On the eve of your third birthday

On the eve of your third birthday, I sat besides your crib*, singing to you and rubbing your back because you had a cough and a runny nose and were so frustrated that you couldn’t get the ‘boogies’ out and were having a hard time breathing.

This brought me back to all of the days** and nights I spent besides your crib, rubbing your back and singing. I remembered your last sleep regression, when you were 18 months and I was 8 months pregnant and sleeping on the floor besides your bed just to get a bit of sleep. I remembered how long it would take me to put you down for a nap because you would wake up the moment the hardwood floor creaked as I tried to sneak out of the room. I remembered the months of you waking up between 4:00-5:00am, how sometimes I would just load you up in the stroller when you got up and head out for a (slow) run and then to grab some coffee, letting your dad sleep. Although most of the time I would try to coerce you to fall asleep again and, when that failed, I would make some coffee and bumble through the morning like a zombie. I could go on and on – so many memories of little you.

When you wake up tomorrow, you will be 3. I can hardly believe it. Where did the time go? You have zoomed into toddlerhood before my eyes. Your words, your ideas, your compassion – I have no idea how the helpless newborn I brought into the world in 2014 has grown to be this loving, imaginative, and awe-inspiring child. You amaze me every day, little nugget.


*We are not quite ready to move X to a toddler bed. Mostly we’re afraid that he’ll recognize he has the freedom to roam outside of his room in the middle of the night/early morning.

**Naps were also not easy for this kid.

Split second

This morning, we had a birthday party at a local playground. The kids were all 2-3 years old. I watched as other parents sat back and observed their kids playing while I chased after mine and made sure he didn’t hurt himself on the large play structure. “Why am I such a helicopter parent?” I wondered. It’s true – my husband and I tend to be very anxious, paranoid, and overprotective when it comes to our kids. As a disclaimer, I don’t think that there is a “right” or “wrong” parenting style. I would actually prefer to be more laid-back and relaxed about parenting, but it may be impossible for me.

In any case, at one point I thought to myself: “I think I can relax. I’m the only parent hovering over my child here. Let me take a step back and chat with some folks.” So I stepped a foot away from my son as he was climbing up a play ladder. One second later, he had tumbled to the ground 6 feet beneath him and had landed straight on his bottom. Shit.

I tried hard not to panic. He was crying and I scooped him and took him to a quiet area to evaluate him. “Can you feel my hands on your legs?” I asked. My heart was beating fast, imaging the worst-case scenario. “Yes,” he responded. Thank goodness. “Can you stand up and walk?”. He could. Phew. I watched him walk and wince in pain, touching his back. He was being a lot more cautious and didn’t want to play as much. I touched his spine, low back, tailbone, buttocks. “Does this hurt?” No, he said. But at first, it seemed like everything did hurt. He would start an activity and then reached down to touch his back. He was momentarily distracted by cupcakes, but then didn’t feel like playing anymore. “I’m tired, I don’t feel well…I want to go home.” Fuck.

I called our pediatrician’s advice line and it was recommended that I take him to Urgent Care. We stopped by our house first and I iced his back a bit. At that point, it seemed like he was climbing and running with less pain, so I second-guessed my logic for a minute. Still, there was no way I could live with myself if something was really wrong and I ignored it. So I took him in. At the urgent care, they have a playground in the waiting area. He climbed up the rope ladder, went down the slide, played on the seesaw. These people are going to think I’m crazy, I thought.

They didn’t say it, but the less than five minute evaluation spoke volumes. They palpated the affected areas – no pain. They asked him to walk – no pain. They asked him to run – fast, no pain. They lifted his legs up and down – no pain. “X-rays of the spine emit a lot of radiation,” the doctor said, “so I wouldn’t recommend it.” That’s all I needed to hear – we were out of there in no time.

I am still worried, of course. I think: what if he fractured his tailbone and the pain is worse when he wakes up from his nap? What if he ends up having a slipped disc/nerve injury/becomes paralyzed? I can’t help myself. Being in medicine, I see worst-case scenarios all of the time. People who didn’t have cancer until they did, were pain-free until they developed debilitating pain, lived normal lives until being diagnosed with a life-threatening condition. So any time anything happens to my kids, I shift into worst-case scenario mode. It’s a terrible way to live.

In sum: I think that helicopter parenting is in my future for a good while longer.

So sleepy

I always stay up past my bedtime. I’m on vacation at the moment, waking up ~2 times per night because our baby isn’t quite used to this travel sleep set-up, but I can’t seem to get myself to bed at night. I should be falling asleep as soon as the kiddos go down, but I stay up because I can. I stay up for this quiet time when no one needs anything. I stay up because I can think without interruption. I stay up because I can waste time or be productive without counting down the minutes until nap time is over or independent play has grown stale.

I love this quiet time. I love my family, and I cherish the moments with them so very much, but I also like this feeling of quiet solitude. I could have it in the morning if I somehow managed to drag myself out of bed before the first baby stirred, but this is impossible at the moment. And so I hold onto these quiet evenings. I wait until everyone goes to sleep and then I sift through my to-do list, I plow through notes and patient messages, I fill in my calendar, I online shop, I wander aimlessly from website to website, I contemplate (and sometimes even write) a blog post. And then I finally feel ready to sleep – having savored a small bit of ‘me’ time, if only for a short while, if only at the very tail of the evening.

My experience with hypothalamic amenorrhea

I started reading blogs when I began to suspect that I had hypothalamic amenorrhea (HA), so it is only fitting that one of my first posts should touch on the subject.

First, some background for readers who are not familiar with HA. Amenorrhea is the absence of menses. It can be divided into primary (a person never menstruates) or secondary (a person who previously menstruated stops menstruating). Secondary amenorrhea can develop when any of the structures involved in the menstrual cycle (hypothalamus, pituitary, ovary, or uterus) are affected. Hypothalamic amenorrhea with no pathologic basis can be triggered by nutritional deficiencies (including eating disorders), excessive exercise, and/or stress.

I developed hypothalamic amenorrhea because I ate too little and exercised too much. For many years, I focused excessively on what I ate and how much I exercised. I counted calories, drafted lists of my daily intake, and worked out 5-7 days a week. Not for a week, not for a month, but for YEARS. Approximately 10 years to be exact. I stopped menstruating 1.5-2 years into this routine, which means that for 8-8.5 years I did nothing to reverse it. I am not proud of that.

It is important for me to back up a bit and detail how this came to be, as it was never my intent to sabotage my fertility. My initial goals of eating clean and exercising regularly were borne out of a genuine desire to be “healthy”. I was a freshman in college and not feeling particularly great about many things – where I fit in socially, the freshman 15, my utter lack of exercise, being away from home, and my future career aspirations. So I tackled what I could: eating better, exercising more, and focusing on my pre-medical training. At first, it was wonderful! I started eating better, hitting the gym daily, sleeping more, waking up early, performing better academically, and feeling good about myself. But true to form, I didn’t stop at good. 5 pounds became 10, 15, 20, 25…I ultimately lost 60 pounds over the course of one year.

The thing is, I didn’t have 60 pounds to lose. I also became incredibly anxious about gaining the weight back. So when I stopped menstruating, my response was not “Hmm…I should ease up on exercise and gain some weight.” I was terrified to gain weight, and indeed gained only enough weight to shift the focus one iota from my excessive loss. And for the next nine years, that weight became my “norm”. As I distanced myself from college, everyone I met assumed that I had always been so slim. This made it harder and harder to gain weight.

I knew that my lack of menstrual cycle was a sign that something was wrong, but I didn’t want to dwell on that. I ignored the worry when we learned about the female athlete triad in college, when the nurse I saw at the student health center ordered a bone density test based on my low BMI, when my gynecologist checked labs and confirmed what I already suspected: I wasn’t ovulating. It gnawed at me, but I ignored it because I was 19 years old and the only thing I knew about pregnancy at the time was that I didn’t want it. What I did want was to continue fitting into a size zero.

Here’s the deal: if you don’t fuel your body correctly and if you then ask your poorly fueled body to draw from its reserves to exercise, it may shut down your reproductive system. And that’s exactly what happened. I remember my gynecologist recommending birth control pills and then saying that I would possibly need fertility treatments in the future if the amenorrhea persisted. We didn’t discuss my undereating and overexercising (I do not blame this on the gynecologist as I am fairly certain I did everything in my power to downplay how much I was exercising and to normalize my weight) and I went about my merry way, which is to say that I did nothing other than start birth control.

Fast-forward those nine years. I had graduated college, graduated medical school, and was a resident. I had gained a handful of pounds since my lowest weight in college, but my BMI was still low and I ate less than I should for the amount that I exercised. I was getting married and had stopped my birth control pill because I wanted to see whether I would menstruate on my own, since I knew that I wanted to get pregnant shortly after the wedding. To no one’s surprise, I did not get my period.

Four years and two babies later, I can still feel the raw frustration and immense sadness I felt during this time. How was it fair that bone-thin celebrities and acquaintances had managed to conceive without gaining weight? How was it fair that some women in the HA community were able to begin menstruating by only minimally decreasing their exercise and just barely increasing their weight? I fought against the “decrease exercise/increase weight” advice SO hard. I wanted to believe that it was stress (I was a resident after all) and turned to yoga, meditation, breathing exercises. I added “healthy fats” to my diet but only incrementally decreased my exercise. I had maintained my weight loss for nine years and resisted gaining weight, believing that it would negate all of my hard work.

However, my resolve wavered with each month that passed without a period. It was a confusing time and I felt torn between two forces – my long-standing commitment to what I had perceived as healthy (working out, eating “clean”, being thin) and my desire to become a mother. I slowly let the pounds pile on – at first, slowly and with remorse, and later quickly and without hesitation. I would plan my meals and then rebel, knowing that I was still adhering to rules. My main form of exercise at the time was long distance running, so I stopped. I would sign up for races, train irregularly, and then cancel. I joined different gyms and then willed myself to sleep in. I stopped waking up at 5:00 am to work out. The pounds piled on and I finally forced myself to buy new clothes. I donated bags full of clothing that no longer fit: I needed them visually out of my closet and physically out of my life as I didn’t want to be tempted to fit into them again.

During this time, multiple co-workers asked me whether I was pregnant. They were used to my being very thin and health-conscious, so pregnancy was a logical assumption as they observed my weight gain. Their questions were doubly insulting: first, they confirmed that others noticed I was gaining weight (this horrified me) and, second, they forced me to answer “no” when I was dying to answer “yes”, to actually be pregnant. My heart would break every time someone asked me whether we were planning to start a family. I know they meant no harm, but I wish they would have thought twice about prying. To this day, I never ask anyone about their plans to start (or expand) a family and I never ask anyone whether they are pregnant – not even if they are very obviously 9 months pregnant.

At the time, it also felt like everyone I knew was becoming pregnant. I was genuinely thrilled for my friends, family, and acquaintances, but I would also cry whenever I had to attend a baby shower or congratulate yet another person. I am sure that my husband dreaded announcing someone’s pregnancy to me.

During the time that I was struggling to gain weight, rein in my exercise, and feel good in my newly expanded skin, I was referred by a new gynecologist to a fertility clinic. At this point, the diagnosis of hypothalamic amenorrhea had been confirmed by ruling out some other entities via laboratory testing and imaging studies. The first fertility specialist I saw said this: I could stop running and gain weight or I could undergo intrauterine insemination. I agreed with his exercise and weight gain recommendations, but our personalities didn’t jive and I wanted to minimize interventions, so I sought a second opinion from someone else in the same practice.

This fertility specialist was my saving grace. He was a kind, gentle man with a wonderful bedside manner. He had been in the business for years and had an optimistic perspective. He also did not push any interventions. I recall him sitting patiently during our appointments and answering all of my nervous questions. One day, he sat across from me and gently said: “This must be a very difficult experience for you – wanting to become pregnant, living far away from your husband [we lived 8 hours away from one another during my medical training], enduring the stress of residency.” I burst out crying. It felt like he truly understood what I was going through. He also provided a bright glimmer of hope when he told me that I was not infertile but SUBfertile. He believed that I would have a baby and I believed him.

I have noticed a lot of doctor-bashing in the HA world: doctors not understanding the diagnosis of HA, not counseling on weight gain/exercise cessation, pushing interventions to make money, not listening, etc. As a physician in the world of Google Medicine, I wonder whether some of this is unfair. Going through any type of infertility (or sub-fertility, as it may be) is an inherently emotional process that can taint our perception. There is also an urgency to it – and this may create dissatisfaction in a system that necessitates testing to rule out other entities, awaiting a specialty consult, multiple procedures, etc. Since there is no specific test that can attribute HA to exercise and eating habits, other diagnoses need to be “ruled out” before this can be “ruled in”. Even then, there is no test that 100% proves causation. I would like to think that doctors are educated in this complex realm and are providing the best possible assessment and treatment to these women. That being said, I recognize that my own perception is biased due to my truly wonderful, attentive, and supportive fertility specialist.

So what did I do? How did I finally become pregnant? When I had HA, I was constantly looking for the magic formula – just how much weight would I need to gain? How much exercise was too much? The truth is, everyone is so very different and there is no one size fits all “solution”.

To this day, I joke with my husband that I became pregnant after purchasing this bracelet. I did, but I also reduced my exercise dramatically (from 5-7x/wk to maybe 1-2x/wk), gained 30-35 pounds, slept in, practiced yoga (including Yoga for Fertility), started acupuncture, and underwent 4 cycles of clomiphene citrate and 1 cycle of letrozole. It was on that fifth cycle that I became pregnant with my first. I sometimes still think of him as my letrozole baby.

However, the most important (and most difficult) change I made was to stop caring about my weight. This was a slow and painful process. Letting go of the pressure and anxiety to be thin was hard. It feels so silly for me to say this now as I truly can’t believe that I spent so much time obsessing about something so trivial, especially with all of the very real problems in the world. Yet at the time, it was strangely important to me, and overcoming that mindset took strength and perseverance.

I loved being pregnant and I love being a mother. Every moment of pregnancy (x2!)and every moment of motherhood has been all the sweeter because there was a time when I truly doubted whether I would be able to have a baby. I know that I was very fortunate: I didn’t battle infertility for longer than 2 years, it was (relatively) rapidly reversible, and only minimal intervention was necessary. I was spared the financial and emotional consequences of undergoing more invasive fertility treatments. But any degree of infertility (or sub-fertility) takes its toll, and my heart truly goes out to everyone currently going through it.

After my first pregnancy, I never resumed working out regularly. I would exercise sporadically here and there (a slow run/walk, a family hike, a yoga class, a stroller work0ut), but never with the same intensity and commitment. My reasons were varied: I experienced “working mom guilt” and didn’t want to spend time away from work at the gym when I could be with my baby, sleep deprivation/low energy, fear of affecting my milk supply/production, and the desire to have another baby soon after the birth of my first. I also worried about whether I could truly exercise in moderation. Despite this, I lost my pregnancy weight quickly while eating everything under the sun. I also regained my cycle at almost 11 months postpartum (while still nursing) and was pregnant a month later with no medical intervention.

If you are struggling with HA, please know that there is so much hope on the horizon! There are also a number of wonderful resources out there, including:

  1. Nico’s blog is a must-read. There is a wonderful community of women formed around it, and also a book.
  2. This lovely endocrinologist’s post, linking to her personal experience
  3. Ashley’s older blog posts
  4. Janae’s perspective

And do feel free to contact me if you have any questions. I am by no means an expert in this field, but I can certainly commiserate.

Back to work

In three weeks, I will return to work after maternity leave.

Before my first was born (he is almost 2), I didn’t understand what was so difficult about returning to work after maternity leave. I was no naive! I watched as colleagues of mine, physicians who had spent years in training and who had accrued sizable debt, decreased their hours to part-time or dropped out of the workforce completely. I vividly remember discussing this with my husband in utter disbelief: “How can they do that? What a waste of all those years!”

Fast forward to 2014: the second we brought my son X home from the hospital, I remember thinking “I can never go back to work again.” My baby boy, my heart, had finally arrived. Despite our struggle with infertility, despite a minor scare at the hospital after his birth – here he was. How could I leave him!? It didn’t help that X refused to sleep longer than 30-60 minutes at a time day OR night unless someone held him. I was exhausted – a zombie subsisting on coffee and snuggles from this warm little being. I’m sure that all of the postpartum emotions did nothing to help my vocational morale. There were days when I couldn’t even get it together to leave the house ONCE. How was I going to wake up early, shower, get dressed in something other than nursing tanks and sweat pants (or maternity pants for that matter – why aren’t huge elastic waistbands trending? It’s a genius design!), and then interact with patients, diagnose their conditions, and actually treat them? All while pumping 3 times during the day? It seemed impossible.

I was fortunate to have a generous maternity leave. 18 weeks of paid leave may not seem generous if you live outside of the US or work at Netflix, but I felt so lucky to have it, especially considering that I had only worked 3 months prior to going out on leave. I count my blessings every day that my employer and colleagues are family-friendly and supportive. It makes working mamahood a lot less stressful. And to any employers reading this: longer maternity leaves will help your company. Moms will return to work MUCH better prepared for peak performance. They will be less sleep-deprived, less upset at having to leave their newborn in someone else’s care, and they will be so grateful for your generosity that they will work their butts off.

So how did I go back to work, and how has that experience prepared me this time around? I wish I could say something like “I wanted to set a good example for my children” or “I couldn’t imagine my life without adult interaction and the ability to use my brain”, but it would not be true and it would also be inaccurate, as I truly believe that you can set a good example, have adult interaction and use your brain as a stay-at-home mom. At the end of the day, it boiled down to necessity and fear of regret:

  1. I had to go back to work. We live in an expensive region and we needed my salary to continue living there comfortably and to accomplish our long-term financial goals. We had just settled in the area and it seemed premature to flee so quickly.
  2. Teenagers can be terrible people. Having been a terrible teenager myself (I used to tell my own mother to go back to work full-time so that she would stay out of my hair – terrible, right?), I envisioned myself frantically second-guessing my life decision when this adorable infant turned into an unbearable adolescent. How marketable would I be in a competitive practice environment after taking so much time off?

And so I counted down the days with dread and cried at the drop of a hat until the actual day came. When it did, I learned that there was much to enjoy about work. Some were hugely gratifying – interacting with my patients again, truly helping people, feeling challenged, learning and being inspired by my amazing colleagues – while others were small but also enjoyable – eating with both hands, using the restroom without an infant, speaking to human beings who could respond with words.

Of course, everything is rosier now. At the time, it was incredibly difficult. Leaving our baby with someone who was, at the time, a stranger, was HARD. Tearing myself away from him in order to arrive at clinic on time was often painful as it meant rushing, pumping instead of nursing, or not reading our usual books. Some mornings I would leave before he woke up, which broke my heart. I was also upset when I could not be there all day when he was sick, or when I learned that he had learned something new in my absence, or when our caregiver did not adhere to the routine I so carefully laid out. Lack of control is terrible when you are a control freak! Eventually, these things stung less. I saw that he was well-cared for and that he was thriving. He knew who his mama was and loved her. I cherished our time together and spent every moment at home trying to be as present as possible.

This time around, I am better prepared to deal with these emotions because I know that it all works out. X has so benefited from spending time with caregivers other than myself. Each has taught him something unique and special, and I feel fortunate that my baby, Y, will have the same opportunity.

At the end of the day, we all do what is best for our sanity. There is no “right” decision and I am so embarrassed to have ever judged mothers in the past for doing what they felt was best. Motherhood has certainly been a humbling experience. For mamas out there who are returning to work or deciding whether to return to work, I’ll share the two bits of advice I found most helpful:

  1. Find great childcare. You will never be able to focus on work 100% if you do not believe that your child is being well cared for. Trust your instincts, don’t settle, and change arrangements as soon as possible if something feels “off”.
  2. Do not make any drastic career decisions during your baby’s first year of life. Sleep deprivation, raging hormones, the postpartum state – these variables do not encourage a clear mind. It is so important to take a step back and look at the big picture and this can be very difficult to do when your time is consumed by an infant’s needs (which is 24/7).

Good luck to any moms returning to work and any moms who have decided to work at home. Mamahood is not for the faint of heart!