Acupressure App – Does it really alleviate menstrual cramps?

The media is abuzz over a study reporting that use of a cell phone app to train women in self-acupressure is effective as pain medication for treating menstrual cramps.

The Android app is called AKUD and is written in German, so unless du sprichst Deutch, it won’t do you much good. But let’s ignore that for now. Here’s the study intervention:

Participants received a menstrual tracking app that included instructions on acupressure for cramp relief. They also got one-on-one instruction on the location of specific acupressure points and use of acupressure using drawings and video. The App reminded them to apply acupressure starting five days before the anticipated menstruation. Control participants received a version of the app that did not include acupressure info and got usual care.

Both groups reported a reduction in menstrual pain, but participants who used the acupressure-containing app had a greater reduction in menstrual cramps compared to those who did not get the app to use, and use of birth control pills to control cramps was higher in the non-app group. Note that menstrual pain was not eliminated by use of the app,

So does acupressure help menstrual cramps?

I don’t know. Why? Because the study did not include an appropriate control.

The right control would have been to give controls a sham app that taught them ‘acupressure’, but used the wrong acupressure points.  This would have controlled for what may be a significant placebo effect of the use of the acupressure app.

A Cochrane review of acupuncture and acupressure for menstrual cramps concluded that there is insufficient evidence to recommend the practice. I would not say this new study changes that conclusion.

Could it hurt? 

Probably not. Although a few users of the acupressure app reported bruising and pain at the acupressure sites, only one user stopped the app due to these symptoms.

It’s not gonna’ kill you to take hormone replacement

It’s not going to kill you to take hormone replacement therapy.

That’s the take home message from the latest analysis of the Women’s Health Initiative, the largest and longest randomized trial of hormone replacement therapy (HRT) in menopausal women.

After almost 18 years of follow up in the WHI, there was no increase in overall mortality, including death rates from cancer, in women taking HRT for up to 5.6 years (estrogen plus progestin) or 7.2 years (estrogen alone). There was a non-significant reduction in mortality among those who started HRT between ages 50 and 59, the group most likely to be prescribed hormone therapy for menopausal symptoms.

I’ve blogged before about the results and limitations of the WHI, which found, on balance, that the health risks of HRT (breast cancer, blood clots, stroke) about equaled its health benefits (protection against colon cancer and osteoporosis). The study (and the US Preventive Services Task Force) concluded that there was no reason for women to take HRT for preventive health reasons.

The biggest criticism of the WHI was that 70% of its participants were 10 or more years post-menopausal. The study did not include women most likely to benefit from taking HRT – those with hot flashes, night sweats, insomnia and other menopausal symptoms – or enough women in the 50-59 year age group. These women start HRT at menopause, not a decade or more after it’s over. In this younger group, more recent research suggests there may be a reduction in heart disease risk not captured by the WHI. Or not. It’s an ongoing debate among health experts not likely to be decided very soon.

In the meantime, millions of women enter menopause every year, some of them with significant symptoms that impact the quality of their life (and sleep), who must decide whether or not to use HRT to treat their symptoms.

For these women, this newest update from the WHI is reassuring.

The breast cancer mortality data from the WHI are complicated, and based on a small number of cases in the study population. Let’s just say there was no statistical increase in deaths from breast cancer among users of estrogen and progestin. Since the breast cancers occuring in HRT users are not inherently less aggressive, its more likely the lack of increased breast cancer mortality is because most breast cancers are not lethal, while those that might become lethal are effectively treated. Paradoxically, there was a significant decrease in breast cancer mortality among users of estrogen alone, perhaps related to the fact that estrogen, when taken after a long hiatus, actually inhibits breast cancer growth. (I told you, it’s complicated. You can read more about this here.)

Will this new information matter to women deciding about using HRT?

The use of HRT has plummeted in the years since the WHI results were published in 2002.

In my practice, the reason for the decline is clear – women don’t want to increase their chances of getting breast cancer, however small that increased risk may be.

I tell my patients this : “If you take HRT for 20 years, your risk of breast cancer will be about 1% higher. Use it for 2-3 years for menopausal symptoms, and that increased risk is less than a quarter of a percent”.

After considering this, the majority of women thank me for the information, and decline to use estrogen. Their symptoms are just not bad enough to entertain even that small a breast cancer risk. (I’m happy to prescribe HRT or non-hormonal therapies for those who opt to use them.)

This new study won’t change that conversation much, but I will now add that taking HRT for a few years around menopause to alleviate its symptoms will not increase mortality. I’ll also tell them that the data on breast cancer mortality, while complicated, seem to suggest no overall impact. That’s most likely because the overwhelming majority of breast cancers are not lethal, either due to their inherent behavior or our improved treatments.

I’m curious to see if this changes the choices they make.

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More Reading on Menopause and HRT 

Tomato Jam

My sisters and I are planning on putting up a some tomato jam next weekend. Before we invest a whole afternoon (and 22 pounds of tomatoes) to it, I figured I should try out the recipe at least once.

I had the loveliest afternoon doing it. A gorgeous, sunny day, with the breeze coming in through the kitchen window, a batch of bread rising on the counter, NPR playing in the background, and me shuttling back and forth between the kitchen and the den, where I’m working on a little writing project that I’ll hopefully tell you about one of these days soon. It was one sweet day.

As sweet as this jam – sweet and savory, with just the right bite to make it the perfect accompaniment to cheese, or as we ate it that evening, broiled lamp chops. Be careful with this stuff – it’s addicting.

TOMATO JAM

Another winner from Mark Bittman. He makes his as a small batch refrigerator jam, which will keep in the fridge. But the recipe is ok for canning as well. Makes about a pint of jam. 

Ingredients

  • 1 ½ pounds good ripe Roma tomatoes, cored and coarsely chopped
  • 1 cup sugar
  • 2 tablespoons freshly squeezed lime juice
  • 1 tablespoon minced ginger (I used crystallized ginger)
  • 1 teaspoon ground cumin
  • ¼ teaspoon ground cinnamon
  • Small pinch ground cloves
  • 1 teaspoon salt
  • Red pepper flakes to taste

Preparation

Combine all ingredients in a heavy medium saucepan. Bring to a boil over medium heat, stirring often. Reduce heat and simmer, stirring occasionally, until mixture has consistency of jam, about 1 hour 15 minutes. (No need for it to be too thick – it will gel as it cools.) Taste and adjust seasoning.

Towards the end of your cooking time, sterilize your jars. Sterilize the lids in a smaller pan.

To refrigerate – Pour into sterile jar, cap, cool and refrigerate until ready to use; this will keep up to 6 months.

To can – Ladle the jam into sterile jars. Wipe the rims, apply mason jar rings and lids and screw to finger tight. Process the jars in a boiling water bath, covered by 1-2 inches of water, for 20 minutes. Remove from bath, cool and then further tighten lids. Label and store for up to 2 years.

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More on Tomato Jam

Einkorn No Knead Artisan Bread (and a primer on ancient wheat)

All wheat is not the same.

What we now call wheat is actually the product of hybridization and cross breeding of wheat species to increase crop yields, ease harvesting, decrease costs and scale up production. As a result, where there were once just 5 or so species of wheat, there are now literally thousands, which genetically, may be virtually unrecognizable to ancient grains from which they are descended.

Allow me to introduce these so-called ancient grains to you now:

  1. Einkorn Wheat (14 chromosomes / Diploid): The first known wheat ever cultivated by humans (circa 3300 BC in Europe) is Einkorn Wheat, which has just 14 chromosomes (diploid) and has a hull. Einkorn has great flavor, and has higher lipid, protein, vit E, lutein and carotenoids that modern bread wheat, and may be better tolerated by those with gluten sensitivities. (But not Celiacs, who should avoid all wheat, ancient or otherwise).
  2. Emmer and Duram Wheat (28 chromosomes / Tetrapoloid): About 10,000 years ago, Emmer Wheat appeared in the Middle East, as a product of natural cross breeding of Einkorn with wild goat grass (Aegelops speltoides). Emmer is a hulled wheat, has a lower glycemic index and is higher in protein and anti-oxidents than typical bread wheat. Some varieties may be lower in minerals than bread flour. Durum wheat is a domesticated form of emmer used for pasta and is a naked wheat (no hull).
  3. Ancient Bread Wheat and Spelt (42 Chromosomes / Hexaploid): Sometime before biblical times, it is thought that Emmer bred naturally with a durum wheat grass called Aegrolops squarosa to yield Triticium aestivum, a higher yield and better baking species that we call “bread wheat”. It is a naked wheat (no hull). Spelt is another hexaploid species that probably formed a little later than bread wheat, and has a hull.  Spelt has similar gluten, and is higher in protein, lipids, and unsaturated fatty acids and minerals when compared to bread flour. It is lower in fiber than bread wheat, and I am told that it does not make as good a bread.

The hexaploid bread flour species are genetically pliable, having 42 chromosomes with thousands of genes available for natural selection and breeding by man. Still, by the mid 18th century, only 5 species of bread flour were being grown in Europe, and until the mid-20th century, most bread flour was pretty similar.

But beginning in the latter part of the 20th century, aggressive modern breeding practices began that created literally thousands of different varieties of hexaploid bread and durum wheat. Much of the breeding was done to improve crop yields and battle environmental scourges such as drought and pests. Some have made wheat easier to process, but dependent on man-made assistance from pesticides and irrigation. Still other breeding may have been done to improve the nutritional content of wheat. But virtually none of the new wheat varieties was ever tested in humans before introduction into the food supply.

While we know how these species perform on the farm and in the wild, what we don’t necessarily know is how they may affect the humans who ingest them. The question now being asked by many is this – In selecting for things like crop yield, harvest ease and bakeability, have we created wheat species with genetic and nutritional profiles that are unfriendly to our bodies? We are not just talking gluten sensitivity here. We are talking glycemic index, fat and protein content, vitamin and mineral profile. Not to mention the effects of the additives food manufacturers add to baked goods to improve shelf life, taste and other qualities that will increase their appeal to consumers.  Many of us are asking if the symptoms we experience such as bloating, weight gain, skin rashes, headaches, allergies, joint pains – in the absence of identifiable disease – may in fact be the result of sensitivities to the proteins found in modern wheat.

Not everyone is waiting for answers. Instead, they are turning back to the ancient grains nature created before modern man got his mitts into Triticum’s genetic pool. American farmers are belatedly joining their Eupropean counterparts in growing Einkorn, Emmer and Spelt, as the demand from consumers for these grains begins to rise. Some of us are enjoying using Farro – the wheat berries of Einkorn, Spelt and Emmer – in salads and side dishes. Others are using the flours of these wheat species to make their own breads and pastas. The anecdotal evidence seems mixed on whether or not there are really any health benefits to using ancient wheats. We know they cannot be used by those with true gluten allergy.

My interest in the ancient grains comes from reading Wheat Belly, cardiologist William Davis’s program for eliminating wheat from the diet to lose weight. I’m still reading it, and have not tried his program – if I do, I’ll let you know. In the meantime, like many, I see no reason not to try these ancient grains. Farro for sure has already won me over.

This recipe is my attempt at seeing what kind of no-knead bread I can coax from Einkorn flour.

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EINKORN NO KNEAD ARTISAN BREAD

Readers of this blog know well my enthusiasm for Jim Lahey’s No knead bread making techniques, made famous by Mark Bittman of the NY Times. (If you don’t, stop right now and go to my previous posts about this technique, and learn it first before trying this recipe.) For this Einkorn bread loaf, I used a recipe from Jovial Foods, makers and distributor of Einkorn Flour.

It was an interesting experience. Einkorn flour has an almost baby powder-like silkiness and consistency, and is clearly a more moist and fatty flour than standard issue modern bread flour. One needs to use 5 cups of flour to get a similar size loaf to Lahey’s, and this flour ain’t cheap. The dough is much stickier and harder to work with, so make sure your board is well floured and use a dough scraper rather than your hands when forming the bread round.

The Jovial bakers do not use Lahey’s cloth technique (probably because the dough is so wet), or let the dough rise a second time before baking. I did both, and next time will avoid since it really was a mess, and the Jovial chefs state it is not necessary.

The results?

First and foremost, there is no such thing as a not delicious home made bread, and this was no exception. The bread is flavorful, moist and dense with a hard crust, and it is just lovely toasted.

But I have to say that it disappoints when compared to the incredible results I get with Lahey’s technique using regular flour. The crumb structure is more cake than bread-like, and I miss the big air pockets and incredible crunch that regular bread flour gives.

I’m going to give it one more try, avoiding the second rise and cutting back a bit on water (which I admit I upped a bit to get the dough to look more like Lahey’s.) The recipe below is exactly as I will make it next.

EINKORN NO KNEAD ARTISAN BREAD

Ingredients

  • 5 cups (600 g) of Jovial Einkorn Flour
  • ¼ teaspoon (1 g) dry active yeast
  • 1 teaspoon (6 g) sea salt
  • 1¾ cups (410 g) of warm water

Instructions

  1. Whisk flour, salt and yeast together in a large mixing bowl (Do not use a glass bowl, as the dough will darken if exposed to light).
  2. Add water and combine using a wooden spoon or spatula (dough will be wet).
  3. When the flour is incorporated, push down sides of dough and flatten the top.
  4. Cover the bowl with a large plate and let rise for 12-14 hours.
  5. In the last half hour of the rise, preheat a covered ceramic or cast iron Ditch Oven in the oven to 500°F.
  6. Turn out the dough on a heavily floured work surface. Using a dough scraper, fold the dough ala’ Lahey (See video here), nudging and tucking the dough into around shape.
  7. Plop the dough right into the pot, cover, lower the heat to 450 degrees fahrenheit and bake for 40 minutes. Uncover and bake another 15 minutes to darken the crust.
  8. Lift the loaf out of the dish and place on a cooling rack.
  9. Let cool for at least one hour before slicing.
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More Einkorn Links

Whole Wheat No-Knead Bread

Summers in the mountains means bread.

I rarely make bread at home in New York City. Not that I couldn’t. After all, this bread is easy enough to make, and despite it’s long rise time, requires very little of my attention.

But thinking about making bread does require, for me at least, a relaxed, open mind. And the inward assurance that in 18 hours I will still be available to move the bread on to it’s second rise, and then to it’s baking. Coordinating that with my schedule in the city makes the bread making feel like a chore and not the joy it is when I undertake it here at the cottage. Here, the day and the next lay ahead of me, open and lazy. The only things on my must do list today are a morning lake trail walk and if its warm enough, a swim. Maybe a bike ride into town to the farm stand market to hunt for inspiration for dinner.

I put this bread up to rise last night at 10, just after we arrived. This morning we read, then I put the bread out for its second rise around 1. We stocked the beach locker with clean towels and then went to town for lunch and to check out the local shops for the first time this season, stopping to hear some bluegrass on the porch and chat with friends outside the Common Ground. After that, I came home and baked the bread while Mr TBTAM cleaned the gutters and mowed the grass and I read some more. By 5 pm the bread was done. It’s in the bread box now, awaiting tomorrow’s breakfast and lunch.  The salmon is marinating, we’re drinking wine and getting ready to start a fire. (Obviously it was too cold to swim today…) Tonight will either be a scrabble or a card game, and something made with the peaches I found at the farm market for dessert.

As I’m thinking about it now, bread making gives a kind of structure to an otherwise completely unstructured existence here on the mountain. It doesn’t depend on the weather (though it may vary a bit depending on temperature and humidity), and needs no one but me to make it happen. If we have company, as we will for much of the rest of the summer, I can adjust the timing accordingly, or make the shorter rise version. But every weekend will have it’s loaf at some point.

The bread making is a touch point for me, a way of grounding myself and transitioning from the hectic overdriven life in the city to the lazy days in the country. It gives me a sense of having accomplished something without demanding that I actually do very much at all.

And it tastes amazing.

NO-KNEAD WHOLE WHEAT BREAD

This recipe is from Mark Bittman, inspired by Jim Lahey’s now legendary No-Knead bread making technique. Before making this bread, watch this video of Mark and Jim making this bread together, and this video of Jim teaching Mark for the first time how to do it. Even better, read Jim’s book, which was what I read today while my bread was rising. And read my previous blog post on my experience making this amazing bread.

This was my first try at making a whole wheat no-knead bread. The results were fantastic – a light, tasty, moist and chewy interior with a crunchy crust. Not as hard and thick and crunchy as Lahey’s white bread crust, but this may have been because I mistakingly baked the bread at 450 degrees instead of the recommended 500 degrees Fahrenheit. (Lahey seems to go back and forth between these two temps a lot – find which is best for your oven and stick to that). 

I went to whole wheat flour looking for something healthier. To that end, my next foray will be to the land of the heritage wheats.  I ordered some Einkorn flour today, and will see what kind of no-knead bread I can coax out of it next weekend.

Stay tuned.

INGREDIENTS

  • 2 2/3 cups bread flour
  • 1 1/3 cups whole wheat flour
  • 2 tsp salt
  • 1/2 tsp yeast (Active dry or instant)
  • 2 cups water.

INSTRUCTIONS

Whisk dry ingredients together in a large bowl. Pour in water and mix well with a wooden spoon. Cover with plastic wrap or a towel, and let rise for 12-18 hours at room temp till well-risen, with a bubble foamy top and the beginnings of darkening color.

Scrape out onto a well floured surface, and with floured hands fold over ala’ Lahey. Place seam sides down on a clean non-terry towel generously dusted with wheat bran or corn meal. Fold the towel over top the bread and let rise another 4 hours, till doubled in bulk.

During the last half hour of the rise, preheat a 4-5 quart cast iron or ceramic french oven on a pull out shelf in a 500 degree Fahrenheit oven.

Open the oven door, pull out the shelf and take off the pot lid. (If your shelf does not pull out, take the entire pot out and place on top of the stove or on a heat proof counter to accomplish the next steps, but work quickly.) Gently place the bread-filled cloth onto an outstretched palm and walk over to the pot. Remove the lid and lay the bread, seam side up, into the pot. (Watch the videos for this technique.) Shake the pot a bit if you need to settle the dough into place. Place the lid back on and bake for 30 minutes. Remove the lid and bake another 15-30 minutes to develop the dark, almost burnt crust. Remove pot from the oven and remove bread from the pot. Let the bread “sing” as it cools for another 15-30 minutes before even considering cutting into it.

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More TBTAM Bread Making 

Spinach Stuffed Mushrooms

stufffed mushrooms

Tired of serving the same old cheese plate and cracker appetizer? Looking for something just as satisfying and crowd pleasing but without the calories or carbs?

Look no further than these delicious, easy to make, healthy spinach stuffed mushrooms.

Eat them with a knife and fork, cut into quarters and you have four incredible mouthfuls. Serve with a bowl of spicy olives – there’s nothing that tastes better than a bite of each in your mouth at the same time.

These mushrooms are so satiating that I’ve served them as a main dish. Add a side salad following a small bowl of soup and you’ve got a light but highly satisfying supper.

Spinach Stuffed Mushrooms

Look for large mushrooms with nice long stems, since you’ll be chopping those stems to make the stuffing. Adjust the amount of bread crumbs and cheese to your liking. Try not to eat any leftover stuffing – you’ll want to use it in an omelet tomorrow morning.

Ingredients

  • 12 extra-large white or crimini mushrooms
  • 1 tbsp olive oil
  • 1 tbsp butter
  • 1 large shallot or 1/2 medium onion, finely chopped
  • 1 clove garlic
  • 1 tsp minced fresh thyme leaves
  • 6 oz bag washed organic baby spinach leaves, chopped coarsely
  • 1/4 cup bread crumbs
  • salt and pepper to taste
  • a pinch of crushed red pepper (optional)
  • 1/4 cup finely shredded Romano or Parmesan cheese, plus another tbsp or so for sprinkling atop (latter optional)
  • 2 tbsp chopped parsley

Instructions

Preheat oven to 325 degrees centigrade. Find a small sheet pan or baking dish large enough to hold the mushrooms in a single layer and lightly brush or spray the base with olive oil.

Clean mushrooms. Remove mushroom stems and chop them finely. Arrange the mushroom caps in the baking dish, being sure they are not too snug.

In a large saute pan, heat olive oil and butter. Saute shallot till soft, the add the mushrooms, garlic and thyme and saute till mushrooms are soft, about 5 minutes or so. Add spinach leaves and cook till wilted – about 3-5 minutes. Turn off heat. Add breadcrumbs and season. Toss in the cheese and parsley. Stuff the mushrooms with the stuffing, being sure to press it in well with your finger to use all available space. Sprinkle a little cheese atop if you want (optional).

Bake for 30-40 minutes, till the mushrooms are well-cooked and the stuffing browned and crusty. (If pressed for time, turn up the heat to 375 degrees fahrenheit and cook for 15 minutes, but watch our that the mushrooms don’t shrivel.)  Serve warm.

Can be made ahead and reheated just before serving.

Ottolenghi’s Roasted Chicken with Clementines and Arak

Chicken w/ Clementines & Arak

One of these days, I’m going to visit Israel, if only to taste in situ the foods that inspire Ottolenghi, whose Jerusalem cookbook has become one of the most used cooking tomes in our household. The hummus recipe alone is worth purchasing his book.

This recipe combines orange and anise flavors with a delightful roasted chicken. Don’t let the use of Arak, a licorice flavored liquor – worry you. The anise flavor is subtle, despite the use of both fennel and fennel seeds – and perfectly balanced by the clementines.

We served it with brown basmati rice and carrots, and I used the leftovers the next day to make a warm Flageolet salad.

OTTOLENGHI’S ROASTED CHICKEN with CLEMENTINES & ARAK

Note – Ottolenghi’s US version of the recipe seems to have made an erroneous conversion of celsius to fahrenheit, and says to cook at 475 degrees. Cook instead at 425, or you’ll find yourself with little juice to serve it with.

Ingredients

Marinade

  • 6 1/2 tbsp/100ml arak, ouzo or Pernod
  • 4 tbsp olive oil
  • 3 tbsp freshly squeezed orange juice
  • 3 tbsp lemon juice
  • 2 tbsp grain mustard
  • 3 tbsp light brown sugar
  • 2 1/2 tsp salt
  • 1 1/2 tsp pepper

Chicken and veggies

  • 2 medium fennel bulbs (500g in total)
  • 1 large organic or free range chicken, about 1.3kg, divided into 8 pieces, or the same weight in chicken thighs with the skin and on the bone
  • 4 clementines, unpeeled (400g in total), sliced horizontally into 0.5cm slices
  • 1 tbsp thyme leaves
  • 2½ tsp fennel seeds, slightly crushed
  • salt and black pepper
  • chopped flat-leaf parsley, to garnish

Preparation

Make the marinade – Whisk together the arak, oil, orange juice, lemon juice, mustard, brown sugar and salt in a bowl large enough to hold the chicken.

Trim fennel and cut in half lengthwise, then cut each half into 4 wedges.

Add fennel, chicken, clementine slices, thyme and crushed fennel seeds to the marinade. . Turn several times to coat, then if tie allows, marinade in fridge for a few hours to overnight.

Preheat oven to 425 degrees. Transfer all ingredients, including marinade, to a roasting pan large enough to hold the ingredients in a single layer (12×14 1/2 inches); chicken should be skin side up. Roast until chicken is browned and cooked through, 35-45 minutes. Remove from the oven.

With tongs, Remove chicken, fennel and clementines to a serving plate; cover and keep warm. Pour cooking liquid into a small saucepan and over medium-high heat, bring to a boil, then simmer until sauce is reduced and you are left with about 1/3 cup. Pour heated sauce over chicken. Garnish with parsley and serve.

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Other Ottolenghi recipes from TBTAM

Flageolet with Fennel and Feta

Flageolet beans w fennel and Feta

I send Mr TBTAM to the market for French Le Pay lentils yesterday, and he returned instead with French flageolet.

It’s partly my fault. After all, he did call me from the store to be sure he had the right brand. My mistake was assuming he knew what a lentil was, and instead focusing on making sure that what he was buying was actually imported from France. He said the word flageolet, and even spelled it out for me. I had no idea what flageolet meant, but it sure sounded French to me, and thinking it was a lentil brand name, I approved the purchase.

Only when he got them home did I discover that flageolet are not a lentil brand, but a type of bean. And not just any bean, but a small, buttery bush bean plucked from the pod while still young and delicate. Sort of the veal of the bean family, but without the force feeding or animal cruelty.

Flageolet beans

Flageolet have been called the “caviar of beans”. I’m not sure I’d go that far – a bean is after all just a bean. And truth be told, I still love the stronger flavor of a good lima bean more than any other legume. But flageolet are a really nice alternative to white beans, and the small size is just lovely.

How I cooked and served my flageolet

I eschewed the overnight soak, instead following Epicurious’s recommended method of bringing the beans and water to a quick boil, then letting them soak for just an hour. Then I added salt and a bay leaf, brought the beans to a boil again and simmered for one and a half hours, till a blow on a spoonful of beans loosened the skin and I knew they were done and ready to be drained. (I saved the bean water to be used as a chicken stock alternative).

While the beans were cooking, I sauteed a diced onion with diced carrots and celery and 4 cloves minced garlic in a few tbsp of olive oil. I had a large piece of chicken, some braised fennel and a few cooked clementine slices leftover from last nights dinner – Ottolenghi’s Chicken with arak and clementines.  I chopped that up and added it to the sauteed veggies, along with the now cooked and drained beans, and finished it all off with some low fat feta, lots of parsley and a drizzle of olive oil. A side of cucumber salad was the perfect accompaniment.

Perhaps a better approach

Ina Garten has a baked preparation for flageolet that I may try sometime soon. She uses the very same ingredients I used, but sautees her veggies in bacon (oh yeah…), adds rosemary and cooks her beans in the oven using beef stock instead of water and with the veggies and herbs, advising that the mild flavor of the flageolet requires them to be cooked with their accompaniments. She also advises not to add salt till the end of the cooking time, as it toughens the beans – which may explain why I did not find the flageolet to be the buttery consistency I’ve read so much about.

A fortuitous mistake

I’m so glad Mr TBTAM got it wrong at the market yesterday. Flageolet are a wonderful bean, a great alternative to white beans, and are now a staple in my pantry.

How do you serve your flageolet?

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Some flageolet serving ideas from around the web

Foraged Delight – The Staghorn Sumac

staghorn-sumac

This is staghorn sumac (rhus thphina), whose gorgeous red fruit berries I first encountered last summer atop High Knob in the Loyalsock. Isn’t it gorgeous?

staghorn-sumac-stand

The branches and berries of the staghorn sumac have a fuzzy feeling like the antlers of a deer (hence the name) and will NOT give you a rash. The stuff that gives you a rash is poison sumac.

Poison sumac has a red trunk. It grows in swamps and standing water, it’s berries are white and hang down, and the leaves look like this.

toxicodendron_vernix

Got it? Good. Now stop being afraid and go get yourself some staghorn sumac.

What to do with Staghorn Sumac Berries

sumac

The sumac fruit is best harvested in late summer after a few days of dry weather. (Rain washes away the oils and lessens their already light flavor)  If you’re lucky and have found it at just the right time, it will feel slightly sticky, and when you lick your fingers after touching it, you’ll taste its slightly acidic, lemony flavor.

Bring along a paid of kitchen shears, and cut the fruits off at the base of their stems.  Handle them gently, and pack lightly into a paper bag for transport. (Or like me, tear them off and lay them across the hatchback floor for the ride home.)

Sumac fruit is high in Vitamin C and antioxidants. The berries can be used to make tea, or dried to make a fabulous spice.

SUMAC TEA

sumac-tea-3

Sumac iced tea is a refreshing, light summer tea.  It’s easy to make. Simply rinse the berries in cold water, then pull them off the cluster and into a french press.

sumac-tea2

Add cold water, 1-2 cup per tbsp of berries, stir and let steep until the flavor is to your liking. (If you go too long and too strong, and it may be bitter.)

sumac-tea

Press. Pour the tea into your cup or pitcher, add a little sugar or honey and enjoy. Better yet, add some Campari, Pimms, simple syrup and a lemon twist for a refreshing cocktail.

You can dry the sumac and use it to make hot tea during the cooler months.

SUMAC SPICE

sumac-spice

The sumac berry, dried (and if you want, ground) makes a wonderful spice.

Ground Sumac is widely used in Middle Eastern food. Israeli chef Ottolenghi loves sumac, and it is featured heavily in his cookbooks. He even serves a sumac martini in his restaurant.

Sumac is primarily used as part of a spice mixture call za’atar.

za'atar
za’atar spice mix

There are as many recipes for zaatar as there are tribes in the Middle East, but most contain thyme, salt and sesame seeds. It’s commonly sprinkled atop pita bread brushed with olive oil, or used as a rub for meats.

MAKING SUMAC SPICE

Clip the sumac fruits off the stem and lay out to dry for a few days.

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Pull the berries off the stems in clumps and place into the bowl of the food processor. Pulse for a few seconds to separate the seeds and stems from the fruit.

Transfer to a fine sieve, and using a pestle, strain the fruit from the stones and twigs.

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The sumac spice is fine threads, with a consistency almost like pencil shavings.

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This is what’s left behind. Toss it out.

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This is the gold.

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Store it in a jar in a cool place out of direct light. It should keep for a year.

Where to buy sumac

If you don’t want to forage your own sumac, you can buy it in New York City at Fairway or Kalustyans. Amazon and Penzys carry it as well.

If you’re ready to try sumac, here’s a recipe for you.

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CHICKEN WITH SUMAC AND PLUMS

Melissa Clarks original recipe uses two whole chickens and is meant for a holiday dinner crowd. I cut it back and modified it to serve 4 using chicken thighs. You can use breasts or a small chicken instead of the parts if you prefer. If you use a whole chicken, omit the thyme from the rub and instead stuff a sprig or two into the chicken cavity, and place the chicken on a small roasting rack atop the plums. (Melissa has a wonderful video showing how she makes the dish using two whole chickens.)

For the chicken

  • 1 large lemon
  • 1 tablespoon ground sumac
  • 2 teaspoons kosher salt
  • 1/2 tablespoon black pepper
  • 1/2 teaspoon cinnamon
  • 1/2 teaspoon allspice
  • 1 tbsp finely chopped fresh thyme
  • 2 tablespoons extra-virgin olive oil
  • 2 garlic cloves, grated or minced
  • Enough chicken thighs and breasts to serve 4
  • Fresh Thyme

For the plums

  • 1 pounds plums, halved or quartered if large
  • 2 shallots, sliced into 1/4-inch-thick rounds
  • 1 tablespoons honey
  • 1/2 tablespoon extra-virgin olive oil
  • 1/4 teaspoon salt
  • 1/4 teaspoon cinnamon
  • 1/8 teaspoon allspice
  • 1/2 bay leaf
  1. Grate lemon zest and place in a small bowl. Set aside the zested lemon.
  2. Stir sumac, salt, pepper, cinnamon, thyme and allspice into the lemon zest. Stir in 1 1/2 tbsp of the olive oil and the garlic. The mixture should feel like wet sand. Rub it all over the chicken parts and place the chicken on a plate. Let marinate, uncovered, in the refrigerator for at least 1 hour or up to 24 hours.
  3. When ready to roast, let chickens come to room temperature for 30 minutes. Heat oven to 450 degrees.
  4. Heat 1 tbsp olive oil in a large saute pan that can go into the oven (We used a cast iron pan). Quickly sear and brown chicken thighs over high heat in a pan, then remove to a plate. Turn down heat and in the pan, toss together plums, shallots, honey, oil, salt, Place chickens over the plums in the pan. Roast for 15-20 minutes.
  5. Meanwhile, squeeze 1 tablespoon juice from the reserved lemon and mix it with remaining 1 tablespoon olive oil. Drizzle this over the chicken, then continue to roast until skin is golden and chicken is cooked through. (another 15-20 mins)
  6. Let chicken rest, covered lightly with foil, for 10 minutes. Serve with the plums and sprigs of thyme for garnish.

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More about Sumac

Summer Fruit Cake

Summer Fruit Cake

Labor Day weekend at the cottage with good friends. A bittersweet end to summer.

Lake swimming, hiking, biking, reading, stargazing.

Shunpiking* to discover gorgeous vistas, plump red sumac berries ripe for the picking (and drying for spice – I”ll post on that later) and the best garage sale ever.

Making Irene’s summer fruit cake to bring to a wonderful outdoor dinner party (great conversation, great food, great people) on an evening cool enough to end inside around a burning wood stove. (Thanks Rick for leaving the stove door open so we could see the fire.)

We left a day early, warned that the impending hurricane would make return to the coast near impossible. False alarm, but a traffic-less return with great music and great conversation more than made up for the early leave.

Here’s to the end of summer in the Endless Mountains, made even better by this year’s strategy of taking off a bunch of Fridays in lieu of a vacation week. The good news is the mountains and the lake are even more beautiful in autumn, the wood stove beckons, and we’ve got a good 10 weeks before we need to close the cottage up for winter.

*Shunpiking: an avoidance of major highways (regardless of tolls) in preference for bucolic and scenic interludes along lightly traveled country roads.

SUMMER FRUIT CAKE

This cake recipe is absolutely perfect and a delicious celebrating of the stone fruits of summer. My mother-in-law Irene makes it with small Italian plums – each slice has a single plum half nestled atop, making for a very pretty presentation. We used larger plums and white peaches from the Farm Market and sliced them before putting them on the cake – not as pretty a presentation but omg delicious. You can also make this cake using apples.

  • 6 oz. soft butter
  • 1 ½ cups sugar
  • 3 eggs separated
  • grated lemon peel from 1 lemon
  • 1 tsp. vanilla extract
  • 3 tbsps. rum
  • 2 cups flour
  • ½ tsp. baking powder
  • ¼ tsp. salt
  • 8 peeled and sliced apples tossed with lemon juice or any summer fruit* such as blueberries, apricots, peaches or small blue Italian plums. If using summer fruit, omit lemon juice. If using blueberries about 1 pint of berries will be needed. If using apricots, peaches or plums about 18 to 24 whole fruits will be needed, depending on size.
  • ¼ cup slivered or sliced almonds

Grease and flour a 9 x 13 inch baking pan. Preheat oven to375 degrees fahrenheit.

Halve the fruits, remove pits. If they are large (i.e. peaches), slice them thick. If they are small plums or fresh apricots, just leave them halved and don’t slice them.

Beat egg whites until stiff and fluffy. Reserve.

Cream butter and sugar. Add egg yolks one at a time beating thoroughly after each addition. Add rum and vanilla to butter mixture. Add lemon peel and mix well.

Mix flour, baking powder and salt together and add to batter, mixing only until incorporated. Do not over beat. Fold in beaten egg whites.

Pour batter into baking pan. Place fruit cut side down on top of batter. (If using apples, slice and arrange in rows on top of batter with a little sprinkled sugar and cinnamon, and ¼ cup currants or raisins if desired.) Sprinkle the top with the slivered almonds.

Bake in pre-heated 375 degree oven for 30 to 35 minutes until tester comes out dry and cake is lightly browned. Cool on rack. Cut in serving size squares and remove from pan.

 

On Balsamic Vinegar, Proscuitto and Why Foodie Friends are Just the Best

Giuseppe Giusti - Il Quarto Centenario

There’s what you think is Balsamic vinegar, and then there’s this stuff.

Quartro Centenario Aceto Basilica, a limited edition, 15 year old Balsamic made by the Giusti family in Modena, Italy to celebrate 4 centuries running the oldest balsamic vinegar house in the world.

OMG. Thick and rich, sweet but still vinegary, full of flavor and well, just heaven.

This balsamic is too special to use in a salad dressing. What you do is drizzle it on something special, in this case an open faced sandwich made with ever so lightly toasted baguette that you’ve brushed with olive oil, then topped with a slice of fresh Mozarella, tomato, basil leaf, and a fast grind of sea salt and pepper.  It’s a lunch of the gods.

Thanks forever to my foodie friend Chris Eden (in his other life an architectural photographer), who gifted me a bottle of this liquid gold that he bought at Di Palo’s food market in Little Italy. DiPalo’s is not just a food store – it’s a portal into Italy, lovingly maintained for four generations by the one special family.

Chris visits DiPalo’s whenever he’s in New York. The store is often very, very crowded (the lines can be up to 45 minutes long). So it was no small feat when one day, Chris managed to get Lou DiPalo’s individual attention when he asked for a half pound of unsliced Prosciutto. Previously on rapid autopilot, filling orders right and left, Lou stopped short.

“You slice the Prosciutto yourself?” he asked Chris.

Yep, he does. Paper thin and just right, using a vintage American slicer that he refurbished himself.

American Slicer VIntage

Pretty sweet, huh? Now look at it slicing the prosciutto

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and the finished product, which Chris served as part of an antipasto spread in April when I visited him and his wife Trish. (Dinner at their house should be a tourist attraction for Seattle…)

Sliced Prosciutto

Yep, you gotta have the right slicer. That’s what DiPalo tells us in his book Di Palo’s Guide to the Essential Foods of Italy: 100 Years of Wisdom and Stories from Behind the Counter, which Chris gave me along with the vinegar of the gods –

You also want to ask for a taste so you can see how it is sliced. You can ruin an excellent prosciutto if you slice it too thick, or use a machine that heats it up or is used to slice other things, even if you don’t start slicing it at the right angle. … More important than the angle is that the slicer be belt-driven or even manual.Prosciutto is raw, remember – an ordinary slicer spins around really fast and creates heat, and that can cook a really thin slice.

That little moment of shared recognition and the discussion that followed between these two prosciutto-slicing aficionados was enough to seal Chris’s reputation with Lou as someone more than just a run of the mill tourist customer. Now, Lou actually recognizes him when Chris visits, though Chris makes a point of doing so only during the weekdays when there’s no line.

On his last visit there, Lou told Chris the back story on how his family chooses and buys olive oils. He even gave Chris an invite for me to attend one of his oil tastings (which one of these days I swear I will do…)

I’m doing my best to savor the vinegar, holding it for special occasions like that Sunday lunch up there. I do admit that sometimes I take the vinegar out of the cabinet and drizzle a little of that liquid heaven onto my fingertip to taste, just because I can. Maybe I’ll head down to Di Palo’s myself one of these days soon, pick me up some sliced Prosciutto and drizzle a little on that. Hmmm…….

Oh yeah. Chris also gave me a Cavitelli maker and taught me how to use it. (He had a spare one lying around the house…)

But that’s a post for another day.

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Tahcheen-e Esfenaj (Baked Persian Rice Cake with Lamb, Spinach & Prunes)

Tahcheen-e esfanaj

I must apologize for the infrequency of my blog posts over the past year. My new position at the medical school has kept me much busier than I’d ever imagined. Now, a year later, things are finally settling in and I’m hoping to bring this blog thing back to life, if only because the act of writing truly grounds me.

One of the better parts of my new position has been getting to know our Qatar-based medical school faculty and staff, who sent me the most amazing Persian cookbook – Saraban: A Chef’s Journey through Persia by Greg and Lucy Malouf. (Thank you Shahrad and team!)

This is a cookbook that deserves more than just a look at the recipes (which are amazing), but demands a real sit-down read. Saraban introduces the reader to an Iran most Americans do not know – a complex and beautiful country of both desert and verdant mountains, with warm, friendly people whose culture is steeped in marvelous food, family, literature (especially poetry) and religion. The grief and impact of years of political unrest and conflict are acknowledged, but are not central to this portrait of a people and a cuisine.

If only one day there were peace within this region and between our nations. We have so much that is beautiful (and delicious) to share with one another.

Tahcheen-e esfanaj

TAHCHEEN-E ESFENAJ (Baked Persian Rice Cake w/ Lamb, Spinach & Prunes)

The authors tell us that Tahcheen means “spread over the bottom”, which describes the tahdig or crispy rice mixture that forms the base of this cake, which is then layered with richly spiced lamb, cooked spinach and prunes.

Getting the cake out with the tahdig intact can be tricky (note I failed at that). I suggest you watch this video to learn how. I used a square pyrex pan, but you can use a glass pan, cast iron skillet if large enough, or a La Cruset pan. Non-stick would be great if you have it.

In this recipe, the meat is stewed and removed from the broth. This leaves you with a lovely broth to be used in future dishes (Pilaf? Soup?) The meat is then marinated in the yogurt/saffron mix for 8-24 hours. That’s a huge make-ahead step. For a quicker version, after the meat is cooked, just cook the broth down into a nice thick gravy, and avoid the yogurt marinade step altogether.  It will mean that the rice yogurt part of the dish won’t have a lamb overtones, but I’m sure it will still be delicious. 

There are many versions of Tahcheen (also spelled Tah-Chin and Tahchin), the most popular being chicken. I could see this being delicious made without the lamb for a vegetarian version.

  • 3 tbsp olive oil
  • 2 large onions, very thinly sliced
  • 1 clove garlic, roughly chopped
  • Sea salt
  • 1 tsp freshly ground black pepper
  • 1/2 tsp ground turmeric
  • 1/2 tsp ground ginger
  • 1/2 tsp ground allspice
  • 1 pound lamb shoulder, trimmed of fat and cut into 2-3 cm cubes
  • Enough water of beef broth to cover meat for cooking
  • 200 gm thick natural yogurt
  • 2 egg yolks
  • 80 ml (5 tbsp) saffron liquid (See recipe below)
  • 200 gm spinach leaves (one standard bag of pre-washed)
  • 2 cups basmati rice
  • 12 prunes, pitted and roughly chopped
  • 2 oz butter, plus extra for greasing the pan

Heat 1.5 tbsp oil in medium saucepan over low heat. Add one of the sliced onions, along w/ garlic, 1 tsp sea salt, pepper and spices and fry gently for 4 minutes. Add meat and enough water or broth to cover, bring to simmer and simmer gently for an hour, or until meat is tender. Remove meat from broth and cool.  (Save that broth!  It’s gold, Jerry, gold…)

Beat yogurt with egg yolks and saffron liquid in a shallow dish. Drain the cooled meat well and add to yogurt mixture. Cover and refrigerate for at least 8 and up to 24 hours.

Heat the remaining oil in a large frying pan over a low heat. Add the remaining sliced onion and fry gently till soft and lightly colored. Add spinach and cook, tossing gently with tongs, till wilted. Cook over a medium heat to evaporate any excess liquid. When cool, squeeze the spinach to remove any remaining liquid and coarsely chop.

Parboil the rice: Wash/rinse the rice well, then soak in cold water for 30 mins. Drain and add to 8 cups boiling water in a large pot. Bring back to a rolling boil and boil for 5 mins. Rinse with warm water and drain well.

Preheat oven to 375 degrees Fahrenheit. Butter an ovenproof dish with an 8 cup capacity. Remove the lamb from the yogurt mixture. Mix half the parboiled rice with the marinade and spoon into the bottom and up the sides of the ovenproof dish. Arrange the lab on top of the rice, then cover with spinach and dot with the prunes. Spoon remaining rice to cover and smooth the surface. Cover tightly with a sheet of aluminum foil and bake for 1 1/2 hours

Remove the dish from the oven and dot with bits of butter. Replace foil and leave to rest for 10 minutes. Turn the rice cake out onto a platter and serve warm.

Saffron Liquid

  • About 60 saffron threads
  • 6 tbsp boiling water

Lightly toast the saffron threads in a small frying pan over medium heat for about 30 seconds or until totally dry. Be careful not to burn the saffron. Place saffron into aa mortar and let sit for a minute or two before grinding into a powder. (If the saffron is well dried, and like me, you don’t have a mortar and pestle, just crush the saffron threads with a spoon against the side of a small bowl and it will grind easily into a coarse powder.) Mix the ground saffron into the boiling water in a small cup or bowel and set aside to infuse for at least an hour before using. The color will continue to develop for at least 12 jours.

You’ll be using 5 tbsp of this liquid in this recipe.

More Tacheen

  • PersianMama makes one gorgeous Lamb Tahchin with black-eyed peas. (Great pics – Check out those sautéed onions…)
  • WorthyPause makes her Tahchin with ground lamb and barberries
  • Persian Fusion makes a vegetarian Tahcheen with mushrooms and aubergine
  • Fig and Quince shows how to make a beautiful Tacheen Morgh (Chicken Tacheen). (She also has great pics from her trips to Iran)
  • Azita of Turmeric & Saffron makes a particularly gorgeous Chicken Tah-Chin
  • PersianMama makes a pretty Tachin Morgh
  • A quick video shows how to make an easy stove-top Chicken Tacheen
  • Jamie Oliver makes a nice Chicken Tahchin

New York City Garden 2016

It’s been a long year or so without our balcony herb garden. Mandatory brickwork outside our apartment started in April 2015 with a Cristo-like gauze wrapping around the entire facade and taping shut our windows and balcony door. We lived like that for almost an entire year, until finally, in April, we were allowed access to the balcony again.

That’s the bad part.

The good part is that I got to start the balcony garden all over again. The building had removed our handmade deck floor, so I replaced it with a wonderful and inexpensive Ikea deck floor.

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I also swapped out our rusting bistro set and rickety plant stand for a bistro table and Sophia Chairs (ridiculously cheap on Craigs list) and a couple of Ikea plant stands.

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The window boxes and all the pots survived on the roof during the construction, although we lost all the herbs save the hardy chives that have come back every spring for almost 20 years. I planted the window boxes with a brown grass, coleus, Thai basil and asparagus fern that I found at my new favorite garden store – GardenWorks in Flushing.

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After some searching around for them, I found some straggling hyacinth beans for a song at Chelsea Gardens in Red Hook. They had wilted in the heat and looked terrible, but the salesclerk promised me they’d be fine and she was right. They are rapidly lining the trellis and railing, keeping the eyes off the ugly white storage building across the street and focused instead on the garden and the skyline view.

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Still left to do is hang a half moon lined planter or two from the brick wall (if the building will let me), and fill them with some colorful annuals. And get an umbrella. And maybe some pretty pillows for the chairs. And some little bistro lights for evening.

Drinks, anyone?…

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NYC Gardening Resources

I would have killed for this list in my early days of gardening here in NYC. Sadly, many of the favorite places I used to frequent (like Dimitri’s and Liberty) are no longer in existence, but these are tried and true. I avoid the small, precious gardening stores, and tend to larger garden centers, which are cheaper. If you have a car, your options increase widely. 

Union Square Farmers Market. The place to go for organic lettuces and herb plants. I’ve got some gorgeous lettuce mixes over the years that have graced my salads well into summer. Also good for annuals.

Plant Shed. On 96th St near Broadway on the Upper West Side. They’ve been there for years, and a consistently reliable source for spring herbs and annuals. Perennials and shrubs more limited. Prices are not outrageous for NYC. They deliver.

Chelsea Gardens: Not cheap, but if you need something, they’ll have it (like the hyacinth beans I was looking for this year.) Staff is extremely knowledgable.  Great place to go to see what is possible in the city. Started in Chelsea, now also in Williamsburg and Red Hook.

Gowanus Nursery. The place to go for something special, and like Chelsea Gardens, see what is possible. If you’re visiting Red Hook, combine it with a trip to Chelsea Gardens.

Kings County Nursery: Very reasonably priced Garden Center deeper into Brooklyn. I like this place. A lot. Good source for trees, vines, grasses, shrubs, as well as garden supplies and annuals.

Garden World in Flushing. My new favorite place. Wonderful selection of healthy, gorgeous plants and trees.

Home Depot. The one on Northern Blvd in Long Island City. Where I go for potting soil, stones, and basic shribs and annuals. (The Home Depot in Manhattan does not have the really large bags of soil or stones.) Occasionally they surprise you with an unusual shrub or annual. Sales can be great. I picked up two crabapple trees for 10 bucks apiece there a few years back – both are thriving. The Spirea I got there for next to nothing have also lasted years.

Jamali Garden – in the flower district. Basic supplies, containers, plant food, lighting, you name it. Like a giant hardware store for your garden. Reasonable prices.

Hicks Nurseries – If you’re up for the schlep out to Long Island, Hicks is well worth the trip. They have everything. Not as cheap as you’d think. But great selection and quality.

IKEA – for containers and fun garden accessories such as funky solar lights, prices can’t be beat. I go to the one in Brooklyn.

For trees. Any of the garden centers in the city and near Long Island are way too expensive for my budget when it comes to buying trees. For these buys, I head out to New Jersey, where garden centers abound. Prices will be much more reasonable, but be careful. The help do not know urban gardening and could recommend the wrong species for your roof or balcony conditions. If they deliver, it may be pricey. So consider renting a truck and delivering to yourself.

What Women Want – How and When to Deliver the News of a Breast Cancer Diagnosis

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If you’re going to have to tell a woman that she has breast cancer, she wants to hear the news as quickly as possible, preferably face to face, ideally within 1-2 days of the biopsy being done, and have an appointment set up to deal with the diagnosis either that day or the next.

That’s what Dr Deanna Attai and colleagues found out when they surveyed over 1000 women, including 784 breast cancer survivors, to find out how and how soon they wanted to get their breast biopsy results, and compared that to what actually happened when they got their results.

It’s no surprise that in almost all cases, when it comes to hearing results, what women got did not match what they wanted. For example, while 40% of women heard their diagnosis within 1-2 days of biopsy, 80% would have wanted their results within that time frame.  Fifty four percent heard their mammogram results within 2 days, but 84% wanted them the same or next day.

A few important nuances emerged from the data – given a choice between hearing results face-to-face and getting them faster over the phone, women opt for speed. If it’s a mammogram or blood test result rather than a biopsy, face-to-face is not as important.

Most interesting were the comments women made on their surveys, which should be required reading for anyone having to give bad news. Here are just a few –

  • “Use the same compassion and candor you would use if you had to give this info to your loved one”
  • “Nothing is worse than calling a patient and telling them to bring someone with them but not telling them why.”
  • “Please remember that a bad test result may throw a person off, so much so that they cannot really hear what you are saying. Be clear and be careful. Ask the person to reflect back what you have said, so you are sure they got it!”
  • “We were starving for reliable information when I was diagnosed. Wish there was information provided with the results that further explained everything.”
  • “Always present situation with hope.”
  • “My oncologist was exceptionally kind. He said ‘I’m sorry this is happening to you’. He was the only one of several doctors to do so’”

The study population by design sampled internet-saavy women, and Caucasian women were over-represented in the sample, so these results may not extrapolate to all women.

But the message is loud and clear – when it comes to breast cancer screening results, we are not meeting our patient’s desire for timeliness or preferred method of communication.

Rethinking Gonad Removal in Individuals w/ Complete Androgen Insensitivity Syndrome

Lauren in MTV's "Faking it" has AIS
Lauren in MTV’s “Faking it” has AIS
What if you were genetically male, but your body was blind to testosterone ?

I’ve just described XY Complete Androgen Insensitivity Syndrome, or CAIS, a genetic condition in which there is a defect in the androgen (testosterone) receptor gene – located, ironically, on the X-chromosome.*

Describing CAIS

XY (genetically male) individuals with CAIS have gonads (testes) that manufacture testosterone, but their body’s cells cannot see the testosterone. As a result, their internal and external genitalia develop as female, but the vagina is shortened and smaller than normal. The testes are either located in the groin or in the abdomen.

At puberty, individuals with AIS develop breasts due to the body’s conversion of testosterone to estrogen. Pubic and underarm hair is scant, since this hair growth requires androgen receptors. With dilation of the vagina, AIS individuals can have sexual intercourse, but they cannot bear children.

As to gender identity, although CAIS individuals are viewed as female and until now, treated that way, it may not be as simple as that. (Huge “Duh” from the AIS community on this one, I’m sure…) Some interesting brain imaging studies do suggest the brain sexual response in CAIS aligns to female, not male. But gender identity is too individual an issue to address here. It could be linked to specific gene defects, and I suspect will be teased out over time as the medical community wakes up to the psycho-sexual needs of this community.

One way in which we are already waking up is in how we are managing the risks of cancer of the gonads in individuals with CAIS.

Cancer Risks in the Gonads of XY individuals with CAIS

Until recently, based mostly on case reports and anecdotal evidence, it had been accepted that there was an increased risk of cancer in the testes of individuals with AIS – a risk as high as 22% in one early published series. Therefore, for many years, one of the tenets of caring for individuals with AIS has been removal of the gonads in childhood, followed by the induction of puberty with estrogen and lifelong estrogen replacement therapy.

All of this has changed over the past few decades. A growing scientific literature finds that the actual incidence of gonadal cancers in CAIS is as low as 5 to 10%, with few to no malignancies prior to puberty. This led to the current standard of care for AIS, which is to delay gonad removal till after puberty is complete – usually between ages 16-18. This allows for a smooth, natural pubertal transition (nature always does it better than pharma), and for the more mature patient to be involved in management decisions going forward.

Rethinking Gonad Removal for Cancer Prevention

Now, the needle is shifting even further, as genetic sequencing allows us to stratify cancer risks in individuals with AIS according to their genetic defect. For those with complete androgen insensitivity, at lowest risk of cancer, the chance of retaining the gonads indefinitely is now being considered, along with various surveillance regimens to help catch cancer if and when it develops in the retained gonads.  Proposed surveillance options include gonad biopsy, ultrasound and serum tumor markers in individuals whose testes can be easily seen on sonogram. For those whose gonads are hard to image, laparoscopic surgery called gonadopexy can move the testes closer to the abdominal wall to allow for biopsy and sonographic surveillance.

(Note that this option of surveillance is only appropriate for those with CAIS. Individuals with Partial Androgen Insensitivity Syndrome or PAIS have a cancer risk as high as 50%. For these individuals, standard of care is to remove the testes, usually before puberty.)

We don’t know yet just what, if any, advantage there is in retaining the gonads past puberty in CAIS, other than the obvious one of avoiding surgery and hormone replacement therapy. Proposed gonadal surveillance strategies have not yet been tested prospectively, and ideally would be done in an IRB-approved clinical trial, which may not be randomized for ethical reasons, but could certainly be matched to individuals choosing to have their gonads removed at puberty.

Paramount to moving forward on any path towards surveillance, research or otherwise, is a well-informed patient. The good news on that front is that there is a lot of information out there now for patients and their families to help them learn about and participate in management decisions around CAIS. And as we move forward, let’s never forget – Prima non nocere.

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SUGGESTED READING

Patel V, Kastl Casey R, Gomez-Lobo, V. Timing of Gonadectomy in Patients with Complete Androgen Insensitivity Syndrome – Current Recommendations and Future Directions, J Pediatr Adol Gynecology 29 (2016) 320-325. This blog post was written in response to this well-written state of the art mini-review and its accompanying editorial by Joseph Sanfilippo, MD.

RESOURCES FOR AIS INDIVIDUALS AND THOSE WHO LOVE THEM

*Note – there are XX individuals with CAIS who carry a gene defect of the androgen receptor on both X chromosomes. These individuals are genetically female and develop as a female, but are minimally affected, though they may be tall, have scant pubic and underarm hair and delayed puberty. This blog post is not about them.