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.



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.


*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. 

Onion & Olive Tart

Onion & Olive Tart

This wonderful onion and olive tart is based on a recipe from Molly O’Neill.  Think if it as an Americanized version of the classic French Pissaladiere – a Nicoise savory tart made with anchovies, onions, olives and herbs.  The classic Pissalidiere is made with a thin pizza crust (though Julia Child made hers with puff pastry) and derives it name from its use of pisalla – a condiment speciality of the coastal area around Nice made from ground anchovies with olive oil, herbs and spices.

Today, I’ve made my mother-in-law Irene’s variation of the tart without anchovies. I plan to bring it to my brother-in-laws kick-ass Second Saturday Party, where it will accompany his amazing chicken wings and the best roast beef sandwiches in the world. Anchovies just don’t seem right, and I fear not everyone will like them.

But making this tart and learning about its origins has me itching to try my hand at a classic Pisalladiere.

Onion & Olive Tart

The original recipe by Molly O’Neill has instructions for making the crust by hand, if you prefer that over using the food processor.  Molly also hides the anchovies and olives between two layers of onions. Maybe she’s also worried about her audience…. I just made the variation without anchovies. 


  • 2 cups flour
  • ½ lb unsalted butter, sliced
  • ½ tsp kosher salt
  • 1 egg yolk
  • 3 tbsp ice water


  • 2 tbsps sweet butter
  • 3 lbs yellow onions, thinly sliced
  • Salt and freshly ground pepper
  • 12 anchovy fillets
  • 1 cup oil-cured black olives, pitted and halved
  • ¼ tsp each, basil and oregano

Make the crust:  In food processor, pulse flour and salt. Add butter, pulse. Add liquids. Pulse, then shape into ball on floured board. Wrap in plastic. Chill for one hour

Make the filling by melting the butter in a large skillet over high heat. Reduce the heat to low and add the onions. Cook, stirring frequently until the onions are light brown, about 15 minutes. Adjust the flame to avoid burning. Season with salt, pepper, oregano and basil. Set aside to cool to room temp.

Preheat the oven to 375 degrees. Roll the dough out on a lightly floured board and place in a large pie or tart pan. Press the dough into the pan and crimp the edges.

Lay in the onions using a fork. Arrange the anchovies in a starburst pattern from the center of the pie. Arrange the olives between the anchovies.

Bake the tart until the crust is golden and the onions are caramelized and brown, 40 to 50 minutes. YIELD: eight servings.

Pie Variations:

Omit anchovies. Sprinkle ¼ cup grated Parmesan cheese on crust before adding the onions. Dot with whole olives before baking.

To make ahead 

Cook up the onions, and refrigerate. Make the pie dough and refrigerate. On the day you are serving, roll out the pie dough, assemble the pie and bake.  Serve at room temperature or warm up before serving.

Bronx River Pathway Ride

Bronx RIver

Boy, is spring ever late coming this year. Last weekend found us more than eager to finally get out in the warmish weather. Figuring Central Park would be packed, we decided to take our bikes north of the city to the Bronx River Pathway.

This Greenway runs along the Bronx River in Westchester County, NY. The trail has three paved segments, which are not continuous. We chose to ride the uppermost section from Greenacres Road to Kensico Dam, about a 10 mile round trip. It’s not an entirely bucolic country ride, since the highway and civilization are never far away, but there are more than enough green spaces and points of interest that we barely noticed the the nearby traffic.

Bronx RIver 2

The trail takes you from north Scarsdale through White Plains to the Kensico Dam Park in Valhalla. You’ll be biking along babbling waters, past a tennis club, along a poorly paved section in the forest, then on a decently-paved path through White Plains, taking some steep and narrow stretches under the roadways (Get off and walk here – you risk hitting a biker coming the other way or worse, hitting your head on the low overhanging bridges).

Bronx River Greenway

You’ll cut across a parking lot and a road or two, including one short stint over a roadway bridge where the trail does not cut perfectly across the road. Just follow the bike signs.

Bronx River Greenway 2

Along the trail, there are numbered outposts of the Bronx River Walk App, a podcast narrated by Dan Rather, who tells the history of the Bronx River, and directs your attention to points of interest, both man-made and natural, along the way. Given that the trail has a slight uphill grade going north and a few steep (but mercifully short) uphill climbs, these little listening breaks were both enjoyable and restful.

Bronx River Greenway 3

Once you climb up the hill to the Valhalla Bridge, you’re almost at the north end of the trail and your ride’s halfway point.

Valhalla Bridge

Stop and look north – you’ll see the Kensico Dam, beckoning like a Mayan Temple in the distance.

Kensico Dam from Valhalla Bridge

The dam, built in the 1920’s, holds back the waters of the Kensico reservoir, which is a terminal collecting point for water from 6 other reservoirs in the Catskills ultimately destined to be delivered to New York City.

It is massively beautiful (my pictures do not do it justice)

Kensico Dam 2

and graced on its south side by a lovely public park.

Kensico Dam Park

You can ride (or in my case walk) your bike up the winding brick road on the right of the dam

Kensico Dam 4

all the way up, where a road allows you to ride right across the top of the dam!

Kensico Dam 7

It’s just so cool – seeing the water high on one side

Kensico dam 10

and the land way down below on the other.

Kensico Dam 8


The park has restrooms and food – if we’d planned the day better, we would have left earlier and planned to stop here for lunch. But we had dinner plans back in the city, so after a brief rest we headed back down the trail. The trail heading south is almost all downhill, and before I knew it we were back at the trailhead!

Bottom Line

The Bronx River Greenway is a great day trip from New York City. Leave early, plan to stop for lunch at the Kensico Dam and make a day of it.

One thing I would have also liked to have done would be to spend some time exploring Scarsdale’s downtown, perhaps having a late afternoon coffee there after the ride. Take Fox Meadow Road south from near the trailhead for about 2 miles, mostly flat according to google maps. If you’re not driving, you can get the train from the Scarsdale station back to the city.

Getting there

This is perhaps the most difficult aspect of this trip if, like me, you live in the city and don’t know West Chester. We drove, and took 87 to the Cross Bronx to the Bronx River Parkway. It’s probably easier to just take 278 to the Bronx River Parkway. The Bronx River Parkway becomes rather narrow and windy as it goes north, and may be closed if it’s a Sunday (See alternate route below). Follow your map carefully. Next time we may just take the train.

  • By train : Take Metro North from Grand Central to Hartsdale. Bike over Fenimore Road, then a left onto Greenacres to the trailhead. If you pass the church, you’ve gone too far.

From Train

  • By car (Enter Hitchcock Presbyterian Church in Scarsdale as your destination.): Head north to the Bronx River Parkway, taking the Fenimore Ave Exit. Turn right onto Fenmore, left onto Walworth ave, then another left on Greenacres Road. Park across from the church.

Bronx River Trail head Scarsdale

  • If it’s a Sunday morning in fair weather season, the Bronx River Parkway may be closed to cars, in which case take the Hutchinson Parkway to exit 22, then take Mamarineck Road to Fenmore and then Greenacres.

alternate route

Helpful links

Almond-Lemon Torte w/ Strawberries

Almond and Lemon torte with strawberries

The never ending search for the perfect Seder dessert continues. This one’s coming close.

Of course, my family would probably say the prefect Passover dessert has already been found in my mother in law Irene’s hazelnut strawberry shortcake. Problem is, delicious as it is, I couldn’t bring the shortcake to my kosher friends’ seder, since it is served with whipped cream and the Seder is a meat meal.

The fallen middle in this torte is a given. It’s what happens when you depend on eggs alone for your leavening, pouring an air filled light batter into your pan, then holding your breath as you place it into the oven. You have two choices at that point – either bake it till its hard and dry, with a crust sturdy enough to stand up as it cools, or keep it lightly browned and moist and just let it fall as it cools. I chose the latter, testing several times till the tester came out clean to be sure I wasn’t under-baking the center, and taking the cake out before the top started to split or got too brown. I was worried when it fell, till I compared my torte to the picture in Epicurious – their’s fell about the same amount as mine.

Despite the fall, this torte is quite delicious. The cake itself is incredibly moist, not too dense, not too sweet and really just plain lovely. The strawberry sauce, while thin, is not too sweet and a perfect accompaniment. Even better, this dessert can be made a day or two ahead, as I have done.

You know what? I think this may actually be the perfect Seder dessert.

Almond-Lemon Torte with Strawberries

Adapted from a recipe by chef Diane Rossen Worthington on Epicurious.  I found using my hand held beater easier than switching and cleaning bowls for the standup mixer. Plus I think it whips things lighter. 

Torte Ingredients:

  • 6 tbsp olive oil (plus a little more to brush the pan)
  • 4 tbsp matzo meal (2 tbsp for the pan, 2 tbsp for the torte)
  • 2 cups almond flour or almond meal
  • 1 cup sugar, divided into thirds
  • 6 large eggs (you’ll be separating them)
  • 2 tbsp fresh lemon juice
  • 1 tbsp orange juice
  • 2 tsp lemon zest, fine (I use this lemon zester)
  • 1/2 teaspoon salt
  • 1/2 cup slivered almonds

Sauce and berries:

  • 5 cups sliced and stemmed strawberries (about 2 pounds), 2 cups for sauce, 3 cups to serve
  • 2 tbsp sugar


Preheat oven to 350°F. Brush 10-inch-diameter springform pan with oil. Line bottom with parchment paper round or wax paper. Brush paper with oil. Place 2 tbsp matzo meal in pan and shake to coat; tap out excess.

Combine remaining 2 tbsp matzo meal, almond flour, and 1/3 cup sugar in medium bowl; whisk to blend.

Separate eggs – yolks to a largish bowl, whites to a medium bowl.

Add 1/3 cup sugar to egg yolks and beat until thick and fluffy. Beat in 6 tbsp olive oil, then lemon juice, orange juice, and lemon zest. Mix in dry ingredients. Clean your beaters and wipe them dry.

In the other bowl, add 1/2 teaspoon salt to egg whites; beat until soft peaks form. Gradually add 1/3 cup sugar and beat until stiff but not dry.

Fold whites into yolk mixture in 3 additions. Transfer batter to prepared pan. Sprinkle almonds over top.

Bake cake until golden brown and tester inserted into center comes out clean, about 40 – 50 minutes. (It took me 50 mins) Remove to rack and cool cake completely in pan.

Can be made 2 days ahead. Store in pan, covered with foil at room temp.

For sauce and berries:

Combine 2 cups sliced strawberries and 2 tbsp sugar in blender or food processor; blend until smooth. Can be made 1 day ahead. Cover and chill.

To serve:

Cut around cake; release pan sides. Cut cake into wedges. Serve with sauce and remaining sliced strawberries.

Prophylactic Mastectomies Increasing Despite No Survival Benefit

fight like a girlOne of the more concerning trends in breast cancer treatment is the growing use of bilateral mastectomy to treat breast cancer that is present in only one breast. We call this prophylactic contralateral mastectomy – or removal of a normal breast in order to prevent future breast cancer.

A new study of almost half a million women with breast cancer reports that in 2009, 12.7% chose to treat cancer in one breast by removing both breasts, a rate almost triple that in 2002. Unfortunately, the additional surgery added no benefit, as survival rates were no better among women who had bilateral mastectomy compared to those who chose to keep their healthy breast.

The trend towards prophylactic contralateral mastectomy (PCM) is most pronounced among women diagnosed with breast cancer prior to age 55. PCM Rates are highest among women with more advanced disease, the group it is least likely to benefit, but also increasing among those with stage 0 or 1 breast cancer. Other factors associated with use of prophylactic contralateral mastectomy are Caucasian race, higher income and education, larger tumor size, use of breast MRI, family history of breast cancer and increased anxiety and fear of recurrence.

While prophylactic mastectomy does decrease the chance of a new primary breast cancer in the unaffected breast, that risk is less than 1% to start with. The study did not address mastectomy of the affected breast, but in most cases, mastectomy does not improve survival when compared with lumpectomy and radiation therapy.


Why are so many women opting for bilateral mastectomy, when local treatment with lumpectomy and radiation therapy will in most cases be more than sufficient treatment, and allow for women to keep both their breasts?

Some are crediting Angelina Jolie, who famously underwent bilateral mastectomies for prevention of breast cancer due to a genetic mutation she carries in the BRCA gene.  Yet only about a third of the increase in PCM seen in this study occurred in genetic mutation carriers, so something else is at play here.

I think that something else is the desire for that elusive “peace of mind”, combined with mandatory insurance coverage of reconstructive surgery and the widespread acceptability of breast implants in the general population. Add in a really good nipple tattoo or nipple reconstruction and you’re set to move on from your diagnosis into a breast-cancer free future.

Because nothing says “I’m done” more than a set of new, cancer-free breasts.

Forget that the odds were already well in your favor before the procedure. Or that the procedure does nothing to improve those odds. Or that your peace of mind comes at quite a price – loss of breast sensation, inability to breast feed, and higher cost and complication rates.

I’m not sure what the right answer is to this obvious conundrum.

We’ve done so much to move away from aggressive treatment to allow for improved quality of life and breast preservation compared to the old days, when the Halsted Radical Mastectomy was standard over-aggressive treatment for what in most cases is a localized disease.  Now it seems we are going backwards, but this time at the behest of women themselves.

I suppose that all we can do it take it on a case by case basis, and try to be sure that women are making this important treatment choice with the best data we can give them. In that vein, studies like this provide important information.


More Reading 



Maple Cheesecake with Roasted Pears

maple cheesecake w roasted pears

She may have gone to prison for insider trading, but Martha Stewart does make one mean cheesecake. Maple syrup lightly sweetens the cheese filling and is brushed on pear slices as they roast before being layered atop the cheesecake, made here with a classic graham cracker crust. Not too heavy, not too sweet. Perfect.

Maple Cheesecake with Roasted Pears 

Martha uses a vanilla wafer crust, but I prefer the traditional graham cracker crust. She broils her pears, I simply roasted them. She sprays her roasting pan with cooking spray, I brush it with canola oil. I used an Epicurious recipe for the crust because it had less sugar – graham crackers are sweet enough – and a little more butter – because you can never have enough butter.


  • 2 – 8 ounces packages Philly cream cheese, room temperature
  • 3/4 cup pure maple syrup
  • 1 cup cold heavy cream
  • 2 tablespoons confectioners’ sugar
  • 1 Graham Cracker crust, made in a 9 inch springform pan (Recipe below)
  • 2 medium Bartlett pears, sliced lengthwise 1/8 inch thick


In a large electric mixer bowl, beat cream cheese on high until fluffy, about 3 minutes. Add 1/2 cup maple syrup; beat until smooth.

In another smaller bowl, beat cream and sugar on high until soft peaks form, about 3 minutes. With a rubber spatula, fold a third of the whipped cream into cream cheese mixture, then fold in remainder. Transfer to prepared crust and refrigerate until firm, 3 hours.

Preheat oven to 450 degrees. Lightly brush a parchment-lined rimmed baking sheet with canola oil. Arrange pear slices in a single layer on sheet and brush with 2 tablespoons maple syrup. Roast until pears are soft and browned in places, about 20 minutes. Let cool.

To serve, arrange pear slices, overlapping slightly, on cheesecake.

Graham Cracker Crust

If you find yourself running short while pressing this onto the sides of the pan (or eating too much while making it), just make a little more. I find how much I use depends on how thick I layer the crumbs, and it’s hard to do it uniformly every time. 


  • About 12 graham crackers to make around 1 3/4 cups graham cracker crumbs
  • 2 1/2 tablespoons sugar
  • 6 tablespoons (3/4 stick) unsalted butter, melted


Preheat oven to 350°F. Make the graham cracker crumbs by processing crackers in food processor till fine. Blend 1 3/4 cups graham cracker crumbs and sugar until combined. Gradually add butter and blwnd until moist clumps form. Press crumbs onto bottom and 1 1/2 inches up sides of 9-inch-diameter springform pan with removable bottom. Bake until set, about 12 minutes. Transfer to rack; cool completely before filling.

False Positive Mammograms & Subsequent Breast Cancer Risk

breast ca risk and false pos mammo
A recent study points to a higher risk of breast cancer in women with a history of a false positive mammogram.

Investigators examined the number of breast cancers occurring over 10 years with whose routine screening mammogram had resulted in either a “call back” normal mammogram or a benign breast biopsy (false positive mammograms), and compared it to the number of cancers in women whose mammogram was normal on the first go round (true negative mammogram.)

Women who had a false positive mammogram had a higher risk of breast cancer in the subsequent 10 years compared to women with a true negative mammogram. How much higher? As you can see in the graph above, for every 1/000 women with a true negative mammogram, 3.9 breast cancers occurred within the subsequent 10 years. This is in contrast to women with false positive mammograms who had 5.5 breast cancers for every 1,000 women, and women with a false positive biopsy who had 7 cancers per 1,000 women.

Thought the relative risks between groups is statistically significant, it’s extremely important to realize that ALL these risks are under 1%, so we are making distinctions between very small numbers.

Here’s what the study results looks like in an icon array, a useful tool for illustrating comparative risks that are under 1%. Among the 1,000 women pictured in each array below, the pink ladies are the ones who developed breast cancer within the 10 years, while the grey ladies remain cancer free.

true neg

False pos


Further stratifying results by breast density, the researchers found that 10 year subsequent breast cancer risk was highest in women with extremely dense breasts and a false positive biopsy (9.01 per 1,000 women), and lowest in women with fatty breasts and true negative mammograms (2.22 per 1,000 women), with the rest scattered in between according to density.

breast ca risk by density

The investigators uses data from the Breast Cancer Surveillance Consortium (BCSC) from 1994 to 2009, studying over 2 million mammograms done in over 1 million women. It’s a robust database that the US Preventive Services Task Force used to advise their recommendations for mammogram screening. They adjusted risk data for age, race/ethnicity, menopausal status, history of breast biopsy, and family history of breast cancer, all factors that are associated with breast cancer risk.  The study results are consistent with those of other studies, adding to a growing body of literature linking false positive mammograms with breast cancer risk.

Now What?

A history of a prior breast biopsy is a known risk factor for subsequent breast cancer, and is already incorporated into the Gale Model and other breast cancer risks assessment tools. It may be time to consider incorporating a history of a prior false positive mammogram into these tools. At this point, breast density has not been incorporated into these risks assessment tools, primarily because it is such a subjective measure with not great reproducibility, and because it changes over time.

How to Use This Information

Women and their doctors may want to use this information to help them decide how often to have mammograms, or whether or not to begin to incorporate sonograms into their breast cancer screening regimen.

That said, it’s important to understand that although the risks for breast cancer are increased by a false positive mammogram, the absolute increase in risk is modest – still less than 1% in even the highest risk group.

Uquora – Hope, Hype and Maybe a Case of Diarrhea


Before you go out and spend $25 for 10 packets of Uquora, the new after-sex UTI prevention drink that launched today, you should consider if it actually works.

What’s in Uqora?

Uqora’s main active ingredient is D-Mannose (2 gm), combined with Vitamin C (600 mg), Vitamin B6, Calcium and Magnesium. (The company website does not list amounts for the last three ingredients.) The ingredients are made into a powder that you mix with water and drink.

The manufacturer claims that Uqora will reduce the chance of getting a UTI if you drink it after having sex, after exercise or during travel, all activities linked to recurrent UTI’s in women.

There is absolutely no data that taking Uqora (or D-mannose) in a single dose after intercourse will prevent a UTI. 

Does Uqora Prevent UTI’s?

Actually, no one knows if Uquora prevents UTI’s.

Uqora’s manufacturers base their claims on a single randomized study of D-mannose powder 2 mg, taken daily for 6 months. The study was published as a brief comment in BJU International. There’s so little data that I can actually post the entire study here –

After initial antibiotic treatment of the acute UTI (ciprofloxacin 500 mg twice daily for 1 week), patients were randomly allocated to three equal groups. The first group received prophylaxis with 2 g of D-mannose powder daily for 6 months, the second received prophylaxis with 50 mg of nitrofurantoin once a day, and the third did not receive prophylaxis. During the 6-month study period 98 of our patients (32%) had a recurrent UTI. The rate of recurrent UTI was significantly higher in the group that did not receive prophylaxis (60%) compared with the groups receiving D-mannose (15%) and nitrofurantoin (20%) which did not differ significantly. The risk of recurrent UTI episodes was significantly higher in the no-prophylaxis group compared with the groups that received active prophylaxis (relative risk 0.24 and 0.34). Also, we found that patients in the D-mannose group had a significantly lower risk of side effects compared with patients in the nitrofurantoin group, although nitrofurantoin was generally well tolerated. In patients who were taking D-mannose, episodes of diarrhoea were the only side effect and were noted in 8% of patients, but they did not require discontinuation of the prophylaxis. Patient compliance (assessed by recording the intake of prophylaxis on a self-report sheet) was very high and there was no difference between patients taking nitrofurantoin or D-mannose.

Note we have no information about the three study populations – were they similar to start with? Did they have similar baseline frequencies of UTI’s? What bacteria caused their infections (not all bacteria have the structure that would make them susceptible to D-mannose)? There is no data on comparative compliance between placebo and study groups, and no controlling for frequency of intercourse during treatment, the factor most important in predicting UTI recurrence in this type of patient.

That’s it folks. A single study, poorly reported, whose authors actually state that “more studies will certainly be needed to confirm the results of our study.”

To make matters worse, Uqora is not taken daily, the way D-mannose was given in this study. It is taken only after intercourse. There is absolutely no data that taking D-mannose or Uqora in a single dose after intercourse will prevent a UTI. And the manufacturers have not done a single study of their product in humans.

What About the Other Ingredients ?

I’m not going to belabor the point, except to say that the data on Vitamin C comes from yet another single study of daily use, this time in pregnant women. There are no data that taking a single dose of Vitamin C after sex will do anything other than turn your urine yellow.

Vitamin B6 is given to “Increase urination and urinary flow”, based on what data I don’t know.

Calcium and magnesium are there “to prevent the loss of these ions through urination”. Which means what, exactly? And how does this help prevent UTI’s?

Uqora Sidesteps the FDA

Uqora’s manufacturers call it a “dietary supplement” so they think they can sidestep FDA oversight. Their site has the usual disclaimer “This product is not intended to diagnose, treat, cure, or prevent any disease”. Yet the same website claims that ‘The Uqora product is an efficacious combination of ingredients that should be taken soon after sexual activity to reduce the risk of developing a UTI.”

This is standard supplement industry behavior.

I have no idea where Uqora is made, but somehow I suspect it’s not in the states or they’d have said it on the website. Being a so-called “supplement”, there is no oversight of the manufacturing process and no one has to verify what’s in it to anyone.

They do have a pretty website and a cute video, which seems to be all you need these days to get your product covered by

You Might Get Diarrhea (and a UTI) from taking Uqora

I wouldn’t believe the website when it says that “There are no known side effects for the active ingredients at any of the suggested doses.”

You can see in the study up there that 8% of women taking D-mannose had diarrhea. Magnesium also can cause diarrhea. So can high doses of Vitamin C. Put them all together in one drink and who knows what may happen.

And of course, diarrhea not uncommonly can lead to …. you guessed it. A UTI.

Bottom Line

$25 is an awful lot of money to spend on an unproven UTI remedy.  Then again, if you happen to be constipated, you may get your money’s worth…

Strategies for UTI Prevention

  • Drink enough water to keep from being dehydrated.
  • Empty your bladder after sex.
  • Wipe from front to back.
  • If you have recurrent UTI’s and are using the diaphragm, consider if another birth control might be worth trying.
  • Cranberry juice may or may not be effective, but as long as you take an unsweetened variety, it is unlikely to harm you.
  • If you want to take Vitamin C, which may be effective if taken daily, you can get it cheaply from the drugstore – take 100 mg daily, and stop if you get diarrhea
  • If these strategies are ineffective in preventing recurrent UTI’s associated with intercourse there are prescriptions that your doctor may prescribe. These include post-coital antibiotics such as macrodantin, and daily suppressive doses of Methenamine hippurate (Hyprex). In post menopausal women, vaginal estrogen has been shown to be effective in reducing UTI frequency.



There’s an awful lot of misinformation out there about HPV and the HPV vaccine. Let’s see what I can do to clear up the confusion. Here are eight myths I find myself having to continually address with my patients. Let’s bust ’em!

Myth#1 – HPV is forever

Wrong. 90-95% of the time, HPV infections clear without any treatment. For those women with persistent HPV infection, we have pap smears to detect and treat precancerous lesions (dysplasia) years before they become invasive cancer.

Myth #2 – If I’ve had the HPV vaccine, I don’t need Pap smears.PAP

Wrong again. While the HPV vaccine is highly effective against the HPV strains it targets, and those strains together cause in excess of 70% of all cervical cancers, you are not 100% protected. Sorry. Until we have a vaccine that protects against all the cancer-causing subtypes, you’ll need to get your pap smears.

The good news in this front is that both Gardasil and Cervarix are showing cross-reactivity against other cancer causing strains of HPV so we may be getting a bigger bang for our buck than we initially thought. Stay tuned..

Myth #3 – The HPV Vaccine is dangerous.


Actually, it’s quite safe. A recent comprehensive review of HPV vaccine safety studies to date, some with over a million subjects each, found no serious health risks from the vaccine.

Like all vaccines and injections, HPV vaccination can cause some local irritation on the arm, and some young girls faint afterwards. This is not serious.

Myth #4 – The HPV Vaccine is a Scamscam

No, it’s not.

There are valid arguments to be made as to whether the HPV vaccine is the most cost effective approach to eradicating cervical cancer in the US, where most women are already getting pap smears, and where those at highest risk (women who can’t afford pap smears) probably can’t afford the vaccine either. And we won’t get into the ridiculously high cost of the vaccine, or how fear mongering and politics have been used to market the HPV test and its vaccine. (I’ve written enough about this before). But that doesn’t make it a scam. The vaccine is real and it works.

Some have raised legitimate concerns that the vaccine’s efficacy could wane over time, effectively just delaying but not preventing cervical cancers. Fortunately, this has not panned out to date – the vaccine has shown no decline in immunity for up to 9 years. Time will tell on this one, but so far, so good.

Bottom line is that the HPV vaccine is safe and effective. I see no reason why young women should not get the vaccine. (My kids have gotten it, by the way.)

Myth #5 – The HPV Vaccine causes sexual promiscuity lips2

Nope. It doesn’t. (Research reference here)

Myth $6- If I have HPV there is nothing I can do about it.

You’re not powerless – there are some things you can do.  In addition to getting your pap smears, you can help your immune system clear the virus in three ways –

  • Use condoms. By decreasing the exposure of your body to more virus, you’ll free your mmune system up to clear the virus you already have.
  • Get 4-6 servings of fruits and vegetables a day. Women who do so clear the virus sooner than women who don’t.
  • Don’t smoke. If having HPV is your wake up call to quit the cigs, then so be it. Ask your doc for help if you need it to get off nicotine.

Myth #7 – All HPV Tests are the same.


Not true. Some are FDA approved, some are not. Ask your doc which test he/she uses, and be sure its an FDA approved test.

Myth #8- I can’t get the HPV vaccine if I’m over age 26.

Actually you can probably get it if you really want it. But you may not need it.

The vaccine is only FDA-approved up to age 26. That’s because by that time, most women have had one or more HPV infections already. From a public health perspective, it doesn’t make much sense to vaccinate a population against a virus that most are already immune to.

But on an individual basis, the vaccine could be effective if you’ve had very few sexual partners and have never been infected with the HPV strains targeted by the vaccine or had genital warts. Even if you have, there’s no way to know what HPV strains you may already be immune to – the HPV test is not strain specific. (Although one test does detect HPV16/18). I do not recommend getting HPV tested just for this purpose.

I’m hearing that some insurers will pay for the HPV vaccine even in women over age 26. And if they don’t, you can pay for it yourself. Talk to your doctor and make your own choice.


More TBTAM posts on HPV

Time Makes a Better Bread – and A Better Bread Maker

Jim Lahey Bread 2

I”ve been making Jim Lahey’s bread for about four years now.

My first attempt was in New York City during Hurricane Irene, when I knew I’d be home for at least 24 hours with nothing to do but make this bread. which has a 12 to 18 hour rise, followed by a second two hour rise prior to baking.  The result was delicious, though a little flat.  But hands down the best bread I’d ever baked.

no-knead-bread first attemps
My first attempt at Jim Lahey’s No-Knead Bread

I decided to try making bread during weekends at our cottage in the Endless Mountains, and immediately gravitated to Mark Bittman’s speedier version of Lahey’s recipe. The shortened 4 hour rise time allowed me to start the bread first thing on a Saturday morning and still have it ready by lunchtime.

That bread making schedule made us some very pretty breads and served us well on many a Saturday lunch.

Bittman speedier no-Knead bread

But not really.

You see, we often did not roll into the driveway of our cottage until very late Friday evening, especially if traffic was bad getting out of New York City. By that point, the thought of bread for tomorrow’s lunch was nowhere near my consciousness – all I wanted was bed. Next morning, by the time I got up and thought of bread, it was way too late to start a loaf if we were planning to do anything else that day.

So the sad truth is, though I like to think I did, most weekends on the mountain I did not make bread.


This summer I got smart and took off a bunch of Friday afternoons. Now we leave earlier from New York City (1 pm is the latest if you want an under 4 hour trip), and I work using my laptop and cellphone hot spot while Mr TBTAM drives. The result? One evening, I actually found myself sitting on the front porch on a Friday evening with a glass of wine at 6 pm!

This got me thinking – why not start the bread now instead of in the morning? After all, Lahey’s original recipe has an overnight rise.

The first phase of the recipe is so easy that I have it memorized and can get the bread set up to rise in 5 minutes. I can even start it at home while we’re packing up the food, and let it start to rise in the car while we drive! Next morning, I can sleep as late as 9 am and still have time to finish the second rise and bake it before lunch, leaving me a free afternoon to hike or swim or kayak.

If I want the whole day free, I set an alarm for 5, set up the second rise and head back to bed till 7:00, at which point I get up, heat the oven for a half hour while I shower, then bake the bread from 7:00 to 7:45 am. After cooling (an absolutely essential part of the process), the bread will be done by 8:15 am, and I have a full day to play.

My early morning bread making schedule

Somewhere along the line, I bought Lahey’s book and learned the actual science behind his bread. This brought home the reality of why this longer making bread is just a better bread than Bittman’s speedier version. The overnight rise is really a short fermentation, and the bread attains a wonderful sourdough-like taste. The crust it forms is thicker and the bread sturdier yet still soft – ie., better gluten. Lacey’s book also taught me to respect the rest after baking, during which the bread “sings” as the steam escapes, and never, ever to cut into the bread till it has cooled.

A big advantage of the overnight rise for me is that it is not as temperature dependent. It can get really cool up here on the mountain, and there were times I put the bread in the car and drove to a sunny spot to get a decent rise from Bittman’s speedier rise recipe. But when the yeast have 12 or more hours to do their thing, temperature seems not to be as critical. (If it’s going to be a really cool night, I do increase the yeast just a teeny bit as insurance.)

Speaking of temperature, I’m still wondering just how hot I can go when baking this bread. Bittman’s original article says 450 degrees, but in the NYTimes video Lahey says “500, even 515” degrees, and in his book, he says 475 degrees. (The bread pictured here was baked at 475 degrees.)

Lahey’s pics of the bread making process in his book are invaluable. I also strongly recommend watching this video from Mark Bittman to understand just how wet this dough is. Over time, I’ve gotten the confidence to know that if following the recipe exactly on a given day yields bread dough that’s a little too thick, I can add water and make it “just right”. This is the sort of skill that only comes with time and experience.

So try this bread. Then try it again. And again. And again.

With time, and sooner than you think, you’ll be making one amazing loaf.

Jim Lahey Basic Bread


More No-Knead Links 

Treating Menopausal Vaginal Dryness

dried roseSex is supposed to be fun, and it’s definitely not supposed to hurt.

But one of the consequences of menopause is vaginal dryness, which for many women means painful sex.

With the loss of ovarian estrogen, vaginal walls that were once elastic, expandable, supple and sturdy can, over time, become tightened and fragile. The vaginal walls can become as thin as tissue paper, unable to withstand the manipulation that occurs with sexual activity, and can tear and even bleed with intercourse.

“Use it or lose it”

When sex becomes painful, the natural response is to begin to avoid intercourse. But without continued sexual activity (masturbation counts, too), the vagina becomes even smaller and tighter, making a bad problem even worse. Add in a partner with erectile dysfunction and it’s not unusual for a woman to present to me not having had sex in a year or more, wondering if there’s anything that can be done to get back the sex life she and her partner once enjoyed.

Fortunately, the answer is almost always a resounding “Yes!”

Non-Hormonal Treatment

The first step for most women is a trial of non-hormonal therapy. You’ll need two things – a moisturizer and a lubricant.

Vaginal moisturizers

Think of how you take care of your skin – you moisturize it daily, right? Well, the menopausal vagina needs the same thing. It doesn’t have to be every day, but it has to be regular and consistent.

I don’t promote products, but I do tell my patients about Replens – it’s been studied and shown to be as effective as vaginal estrogen in restoring the premenopausal vaginal mucosa.

Vaginal Lubricants

Have fun trying out brands, but avoid flavored and scented products if you tend to be sensitive to them. If you need STD protection, stick to water-based lubricants that will not degrade condoms.

Don’t be shy about using lube – slather it on him and yourself and have fun.

Vaginal Estrogen Treatment

Probably the most effective treatment for dryness is vaginal estrogen. It works by restoring and thickening the vaginal mucosa, and by increasing vaginal secretions. Vaginal estrogen comes in one of three forms –

  • Estradiol tablets (Vagifem) – A small tablet inserted into the vagina once a night for two weeks, then twice a week thereafter. The vaginal estrogen tablet is for many women the easiest and least messy option, although not all women can seem to remember to use it regularly on a twice weekly basis.
  • Estrogen creams (Estrace, its generics and Premarin) – A cream inserted into the vagina once a night for two weeks, then twice a week thereafter. Same issue as with the tablet – remembering to use it. Estrogen doses are highest for the cream when used according to the package insert, but one can adjust the dose of cream by simply using less. This allows for higher doses at the onset of treatment, with lower maintenance doses once vaginal integrity and sexual function are restored.
  • Estradiol vaginal ring (Estring) – A ring inserted once every 3 months. Systemic estrogen absorption is lowest for the Estring estrogen vaginal ring, but not all women’s vaginas are large enough to accommodate the ring at first.

Safety of Vaginal Estrogen

Women hear the word “estrogen” and immediately become concerned – not surprising given the findings of the Women’s Health Initiate in 2002 that hormone replacement is associated with a small increase in breast cancer risks. However, estrogen exposure from use of vaginal estrogen is much lower than that with hormone replacement, and blood levels of estrogen remain within the menopausal range.

These small amounts of estrogen do not carry the same risks of blood clots as does hormone replacement, and there is no increase in uterine cancer rates with vaginal estrogen use for up to 5 years. Despite these differences, vaginal estrogens carry the same FDA warnings as systemic hormone replacement, and menopause experts have petitioned the FDA to correct the vaginal estrogen package insert.

All of that said, we do not have long-term data on breast cancer risks from vaginal estrogen, and women at high risk for breast cancer or with a history of breast cancer generally want to avoid even the small amounts in vaginal estrogen, especially if they are taking aromatase inhibitors to lower breast cancer risks.

If non-hormonal treatment are ineffective, some high risk women may be willing to use a short course of estrogen to restore vaginal integrity and sexual function, followed by over the counter moisturizers for long-term maintenance therapy.

What About Estriol Cream ?

Estriol is a weak estrogen that is effective for vaginal dryness, but is not FDA-approved. If you’re avoiding the FDA-approved products because you don’t want to take estrogen, then take estriol off the list as well. It’s just another estrogen.

Oral Treatment

Ospemifine (Osphena) is an oral SERM (Selective Estrogen Receptor Modulator) that was FDA-approved in 2013 to treat menopausal vaginal dryness. In the vagina, Ospemifine acts like estrogen, restoring vaginal moisture and the integrity of the vaginal mucosa. Ospemiphene can stimulate growth of the uterine lining, although in postmenopausal women, this effect is minimal.

In animal studies, ospemiphene has been shown to block estrogen receptors in breast tissue. While this is an intriguing, it has not yet been proven in humans or shown to translate into a lower breast cancer risk for ospemiphene users.

Ospemiphene does carry a small blood clot risk, although it is smaller than that of hormone replacement. It can also worsen hot flashes, which makes it not a good option for women having menopausal symptoms other than just dryness.

What about vaginal laser treatment?

The FDA recently approved a vaginal laser called Mona Lisa Touch for treatment for menopausal vaginal dryness. The biggest potential advantages of this approach is that no hormones are used. The downsides are the need for multiple visits to complete therapy, extremely high cost (One hospital is charging $1500 for three visit treatment, none of which is currently covered by insurers) and very limited data on efficacy and long-term safety.

My biggest concern is what the risks are when this laser becomes more widely used by clinicians outside of clinical trials. It’s being promoted aggressively, and it’s non-covered insurance status could make it a real cash cow for practices. That said, I’m intrigued by the laser as a possible alternative for women unable or unwilling to use estrogen, so stay tuned on this one.

Vaginal Dilators

If you’ve been menopausal and celibate for a long time, the size of the vagina can actually decrease, and estrogen and lubricants may not enough to restore normal sexual activity. In that case, your doctor can prescribe a set of vaginal dilators – soft plastic rods that come in graduated sizes from 3 mm to 10 mm in diameter, allowing for a gradual increase in vaginal capacity.

With patience and determination, I’ve had many patients who’ve re-created the vagina of their youth. But not every patient I’ve offered dilators feels up to the task. In that case, they confine their sexual activities to non-penetrative sex, which for many women is where the fun is anyway.

Which brings me to –

The forgotten art of foreplay

Over years of being together, what with children and a busy life, some couples may have gotten out of the habit of foreplay and have had a very satisfactory sex life just getting down to business.

But with age, her vaginal dryness and his erectile dysfunction, the old “Wham, Bam, thank you Ma’am” may not work so well anymore. The good news is that age also brings the time to take a more leisurely approach to sex and rediscover the joy of foreplay, as well as the wide variety of intimacies beyond intercourse that couples can use to have a fulfilling and enjoyable sex life.

I often refer my patients to this reading list from SEICUS – the Sexuality Education consortium of the United States – addressing the changes to sex that come with age, and strategies for adapting to and enjoying them.

One more piece of advice

If, because of dryness, it’s been awhile since you’ve had sex, don’t start treatment and then sit and wait for the urge to hit you to start having sex again. Your libido is not going to suddenly turn back on just because your vagina is ready.

You’re just going to have to do it anyway, whether you think you want to or not. If all goes well, your body will respond – “Oh yeah – Now I remember – this is fun!”


A modified version of this post was published on

Smoked Trout

smoked trout

It only took us 10 years to get Mr TBTAM’s cousin Lou and his wife Maria up to our little town in the mountains, but it was a visit well worth the wait.  Not only did we have a great time, but Lou and Branch caught two trout in one of the feeders streams to the Loyalsock. A real team effort, and on a warm summer day, when trout are supposed to be nowhere to be found in shallow waters.

Of course, I smoked the trout. I’ve been wanting to make smoked trout since I first tasted it in Austria three years ago. My own attempts at fishing last year had yielded nothing more than a few tasty little perch. Now I had not one, but two 12 inch trout to play with! Not to mention, Lou had scaled and cleaned the fish himself. (Thank you Lou!)

How I Smoked the Trout

I cut off the heads and tails and butterflied the trout, then brined them (recipe below) in the fridge for about an hour. While they were brining, I soaked some mesquite chips and figured out how to light the Weber grill  – Do you believe I’d actually never lit a grill fire myself? But the boys were all off doing some evening fishing before dinner, so I was on my own.

I waited for the coals to turn grey and the fire to really get hot.  Then, I took the filets out of the brine, rinsed them under cold water, patted them dry with a paper towel and brought them out to the grill. Off the fire, I brushed the grill rack with olive oil. I then added a couple of handfuls of drained wet wood chips to the fire, put the grill rack on the grill and placed the filets skin side down on it. Then I put on the lid and watched the fragrant smoke pour out the vent holes while the fish cooked. (Thanks, Janet, for watching the grill!)

When the flesh was flaky but still moist (about an hour), they were done. I pulled out the bones, placed the flaked fish meat into a small bowl, and served it at room temp as an appetizer, along with a bowl of lemon aoli and some small crackers.

OMG – amazing! I don’t think I’ve ever had smoked fish so delicious.

Now that I know the fishing spot to get trout, I am going to head there myself next weekend and see if I can scare up a few more. Next time, though, I’ll be using applewood chips instead of mesquite. And I”ll try drying the brined filets before smoking them – a process that supposedly creates a very pretty surface (called a pellicle) on the smoked fish.

Finally, I’m thinking I should get one of those egg smokers – anyone have one and think it’ll give me even better results than using the Weber?

Brine for Smoked Trout

4 cups water at room temp
1 C. Kosher salt
½ C. brown sugar
3 tbsp lemon juice
8 peppercorns

Whisk ingredients in a glass or ceramic bowl until thoroughly dissolved. Place fish in brine – make sure all pieces are completely covered, if necessary, placing a dinner plates on top of fish to keep them underwater.

Refrigerate for about am hour. Remove fish from brine, quickly rinse in cold water, and pat dry. It’s ready to be smoked.

What I did not do, but will next time –
Place fish skin side down on lightly oiled grill rack (bot not yet on the grill). Season with herbs if you’d like – parsley or dill or cracked pepper. Dry for about an hour till skin is dried to point of being barely sticky – this is called the pellicle. A fan can speed up this process. Now it’s ready to be smoked.

Lemon Aoli to serve with Smoked Trout

  • 1/2 cup mayo
  • 1 tsp lemon zest
  • 2 tbsp fresh lemon juice
  • 1 clove garlic, finely chopped
  • 1 tsp dijon mustard
  • Sea salt and large cracked pepper to taste

Mix all ingredients in a small bowl and serve alongside smoked trout.

Additional Reading

I read a bit on how to smoke fish before I tried it myself. Here are some posts I found particularly helpful.

The Caya Diaphragm – What You Need to Know to Prescribe or Obtain It

A new diaphragm has become available in the United States – It’s called Caya, and it’s available in a single size and by prescription only, and is designed to be used with a nonoxynol-9 contraceptive gel.

Caya was developed as a collaboration between PATH and CONRAD, two non-profits responding to the needs of women for easy to use, effective, non-hormonal, user controlled contraception. Researchers at CONRAD, in a user-centered design process, worked their way  through over 200 different prototypes to arrive at the current one-size, non-latex diaphragm, which was initially called the SILCS diaphragm. The SILCS diaphragm was evaluated in research studies in the US and internationally, and proved not only to be equally effective to currently marketed diaphragms, but also easy for women to learn to insert and remove. The diaphragm was licensed to Kessel in 2010, who now markets  it as Caya in over 25 countries.

Caya was FDA-approved last year and will now be distributed in the US by HPSRx.


The diaphragm is a great option for women unwilling or unable to use hormonal contraceptives or the IUD, and who are motivated enough to use a method with every act of intercourse. Breastfeeding women are a group who may especially like the hormonal-free aspect of the diaphragm.


The diaphragm is by no means the most effective contraceptive available. If 100 women use it for 12 months, 17.8 with will become pregnant; with perfect use, there will be 14 pregnancies. However, in motivated married couples, efficacies close to 95% have been reported with previous diaphragms, a fact I can attest to, having been a highly successful diaphragm user myself for many years.

User coaching could make a difference in efficacy – in Caya clinical trials, correct insertion increased from 76 to 94%. when users were coached rather than simply given written instructions.

Combining the diaphragm with use of the male condom brings contraceptive efficacy close to 100%. Combining it with fertility awareness could also increase efficacy, as women using fertility awareness would avoid intercourse or use a condom during more fertile days. I would predict that breastfeeding women, whose fertility is lower to start with, probably will experience high rates of contraceptive efficacy with Caya.


Caya is available by prescription only. The cost is $85. Spermacidal jelly is extra – cost for this will depend on where you buy it and how often you have intercourse and need to use it.

  • Prescribers.  Although Caya does not require a traditional fitting visit, clinicians can order free “Try Before You Buy’ disposable test units to be sure patients are comfortable using Caya and know how to insert it.  Those clinicians who want to stock and sell Caya directly to their patients can order it directly from HPSRx. Otherwise they can simply write their patients a prescription and fax it to the pharmacy or give it to the patient.
  • Patients: You have three options for obtaining Caya  –
    • Your Clinician. You clinician may stock Caya and be able to sell it to you directly.
    • Your Local Pharmacy – Get a prescription from your clinician and take it to your local pharmacy. Your pharmacist may have to order Caya if they do not have it yet in stock.
    • Mail Order – Get a prescription from your clinician and send it by mail with an order form to either American Mailorder Pharmacy ($80 plus $5 shipping) or Health Warehouse pharmacy ($85 w/ free shipping) , two mail order pharmacies who are stocking Caya for distribution. (Click the pharmacy link for the order form and address). You can also order spermacidal jelly along with your diaphragm, but it’s cheaper to get it from other vendors..

Don’t foget spermacidal gel.

Caya won’t work without it.

Spermacidal Gel is available without a prescription at pharmacies and online. The manufacturer is offering Options GYNOL II Gel or Contraceptrol pre-filled applicators at a cost of $18.50 and $17.50, respectively. By comparison, the cost of these spermacides is between 11 $11 and $15 from most online vendors, plus shipping.

Use of nonxynol-9 spermacidal gels can increase HIV transmission rates if you’re exposed to an HIV infected partner. I’d recommend that you and your partner have negative HIV testing before considering giving up condoms and moving to the diaphragm for birth control.

How to Insert Caya

Instructions are here.  The manufacturer also has a video.



Learn how Caya was developed – a  story of innovation and collaboration between non-profit and for-profit sectors.

Ave Verum Corpus

Thought I’d share this one piece from my my choral concert last month. It’s one of the most beautiful pieces of music ever written – Mozart’s Ave Verum Corpus. It’s not perfect, but I think we actually did it justice.

Hope you enjoy listening to it as much as we enjoyed singing it.

(I sing with the Collegiate Singers of NYC, a community choir on the Upper West Side. We performed in concert with The Plymouth Choir on May 9th at the First Baptist Church on Broadway and 79th. A wonderful space with great acoustics. Check us out if you love to sing. No audition required, though we assume you can hold a tune and sing on pitch. This is for the joy of singing, and it’s a great group of people.)


Note – if you cannot see the link, it may be your cookie setting.

Late Night Dinner at Five & Ten in Athens, Georgia

5&10 sign

At first, I was really, really upset that my flight to Atlanta was delayed, making us miss our 8:30 dinner reservation at Five & Ten in Athens, Georgia.

This was no ordinary dinner reservation. My brother Joe and wife Rachel had arranged a special tasting meal for us with Five & Ten’s executive chef, Jason Zygmont, who they originally met when Joe stopped into the kitchen one day last year unannounced to borrow preserving salt for some charcuterie he was making. Joe returned a few weeks later to give Jason some of the duck proscuitto he had cured, expecting to quickly drop it off with the busy chef, only to have Jason invite him in and then cut into the breast and taste it right there, declaring it delicious. The charcuterie geeks bonded, and after repeat visits to Five & Ten, Joe and Rachel have gotten to know a number of folks there, including Eric, who runs the bar – apparently the place to experience dinner there, as well as to taste Eric’s concoctions which line the shelves.  If Eric is one of the first people you meet in the Athens food scene, you will immediately understand the warm and convivial nature of the town.

These guys help run one of America’s finest restaurants, not as a pretentious celebrity chefs and “mixologist”, but as real people who are into what they are doing and just want to excel and share.

True, Five & Ten’s owner and founder Hugh Acheson is a bona fide celebrity chef, with a James Beard award, four restaurants and several stints on Bravo’s Top Chef to his name. The staff at Five & Ten are proud of Hugh of course, but not so impressed by it all, if that makes sense, because they and Hugh are Athenians first, and they know what’s most important is the food not the pretense. And so the T-shirts they wear feature not Hugh’s prominent name, but his prominent unibrow. They mock, yes. But it’s not the Brooklyn-hipster, cooler than everyone and everything mocking that puts off those of us uncool enough to get the joke. It simply says this – Ignore all that. Come. Sit down. Let us feed you.

Joe had been talking about Hugh and Jason and the crew at Five & Ten for ages, and we had tried and failed on more than one occasion to find a weekend for me to come down and enjoy a meal there. So you can see why I was upset when our plane left two and half hours late due to thunderstorms in the Atlanta area.


I called when we touched down in Atlanta.  Just meet us at the restaurant, Rachel said. So we did. At 11 pm. After a long, dark and rainy drive.  Half an hour after the last seating.

Ironically, that was the best part!

By then the place had cleared out of all but one large table on the front porch of the rambling formerly private home next to the Greek Houses along the Fraternity/Sorority Row known as Milledge Ave.

The wait staff were leaving, and the kitchen crew was cleaning up. But Joe and Rachel were at the bar, relaxed after a long day and well into their second (third?) drink. We plunked ourselves down next to them. By now Jason’s girlfriend, a former New Yorker, stopped by to meet Jason, who by now scrapped his after work plans to make good on his promise of blowing our minds. They just added another place setting for her and we grew by one more. Eric welcomed us all with a glass of wine, and Jason came out to greet us personally.

And then he fed us, right there at the bar, the most wonderful meal I think I ever have had.


Every ingredient on the menu at Five & Ten has a story, a history, a tale of the making. Not in a way that is precious or off-putting, but in a way that makes you pause before you bite and say a little prayer of thanks to the ranchers and farmers and to the chef, who worked so hard to put it all together so wonderfully, taking the time to infuse those two strawberries with Urfa Chilis, or pickle those blueberries or braise those lamb ribs.

As for the flavors, there an earthiness in these dishes that keeps them accessible despite the complexity of their ingredients. It’s incredible cuisine, but with a taste of home in it. I tell this to Jason, and it seems to not make any sense. How can cooking this complex make me think of mom, of home?

But now I realize it does make sense. The ingredients are of home, of the heartland. Grass fed beef and pork, sorghum and morels, dandelion and tomato, peas and strawberries, blueberries and chard.  This is Southern Cooking, but Southern Cooking for the 21st century. Jason has managed to combine these familiar ingredients in remarkable ways that allow you to see and taste them anew, evoking a memory but then layering on a richer, more complex experience.

I’m reminded of how classical composers might evoke a theme from a familiar folk tine in a more complex piece of music.  Think “Simple Gifts” in Appalachian Spring by Copeland. (I’ve linked it up there) The listener says, “I know that!” and is immediately at home in an otherwise very challenging piece of music.

That’s exactly what this food does. It makes you feel comfortable and at home, all the while taking you to places gastronomically that you’ve never been before. A most incredible experience.


All right, enough. Let me tell you about what we ate –

Pig Nose

Fried Stuffed Pig Snout Medallions, riccotta gnocci, spring onion vichyssoise, and tomato marmalade. Don’t let the name put you off. These fried medallions are to die for. Nose to tail eating they call it, and this is the nose. With a bit of guanciale and some other magical ingredients, rolled into a galantine, wrapped in cheesecloth, braised in broth, then sliced, rolled in crumbs and fried. The gnocci was tasty and the sauce and marmalade a perfect accompaniment to both. We practically licked the plate clean. I’m not sure if Jason intends to add this dish to the menu, but if he does, all it will take is a little coaxing from the wait staff to become a hit.

RIBS 5&10

Sweet and Sour Lamb Ribs with sorghum gastrique, charred scallion, benne seed, and brussel kimchi. A little translation is in order here.  Gastrique = caramelized, sugar, deglazed with vinegar. Sourghum – a traditional Southern sweetener, product of the sugar cane, now the go to sweetener for Southern chefs. According to the NY Times  “It’s sweet, yes, but complex enough to hold your interest. Sometimes vegetal, sometimes smoky and always bright, sorghum fits in anywhere” . Benne seeds = Southern for Sesame seeds (Benne comes from the african word for sesame).  I assume Jason made a brussel sprouts kimchi, but I’m not sure. But you see what I mean about the complexity of the ingredients?


DAY BOAT SCALLOPS grilled little gem lettuce, field peas, soy pickled mushroom, Meyer lemon, mint. Perfect. I loved how the separate flavors of the ingredients stood out from each other, yet blended so well in the mouth. That’s what was so much fun about eating Jason’s food. Each ingredient beckons you to taste it alone, but you don’t really want to miss tasting them all together, so you find yourself planning strategically, taking teeny little bites of each separate thing first, then grouping them into small bites together, exploring how the tastes play off each. So much more fun than just grabbing a forkful of something and shoveling it in.


PAINTED HILLS BEEF NY Strip, braised veal breast with glazed field peas and grilled carrots, tomato marmalade, broken garlic vinaigrette, dandelion greens. A real meat sampler, neither overdone nor overwhelming. What meat should be. The strip steak was aged two weeks in house (of course!). Kudos to the Painted Hills ranchers in Oregon for raising some amazing meat.


ANDERSON FARMS PORK CHOP sorghum glazed,  smoked beets, radicchio, swiss chard puree, pickled chard stems and chard marmalade, strawberry compressed with urfa chili. That’s right. Swiss chard three ways in the same dish. Insane and amazing how much work goes into this food. This was when Joe revealed his truly expert palate, asking Jason “There’s something smoky in those strawberries. what is it?” (The urfa chili infusion).


FAVA BEAN and RAW COWS MILK RICOTTA ANGLIOTTIs with sunchoke puree, sunchoke chips, morel mushrooms, pickled blueberries, smoked pecans and  herbs. My favorite dish of the evening. Jason makes each of the pastas himself, telling me how if it took him a couple of years at Per Se to get it right, he couldn’t just pass the task off to someone else in the kitchen now. And the morels? Joe has a friend who forages morels and Jason jumped on them.The forager harvests only “restaurant quality” and leaves the rest for the deer. There were three bags of those babies in Joe’s fridge at home too, and we cooked them up the following night.  Joe’s job is putting people together and this connection was perfect.

GROUPER glazed in vegetable dashi with fava beans. soy braised artichokes,  cilantro oil and pea shoots. Just lovely. (no pic, sorry!)

ice cream

ICE CREAMS  – Home made, light and delicious. I can’t believe we ate it after that dinner, but we did.  I think these were the flavors -banana puddin’ | cherry sorbet | peanut butter brownie chunk | dreamy blood orange.

Thank you so much, Jason for a truly amazing meal! And Eric, for your hospitality, warmth and company at the bar. And the crew at Five & Ten for a most wonderful experience.  I can’t believe you guys hung around to wait for us – you were just so damned gracious; I’m still stunned thinking about it. This meal will go down in my history as one of my most memorable ever because of the food and because of you two. That Five & Ten is located in an old home seems so incredibly fitting.

If you get to Athens, GA, you need to eat here. That simple.