very rare in Australia – for now.

But with increasing levels of international travel, when people visit countries with much higher levels of resistance in the general population and environment – places such as Greece, India, Brazil, Thailand, and China – they can be exposed to, and become silent carriers of, the deadly bacteria. It is important that, if in hospital for an infection or surgery after an overseas trip, you let your doctor know that you have been travelling.

Finally, good hand washing is one of the most effective ways to help prevent the spread of these silent assassins.

Are drug expiration dates fact or fiction?

Featured Articles in Internal Medicine In the News

Are drug expiration dates fact or fiction?

Naveed Saleh, MD, MS, for MDLinx | October 11, 2019

People commonly think that the stamped dates found on the packaging of eggs, dairy, poultry, meat, and other food products are “expiration dates.” They’re not. Rather, these dates indicate when the product in question is “best used by.” Where an expiration date alerts the consumer to the last day a product may be safely consumed, a “best used by” date informs the consumer to when a product may begin to lose its freshness, taste, aroma, or nutritional value.

The American Medical Association has looked into the issue and found that the shelf lives of many drugs extend well past their dates of expiry.

Unlike Food Product Dating, which is voluntary, federal law requires that drugs be stamped with expiration dates. But, like Food Product Dating, these expiration dates are more akin to “best used by” dates. They are simply a guarantee that the drugs will remain good until the listed date.

The US healthcare system is the most expensive healthcare system in the world. According to ProPublica, nearly $765 billion per year is wasted on healthcare. This waste comes in many forms, including the practice by pharmacies and hospitals of tossing out expensive meds that are inaccurately thought to be expired. In fact, “expired” medicines can remain potent decades after their manufacture.

The issue

You’ve likely been asked by a patient at some point during your medical career whether drugs expire. It’s a good question—and one that has been raising interest from various stakeholders over the past several years.

In a review article published in JAMA, expiration date was explained as follows:

“The date does not necessarily mean that the drug was found to be unstable after a longer period; it only means that real-time data or extrapolations from accelerated degradation studies indicate that the drug in the closed container will still be stable at that date. Most drug products have a labeled shelf life of 1-5 years, but once the original container is opened, the expiration date on that container no longer applies.”

Of note, there have not been any reports of toxicity after consumption or other use of expired drugs in current formulations.

From a legal perspective, drug companies don’t recommend using medications after the dates listed on their labels.

The American Medical Association has looked into the issue and found that the shelf lives of many drugs extend well past their dates of expiry.

The profligate cost of dumping perfectly good meds has not been lost on the US military, specifically the US Department of Defense—which, in coordination with the FDA, runs the shelf-life extension program (SLEP) and maintains the Strategic National Stockpile (SNS). To be ready for anything, such as a public health emergency, the federal government stockpiles pharmaceuticals in their original packaging.

The research

In a SLEP report summarizing data for 3,005 lots representing 122 different drug products dating back to 1986, 88% of the lots were extended past their original expirations dates. Furthermore, only 18% were discarded secondary to failure. 

Although a bit mealy-mouthed, here is the conclusion of the study:

“The SLEP data supports the assertion that many drug products can be extended past the original expiration date, but this additional stability period is highly variable. Due to the lot-to-lot variability, the stability and quality of extended drug products can only be assured by periodic testing and systematic evaluation of each lot. The results of this stability program can only be related to products that have been carefully stored in their original sealed container closures.”

Furthermore, in another study, the drug contents of flucloxacillin capsules, cefoxitin injection, captopril tablets, and theophylline tablets remained 98% intact 18-170 months past their expiration dates.

In another JAMA study, researchers examined the stability of aged drugs that were discovered in their unopened original packaging in a retail pharmacy. The 8 unopened medications, which had 15 different active ingredients, had expired 28 to 40 years prior to the investigation. In total, 12 of 14 tested drug compounds retained ≥ 90% of their concentrations per their labeling, including codeine, hydrocodone, and acetaminophen. Notably, however, aspirin lost nearly all of its active concentrations.

“The most important implication of our study,” wrote the authors, “involves the potential cost savings resulting from lengthier product expiration dating.”

It should be noted that drugs in suspension—like epinephrine—do lose their potency over time; thus, expiry dates should be followed for EpiPens and the like.

The stability and quality of expired medications varies greatly. And although no toxicities have been reported as a result of using expired drug products, drug potency may be affected. Physicians are urged to err on the side of caution, as are patients.

What do normal labia look like? Sometimes doctors are the wrong people to ask

What do normal labia look like? Sometimes doctors are the wrong people to ask

March 1, 2019 6.26am AEDT Some doctors’ websites make false claims to encourage women to have genital cosmetic surgery. rawpixel


  1. Maggie Kirkman Senior Research Fellow, Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University

Disclosure statement

Maggie Kirkman received funding for this research from the Australian Research Council (LP130100025) with partners Jean Hailes for Women’s Health, Women’s Health Victoria, Family Planning Victoria, the Australian Federation of Medical Women, and Monash Health. Maggie Kirkman is a member of the Australian Psychological Society


Monash University
Victoria State Government

Monash University provides funding as a founding partner of The Conversation AU.

View all partnersRepublish this article


Women’s genitals are as diverse as our faces, as you can see in the Labia Library photo gallery. We are accustomed to some faces being accepted as “beautiful”, and know that the standard varies across time and culture. We may be less familiar with the idea that similar judgements are made about the vulva.

The vulva includes the inner lips (labia minora) and outer lips (labia majora), the clitoris, and the vaginal opening. Labia can be long or short, wrinkled or smooth, dark or light. One side is often longer than the other, consistent with the asymmetry of most body parts. The exterior of the clitoris can be pea-sized or as big as a thumb.

Wes Mountain/The Conversation, CC BY-ND

Just as some people seek cosmetic surgery on visible parts of their bodies, women have resorted to cosmetic surgery on their genitals to make them resemble an ideal. The Western ideal vulva is represented by the Barbie doll: “a clean slit”.

More than half of GPs surveyed in 2016 reported being consulted by women and girls wanting genital cosmetic surgery.

Read more: What’s normal, anyway? GPs should discourage women from unnecessary genital surgery

But what do women see when they search for cosmetic surgery?

Doctors advertise online, offering procedures including labiaplasty to reduce the labia minora, reduction of the clitoral hood, and plumping up of the labia majora.

Our research team wanted to learn what was in popular websites advertising Australian clinics, and analysed 31 websites in 2016. The same or similar websites came up in our search this week.

Websites gave a strong impression that female genitals diverging from the “ideal” need surgery. Although most websites acknowledged that vulvas were naturally diverse, they used language that pathologised any appearance other than a Barbie doll.

Visible labia minora were described as “hypertrophic” (showing excessive growth), which sounds like a medical diagnosis. According to one doctor:

The primary goal of labiaplasty is to reduce the size of the labia by surgically removing excess skin and shaping it into a more youthful and attractive form.

Websites didn’t say why it was better to be youthful than mature in sexuality or sexual organs. “Youthful” implies a yearning for women who are compliant and self-effacing, with no alarming sexual organs and presumably sexual needs.

Websites also emphasised the need to be “feminine”, with a “neat” and “tidy” vulva, conjuring up images of a 1950s housewife. These doctors reinforced the idea of binary sex, in which women must look undeniably female, with no visible clitoris. One website claimed a protruding clitoris “can feel and appear like a very small penis, which can cause deep insecurity and sexual anxiety”.

“Excess, floppy or uneven Labia Minora” justified cosmetic surgery, as did psychological, emotional, and physical discomfort. These were often described as “symptoms” requiring surgery to improve women’s health and well-being. According to one website:

The truth is that relationships, exercise, even dressing can be negatively impacted by a large inner or outer labia.

A typical “patient testimonial” claimed that, after labiaplasty, “Suddenly empowered, I felt more womanly than ever.”

Large labia minora were said to be “unhealthy and unhygienic”. Women were warned that, should “symptoms” be left “untreated”, they would worsen and “contribute to an unpleasant smell developing in the sensitive area”.

Only one website talked about the lack of evidence to support claims about hygiene:

There is no evidence to suggest that labiaplasty surgery can reduce problems with recurrent thrush or address hygiene concerns or problems.

It was also claimed on some sites that women’s sex life would improve because they would no longer be anxious about the way their genitals looked, and because cutting off visible labia minora would make women more attractive:

It will be very apparent to your sexual partner that the external structure of the labia will have been altered visually—namely they’ll be smaller and better aligned. Your sexual partner will clearly notice this change for the better.

Some websites claimed cosmetic surgery had nothing to do with fashion or social pressure and everything to do with individual choice:

Labiaplasty is an individual consideration. It is not merely the domain of strippers or porn stars. It can improve the physical and psychological quality of life for women who [are] affected by genital irregularities. […] Part of being a woman is not ‘putting up with it’ but taking control by having access to choice.“

The sales pitch emphasised that labiaplasty was “simple,” “safe and pain-free”, “one-hour surgery”.

The websites’ primary interest appeared to be commercial. While most doctors showed awareness of at least some ethical practices (including risks or side-effects, usually described as “rare”), few gave evidence of practising ethically, such as performing surgery only on adults.

Only two warned of potential loss of sensation or the harmful effects of scarring.

Three websites did recommend that women seek a second opinion and another required a recommendation from an independent doctor.

Genital cosmetic surgery can cause loss of sensation and scarring. Shutterstock

Of course, doctors may practise ethically without giving details on their websites. However, it could be considered poor ethical practice to persuade women they need surgery on genitals showing no evidence of abnormality.

Medical organisations point to the lack of “high-quality evidence” to support female genital surgery for cosmetic reasons. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, for example, dismisses claims cosmetic genital surgery enhances sexual function or women’s self-image. The college has also raised concern that such surgery may exploit vulnerable women.

While supporting genital surgery for female anatomy following trauma, mutilation or congenital anomalies, the Australian Federation of Medical Women opposes the promotion of surgical techniques that make unproven claims about sexual satisfaction or attractiveness:

promoting and performing such surgery carries significant risks of physical and psychological harm to women and girls.

Because these websites represent GPs and surgeons, they carry the weight of professional and scientific respectability, which gives power to their message: women’s most intimate bodies need to be shaped to conform to fashion or beauty ideals.

The first principle of medicine is to do no harm. Encouraging women to cut off bits of their genitals to suit a fashion trend or social constructions of womanhood has at least the potential for harm. The time has come for stricter regulation and monitoring of medical advertisements rather than of women’s bodies.

What is CRISPR gene editing, and how does it work?

What is CRISPR gene editing, and how does it work?

February 1, 2018 6.04am AEDT Scientists discovered some bacteria can cut the DNA of invading viruses as a defence mechanism. They realised they could use this to cut human DNA.


  1. Merlin Crossley Deputy Vice-Chancellor Academic and Professor of Molecular Biology, UNSW

Disclosure statement

Merlin Crossley receives funding from the Australian Research Council and National Health and Medical Research Council. He is a Trustee of the Australian Museum, on the Board of the Australian Science Media Centre, and the Editorial Board of The Conversation.


UNSW Australia

View all partnersRepublish this article


Republish our articles for free, online or in print, under Creative Commons licence. Email t

You’ve probably read stories about new research using the gene editing technique CRISPR, also called CRISPR/Cas9. The scientific world is captivated by this revolutionary technology, since it is easier, cheaper and more efficient than previous strategies for modifying DNA.

The term CRISPR/Cas9 stands for Clustered Regularly Interspaced Short Palindromic Repeats/CRISPR associated protein 9. The names reflect important features identified during its discovery, but don’t tell us much about how it works, as they were coined before anyone understood what it was.

What does CRISPR/Cas9 do?

CRISPR/Cas9 is a system found in bacteria and involved in immune defence. Bacteria use CRISPR/Cas9 to cut up the DNA of invading bacterial viruses that might otherwise kill them.

Today we’ve adapted this molecular machinery for an entirely different purpose – to change any chosen letter(s) in an organism’s DNA code.

We might want to correct a disease-causing error that was inherited or crept into our DNA when it replicated. Or, in some cases, we may want to enhance the genetic code of crops, livestock or perhaps even people.

So do we just snip the unwanted gene out and replace it with a good one?

Read more: Explainer: what is genome editing?

We first have to remember that animals and plants are composed of millions of cells, and each cell contains the same DNA. There is no point editing just one cell: we would have to edit the same gene in every single cell. We’d have to snip out millions of genes and paste in millions of new ones.

And not all cells are easy to get to – how could we reach cells buried in our bones or deep within a brain?

A better approach is to start at the beginning and edit the genome while there is only one cell – a very early embryo.

So, all we need is a giant microscope and a tiny pair of scissors. And that is basically what we use.

Cas9 is the technical name for the virus-destroying “scissors” that evolved in bacteria. The CRISPR part of the name comes from repeat DNA sequences that were part of a complex system telling the scissors which part of the DNA to cut.

Find, cut and then paste

In order to target our Cas9 scissors, we link them to an artificial guide that directs them to the matching segment of DNA.

We give the scissors a copy of the DNA we’re after so they know where to cut. CC BY-ND

Remember, DNA comes in two strands, with one strand fitting alongside the other. We make a guide with a code that will line up with only one part of our 3 billion base pair long genome – it’s like a “Google” search. It’s truly possible for our guide to comb through vast amounts of genetic material to find the one section it matches exactly. Then our “scissors” can make the cut in exactly the right place.

Once the Cas9 scissors cut the DNA just where we intend, the cell will try to repair the break using any available DNA it can find. So, we also inject the new gene we want to insert.

If we inject new DNA it will take the place of the DNA we have cut.

Read more: Now we can edit life itself, we need to ask how we should use such technology

You can use a microscope and a tiny needle to inject the CRISPR/Cas9 together with the guide and the donor DNA, the new gene. Or, you can punch holes in cells with electric currents and let these things just float in, use guns to shoot them in stuck-on tiny bullets, or introduce them encapsulated in bubbles of fat that fuse with the cell membrane and release their contents inside.

But how does the new gene find the right place to embed itself? Imagine you wanted to put in the last piece of a jigsaw puzzle with 3 billion pieces, and it’s inside a cell, filled with goop like a passionfruit.

What you’d do is fabricate a jigsaw piece of precisely the right shape and inject it into the passionfruit. Then it’s just a case of jiggling around until eventually the piece finds its way to the correct part of the puzzle and slots into the only place it fits.

You don’t need to be able to see the DNA in our genome through the microscope – it’s too small. And you don’t really have to jiggle either – random diffusion (called Brownian motion) will always deliver the jigsaw piece to the place where it fits in the end.

First, the guide will jiggle along and find the right place for the scissors to cut, and then the new donor DNA will similarly line up where it fits and will be permanently stitched into the DNA strand via natural DNA repair mechanisms.

Recently, though, new CRISPR editing systems have been created that don’t even require a cut through the DNA. In this case, the CRIPSR/Cas and guide system can deliver an enzyme to a particular gene and alter it, changing perhaps an A to a G or a C to a T, rather than cutting anything out or putting anything in.

What are we doing with CRISPR/Cas9?

Most experiments use mouse embryos or cells grown in petri dishes in artificial liquid designed to be like blood. Other researchers are modifying stem cells that may then be re-injected into patients to repopulate damaged organs.

Only a few labs around the world are actually working with early human embryos. This research is highly regulated and carefully watched. Others work on plant cells, as whole plants can be grown from a few cells.

As we learn more, the scope of what we can do with CRISPR/Cas9 will improve. We can do a lot, but every organism and every cell is different. What’s more, everything in the body is connected, so we must think about unexpected side effects and consider the ethics of changing genes. Most of all we, as a society, should discuss and agree what we wish to achieve.

Read more: Why we can trust scientists with the power of new gene-editing technology

Safety and efficacy of testosterone for women

Safety and efficacy of testosterone for women: A systematic review and meta-analysis of randomised controlled trial data

The Lancet Diabetes & Endocrinology — Islam RM, et al. | September 23, 2019

As the benefits and risks of testosterone treatment for women with diminished sexual well-being remain controversial, researchers evaluated potential benefits and risks of testosterone for women. The study sample consisted of 8,480 candidates. According to this systematic review and meta-analysis, testosterone significantly increased sexual function, including satisfactory sexual event frequency, sexual desire, pleasure, arousal, orgasm, responsiveness, and self-image compared with placebo or a comparator (eg, oestrogen, with or without progestogen), and decreased sexual concerns and distress in postmenopausal women. Testosterone is efficient for postmenopausal women with low sexual desire causing distress, with administration through non-oral routes (eg, transdermal application) preferred due to a neutral lipid profile. Further inquiry warrants the impacts of testosterone on individual well-being and musculoskeletal and cognitive health, as well as long-term safety.