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Interviewer: We all know that a stroke is a serious and potentially life-threatening situation, but it might surprise you that it impacts women more than men. According to the CDC, stroke is the fifth leading cause of death for women in the U.S., and as many as one in five women between the ages of 55 and 75 will have a stroke.

To help us better understand why women face an increased risk of stroke, were joined by Dr. Jana Wold, an associate professor of neurology and a stroke specialist at University of Utah Health.

Dr. Wold, let's start out with why are women at more risk of stroke than men?

Dr. Wold: So the best way to understand it is because women live longer than men and because stroke risk increases with age. So because we have a larger proportion of the population in this older age group, the greater-than-85-years-old age group that are women, and also that's when your stroke risk really ramps up, overall more women have strokes than men.

Interviewer: So I'm hearing that more older women might have strokes than men. What about younger women?

Dr. Wold: Unfortunately, there is a risk of stroke in pregnancy. So, at a younger age, there also is a brief period of time when women are of childbearing age that their stroke risk could be higher than some men.

Interviewer: Yeah. And that is very unique, childbearing, to women obviously. What are some other risk factors that are very unique to women versus men?

Dr. Wold: Yeah. So women take oral contraceptives. Not all women, but some women do. And those medications, unfortunately, do carry a small risk of stroke. So in the wide scheme of things, it's a very small risk.

And women who take oral contraceptives tend to be women younger than the age of 50, so their overall risk of stroke is low, but if you are taking oral contraceptives, that can double your stroke risk. And if you are smoking while you are taking your oral contraceptives, that can dramatically increase your stroke risk.

Also, in speaking of oral contraceptives, oral contraceptives should not be given to women who have migraine with aura because that also increases your stroke risk, because migraine with aura independently increases your stroke risk.

Hormone replacement therapy. So if you are taking hormone replacement therapy for a long period of time, this also can increase your risk of stroke. There was a time many years ago when we thought maybe taking hormone replacement could actually decrease your risk of stroke, and that is not true.

The other important thing that I haven't mentioned yet — atrial fibrillation. So atrial fibrillation carries a high risk of stroke. It is uncommon in the younger population, but as you age, your risk for atrial fibrillation increases. And it's actually riskier for women to have atrial fibrillation than it is for men when you consider their stroke risk. So atrial fibrillation, you can be screened for this in your doctor's office when you are above the age of 75.

Interviewer: So if a woman's listening and she recognized some of these increased risk factors, does that mean that perhaps hormone therapy is not a great idea, birth control is not a great idea? How can a woman weigh the risk versus the benefits of those things?

Dr. Wold: Yes, absolutely. So this is where your primary care doctor comes into play. Everyone should have a primary care doctor whether or not you're a woman or a man, and you need to discuss this with your primary care doctor.

So, for example, if you are a young woman and you're considering going on oral contraceptives, you need to make sure that your physician is aware if you suffer from migraine with aura or if you are a current smoker or if you have high blood pressure. So you need to be in good communication with your primary care physician to make sure that they are also considering your overall risk of stroke.

When it comes to hormone replacement therapy, again, I would have a conversation with your primary care physician or whichever physician would be prescribing this treatment for you. And you would just need to understand the risks and the benefits, because it's going to be different for different women.

Interviewer: And I understand that women sometimes don't experience the standard stroke symptoms. What are those standard symptoms?

Dr. Wold: Yeah. So the standard stroke symptoms, the way we like to remember them is an acronym known as FAST. This stands for face, arm, speech, time.

Face is for that facial asymmetry that you were speaking of before. So if your face is droopy on one side, that can be a symptom of stroke.

Also, if you have one arm that is weak, that can be a symptom of stroke.

And then if you have a change in your speech, that can be a symptom of stroke as well.

The T is for time, because if you notice any of those symptoms, you need to immediately call 911 and go to the emergency room to be evaluated.

Interviewer: And those standard symptoms, those aren't necessarily always the way women experience stroke symptoms. Can you expand on that?

Dr. Wold: Not necessarily. There are some studies showing that women are more likely to have atypical symptoms of stroke, but it's not clearly defined what those would be. So, overall, I would say when you experience any sort of acute change in your vision or your speech or your strength or your walking, that's when you need to consider stroke.

Interviewer: And are there other risk factors that women would want to keep in mind?

Dr. Wold: I would just consider changes in those areas. And a lot of women, also men, like to call their neighbor, call their son, call their daughter. I would encourage you to call 911 when you notice those symptoms.

Interviewer: Right. Because the tricky thing about stroke is it can kind of trick you, can't it?

Dr. Wold: It can. And the medications that we can provide in the emergency room, there's one medication and it's time sensitive, so you need to get to the emergency room very quickly.

Interviewer: Dr. Wold, in your experience, what are some of the misconceptions that you find that people have when it comes to women and stroke?

Dr. Wold: I think a misconception can be that there's nothing that you can do about your risk for stroke, and because the risk of stroke increases as you age, that it sort of is just inevitable, and that once you have a stroke, then you need to try to prevent the second one. But we as stroke physicians would certainly like people to be interested in preventing that first stroke, which you certainly can do.

Interviewer: If there's a woman listening and she might be worried now about her risk of stroke, what takeaway message would you give to them?

Dr. Wold: The takeaway message would be to know what your independent risk is for stroke, and so to consider if you have high blood pressure. If you have high blood pressure, you need to be under the care of a physician. You need to have it properly treated. And if you are a smoker, you should consider stopping smoking.

The other thing that you can do as far as lifestyle measures are concerned is to exercise regularly, and we mean cardiovascular exercise, and also keep a healthy diet that is high in fruits and vegetables.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Troy, I've got a question for you. I'm going to say a word, and I want you to tell me the first thing that comes to mind. Botox.

Troy: Crow's feet.

Scot: Okay. Mitch, Botox.

Mitch: Wrinkles.

Scot: All right. That's the same for me, crow's feet and wrinkles. Today, on "Who Cares About Men's Health," we're going to talk about Botox, not only for a more youthful appearance, but also some other things that it can treat that men might find useful. And also, we're going to answer the question "Is it safe?"

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. I'm curious if you might have a different opinion about Botox by the end of this episode. We're going to find that out. My name is Scot Singpiel. I bring the BS. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. I'm excited to learn about Botox for something besides my wrinkles.

Scot: All right. A guy who's working on his health and always has a unique perspective, Mitch Sears is on the show.

Mitch: I'm curious because TikTok keeps telling me in my 30s, I should start preventative Botox, and that worries me. Am I doing something wrong?

Scot: And Dr. Sarah Akkina, director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at University of Utah Health. Welcome to the show.

Dr. Akkina: Thanks so much for having me. I'm very excited to blow your minds about the other uses of Botox, botulinum toxin.

Troy: This is great.

Scot: I actually looked it up and it was really shocking some of the other things that Botox can do, because at the beginning of the show, as we all said, we tend to think about crow's feet or wrinkles, using it to get a more youthful appearance, right? And a lot of times, guys hear that word, too, and we have that misconception that maybe it's not for us, right?

Mitch, you had a similar experience. Tell us about how you reacted when you heard that you needed Botox for another reason.

Mitch: Oh, frustrating. So I had Bell's palsy, right? We've talked about it. It's another episode. We can direct you towards it. But one of the weird after effects was that I have a thing called crocodile tear syndrome, which means when I eat, my eye will sometimes tear up. Big tears sometimes, whatever, it depends on what I'm eating, etc. It just is a nerve that didn't quite match up right.

And so I went to the ophthalmologist and they looked at it, and the potential treatment was Botox in that area to see if we couldn't numb up the nerve that was misconnected.

And unfortunately, I immediately just said, "Nah, I don't do Botox." I don't even know where that comes from, this idea, "Yeah, I hear what you're saying, but no, that's not for me. I'm a man." How dumb is that?

But then afterwards, I thought about it and whatever, and there were some other things that I wasn't quite super excited about. But yeah, the second that word Botox came out, I shut down very quickly.

Troy: Oh, I think I would do the same thing, Mitch, if I had to tell people, "I'm going in for my Botox injections." Number one, I wouldn't tell people that, but if I had to admit it, I would be embarrassed.

Scot: Yeah. You would rather cry when you eat, huh?

Troy: I'd just rather tear up.

Mitch: Yeah, I would apparently.

Scot: Than tell somebody you were . . . Yeah. Dr. Akkina, is this how guys typically respond when they hear Botox, that word?

Dr. Akkina: Yeah, absolutely. And I think it's funny because in the zeitgeist in our society, it's become so synonymous with cosmetics and appearance, and then people think, "Oh, it's mostly for women." But there are so many different ways that we can use it.

So stepping back, Botox is a brand, first of all. So it's a type of botulinum toxin. If we want to be more cool, if you want, we can say the toxin.

Scot: Yeah, you're getting the toxin.

Dr. Akkina: So you can say you're going in for your toxin treatment.

Troy: I'm getting my toxin.

Mitch: Rad. I love that.

Dr. Akkina: That's right. So, heretofore, we'll say toxin. So your toxin treatments, the best way to think about it is it's this really cool drug that we can use that basically shuts off muscles right at the junction that the nerve is giving them input.

So when you think about it like that, this toxin can be used to basically shut down any muscle that we feel like is not working well. In Mitch's case, one of the kind of muscles that I think you're talking about treating for the crocodile tears, it's basically things around the lacrimal gland. So we can use it to stop that gland from secreting things because you're affecting that muscle function.

And another way that we can do that in a similar case, which probably a lot of people don't know, is you can actually use toxin to treat over sweating. So actually there are especially a lot of men who use it. Actually, we can use it in your armpits or other areas that you feel like you're sweating a ton and it's embarrassing or you're just not into it. We can treat that with Botox, or toxin, as we're saying.

But that does require a little bit of higher doses than we're typically talking about versus things like wrinkles. So that's one option that we can do.

Another really great use of toxin is in your masseter muscles to stop teeth grinding. Do any of you guys teeth grind?

Scot: Yeah.

Dr. Akkina: Fancy word, bruxism So that masseter muscle is often the culprit in what's really causing that grinding.

And fun side note, my husband was very much like you guys and was very anti all sorts of toxin treatment. But when I told him about this and he had been having a lot of struggle with teeth grinding and stress, things like that, he actually let me attempt to treat his masseters and his teeth grinding stopped. It was amazing. And to this day, this is actually two years later, he's still not grinding his teeth. I think because his body just learned to adapt without it a little bit.

Troy: After one injection, one treatment?

Dr. Akkina: Yeah, after one series of treatment.

Important things to just remember for toxin treatment, it does take about a week to bring into effect. And then it only lasts three to four months. So you do have to know that. So typically that effect wears off. Some people are able to use that for teeth grinding, for instance, just to kind of rewire their body a little bit. Other people certainly need treatment still every three to four months.

But it's a great way to, like I said, selectively stop these muscles from over-activating and to help you in whatever that means for you for that muscle.

Troy: And what about things like facial twitches? If someone notices their face gets kind of twitchy when they get anxious or something like that, have you used it for that?

Dr. Akkina: Yeah. So blepharospasm, or that twitching around the eyes that can happen when people are stressed, tired, things like that, super common indication, and actually one of the first indications for using Botox, or toxin.

So toxin initially was actually developed and promoted in the '80s by ophthalmologists who were treating something called strabismus or basically crossed eyes where your eyes are misaligning. And that was one of the first uses in humans. And then quickly after that, they realized they could use it for blepharospasm or the spasms around the eyes. And then that led to saying, "Hey, we don't have crow feet anymore. How exciting."

Scot: That was the side effect, huh?

Dr. Akkina: That's right. So that was a side effect of all the initial use of toxin. So that's how we started to develop in the market.

And all jokes aside, there are some very serious other medical conditions that we can treat with toxin. One of the other things in my field of otolaryngology is for people who have spasms in their larynx. So you can have these spasms that really prevent you from having normal speech and normal talking patterns. And our laryngologists, or throat specialists, are able to basically direct toxin to those specific muscles and help shut that down so people can talk normally.

Another really common indication, probably more than that, is things like migraines, or anything that you can think of that's a muscle chronically or misfiring where we can kind of gently turn that off.

Now, it's a little tough because the dosages are obviously all different for different areas. So, depending on what you want to treat and what the indication is, insurance can cover some.

So, Mitch, if you'd gone forward with your crocodile tears, it's likely that insurance would cover that because that's a medical disease and illness that you're treating with it. Certainly, for cosmetic things like the crow's feet and forehead wrinkles, things like that, that is out of pocket.

Troy: And where would you do an injection for a migraine?

Dr. Akkina: Yeah. So you can inject things like the temporalis muscles and sometimes even behind. Our neurology colleagues do treatments for that typically. But yeah, there are different things that we can work.

For me, I used to get a lot of tension headaches, and when I started getting toxin for my forehead wrinkles, actually my tension headaches went away because I think I wasn't contracting or squeezing my brow angrily all the time.

Troy: Wow.

Dr. Akkina: I don't actually do that, for the record, but . . .

Scot: You don't sound like an angry person, so I can't imagine that.

Dr. Akkina: Well, I can't contract my brow right now.

Scot: Because the toxin shut that muscle down.

Dr. Akkina: Because of the toxin, yes. Very smooth and content all the time now.

Scot: So what is the actual name of it, not the brand name?

Dr. Akkina: So botulinum toxin, that's the actual name.

Scot: I don't know. That doesn't sound too good to me. On one hand, it sounds cool because, "Oh, I'm tough, I'm taking my toxin," but on the other hand, is that safe?

Dr. Akkina: Yeah, there are very little side effects. So a few important things is that whenever that toxin is injected, it can diffuse to other things in the area. And this is a little dependent, of course, on where it's injected, what the concentration it's injected at, things like that.

So you do have to be careful, and that's why I always recommend going to someone who knows what they're doing and is very familiar in the anatomy and structures in whatever area that they're injecting.

But it's relatively safe. The nice thing, again, is that while it takes often five to seven days to act, it goes away in three to four months. So if you don't like whatever the action is, it will wash out eventually.

Very few people do have allergies to toxin. If you have egg allergies, actually the botulinum toxin A in Botox, for instance, is formulated with egg proteins, albumin, so you have to be a little bit careful to just think about that.

And if you have other things like neuromuscular diseases or disorders, yes, you definitely have to be very careful about the effects of it.

Also, certain antibiotics, like aminoglycosides, botulinum toxin can potentiate some of the effects of that.

But outside of those pretty specific circumstances, it's got a really safe profile for use in a lot of different ways.

Scot: I've heard of something else called botulism. Is it related to that?

Dr. Akkina: Yeah, the toxin is the same, believe it or not. So that is how they initially learned about it. And yes, that's a serious disease. That is more if you have canned food, like cans that are crushed or look funny or things like that, those can harbor botulinum toxin. Honey can actually technically have some relation to that too, but not in the ways . . . mostly just serious for babies and infants, things like that.

Scot: Sure. But the way you're using, it's . . .

Dr. Akkina: Yeah, very different.

Scot: It's safe. I'm not getting any of that illness.

Dr. Akkina: Correct. Yes, you're not getting any of that illness from an injection of the toxin.

Troy: My one piece of advice, Scot, would be to avoid botulism. Don't drink pruno. It's a prison wine. We had a big case series we published. A bunch of prisoners who unfortunately drank that, and they had a potato in it, which was the source of the botulism. But it was a big CDC report that we published with multiple prisoners. So yeah, if you want to avoid botulism . . . But this is not botulism. I think that's the point here. You're not putting yourself at risk of botulism.

Dr. Akkina: Yes, correct.

Scot: So it has a lot of really, really cool uses. The sweating thing, I bet you, for some guys could really be a game changer. We talk about the Core Fore, and emotional and mental health is one of them, and if it makes you self-conscious or anything like that . . . Lazy eyes, I think you mentioned that as well. Any sort of spasm disorder. To remove that from your life, I would imagine, can be a great thing.

Do you have any guys that have ever used it for those purposes and how did it change their lives?

Dr. Akkina: Yeah. I think the sweating thing in particular, I remember a patient a few years ago who came in, it was a gift from his mom for his 19th or maybe his 18th birthday, because he was going to be taking prom pictures soon and he didn't want to sweat through his shirt during prom, which is actually a really sweet gift I thought from his mom. So small things like that, I mean, they can make a big difference in people's lives.

Troy: Sweaty palms, people use it for that?

Dr. Akkina: I've not personally done that, but I think in theory you could. When you're treating large areas like that, again, you do have to be a little bit careful because it's probably just going to be a high dose. So it might just be a little bit dose-limited in terms of having to inject all these little areas there. The other tough part there is you wouldn't want to turn off the muscles in your hand.

Troy: Right. That could get awkward.

Dr. Akkina: It's always a balance. You can inject it in glands and things like that, but yeah, if you're injecting around muscles, you have to be prepared that it might diffuse a little bit.

Scot: So it can do a lot of really cool things. And since you're here, let's talk about using it to remove wrinkles. I'm just gathering information. I'm not saying it's for me.

Troy: Asking for a friend.

Dr. Akkina: For a friend, yeah.

Scot: I'm just asking for Troy.

Troy: I was curious. Yeah.

Scot: So, actually, I want to throw that out. Mitch, you had mentioned that it had been recommended that maybe . . . well, on the internet . . . that you start doing some preemptive Botox.

Mitch: Oh, no. I have a friend in my life who has also said it's not that big of a deal and if you start now, you'll never have wrinkles. I don't know if that's true or not, but . . .

Scot: Have you considered ever using Botox for a more youthful appearance?

Mitch: See, I have a pretty youthful appearance anyway, and the rule I've always told me is as long as I could play a high schooler on a CW original, I am okay. But there is a part of me that does wonder . . . I don't know. I don't particularly love the idea of becoming super duper wrinkly. Maybe. I'm open to it, but I'm not super excited about it.

Scot: What would your dad have to say about all this?

Mitch: I don't know. He's probably listening right now. I'm sure I'll get an email.

Scot: Troy, is this anything you've ever considered?

Troy: Botox? I haven't seriously considered it. No. It's probably crossed my mind because I'm at a point in life where I do see more wrinkles appearing, but I can't say I've ever really looked into it beyond thinking, "Huh, maybe."

Dr. Akkina: Well, fair enough. I think a lot of patients, and especially men, are in that boat. But it is nice because from that . . . Mitch, you asked earlier I think about the preventative part. So Botox or toxin can't take away wrinkles that are already formed.

So when I think of wrinkles, there are both static wrinkles and dynamic wrinkles. So when we're young, if I raise my eyebrows, you can see typical areas where my muscle is causing contraction of the skin. That's causing temporary wrinkles. But when I relax, you can't see any of those wrinkles. Versus in another 20 years, unless I keep my toxin up, then those wrinkles are kind of permanently etched in the skin.

So important distinction. Toxin can't take the permanent wrinkles away because that's just part of your skin at that point. But it can always, as we said, inactivate the muscle under it.

So for forehead wrinkles, for instance, that's the frontalis muscle. We can make that muscle calm down, be much less active with the toxin, and then you're not actively working to keep forming those wrinkles. So that's why it can still help even if you have static wrinkles that are there.

Scot: What are other wrinkle locations it could help? So crow's feet, if I already have them, that's not going to help that, right?

Dr. Akkina: It still will make I think the appearance of the deep wrinkles less, right? If you have the crow's feet, yes, they're there, but if you're not activating the muscle all around it, it can still look a little bit softer, a little bit less aged overall.

For other areas . . . So we talked about the forehead. The between-the-eyes area, that brow, that's another super common one. And especially for men, right? It's that kind of furrowed, angry brow look. We call those the 11 lines because it leads to those two often horizontal lines in the very middle of your forehead. Those can respond really well to Botox.

And again, if you have permanent wrinkles there or static wrinkles, it's not going to take them away, but it does soften the overall appearance of your brow. It can help you look a little bit less angry or things like that.

Scot: How many men do you see in your office that actually come in and get treatment? And what are their reasons? Because I had read somewhere that Botox has just exploded among men. I think a 400% increase in treatment since 2000, so a lot more men are getting it nowadays. Why are they doing that?

Dr. Akkina: And most of it is for appearance. Yes, overall, for my patients coming in for toxin treatments, less than maybe . . . It's certainly a minority. I would say probably at this point, maybe 5% to 10%. But among those men, certainly things like the forehead wrinkles, but the masseters is also another really common indication for people who want to try to stop grinding their teeth.

That's another actually great thing that I'm getting more folks coming in for. I'm glad that it's getting out there that's something that we can use toxin for.

Scot: Yeah. I Googled a couple things because I was curious. I was like, "Gosh, is it vain that I want to get rid of my wrinkles?" For me, it's not actually wrinkles. I don't think Botox is the solution to my problem. I have these bags under my eyes. I look like I'm constantly fatigued. Botox isn't going to help that.

Dr. Akkina: No.

Scot: And I never thought I would think about getting any sort of cosmetic anything until we came into this world of Zoom. I'm looking at my face all the freaking time and I just look so run down and so tired, and I'm afraid people in the office are going to think, "Does he ever sleep? He looks sleepy."

So social media was one of the reasons why. And I thought, "Well, again, that's kind of vain." But then it said online dating. Well, okay. We're representing ourselves in a completely different way than we've ever had to, our dads or grandfathers have ever had to, in high resolution. So do you guys come in for those reasons and . . .

Dr. Akkina: Yes, absolutely. I had a patient the other day who was telling me that he's a little bit upper level in his company now, but he feels like some of the other people in the company are much younger than him and seem more youthful. And he gets embarrassed on these Zoom calls where he feels like he's the old person in the group, and he just wanted to feel more youthful.

So talked to him about things like facelifts, blepharoplasty. That's the under-eye or over-eye surgery where we try to help reduce that evidence of the extra skin and the bags, things like that. And he's really excited to get a little bit more of a youthful appearance just so he feels like he can stand up with the younger folks at his company.

Troy: I was going to say what about . . . The big thing I've heard with Botox is kind of the mask face where you get to where you always look like . . . Your expression doesn't change.

Mitch: You're a Barbie?

Troy: Yeah, exactly. Is that common, or are people just overdoing it when that sort of thing happens?

Dr. Akkina: Yeah, I call that a frozen face or freezing someone out. I don't like to do that. And when you have an injector that you're going to, I think talking about what your expectations and what your goals are is super important. And then having your injector listen to you and make sure they're not overdosing things to freeze things out is important.

So when folks come to see me, I talk through exactly what they're interested in getting. We talk through wrinkles often. And then I discuss my normal dosages.

And usually, I like to err on the lower side, right? I never want to free someone out. That's just my preference. So starting on lower ends of dosages, and then always coming to back for touchups, things like that. Super easy to do.

In general, when we go through the process of injecting Botox or Dysport or Xeomin, it's a very tiny needle. It's a couple little sticks. Yes, there is a risk of just a little pinpoint bleeding, things like that, or just a tiny bit of bruising. But overall, it's a pretty short and sweet procedure.

So we can start at low doses. I can have people come back and we can kind of keep augmenting until we find a regimen that they like in terms of its outcome.

Mitch: Now, I've heard about Botox parties. I've heard about going to a "spa." Is there a benefit? I mean, it sounds like this drug is pretty safe. Is there a reason that we should maybe err towards going to a medical person rather than some of these other things?

Dr. Akkina: Yes, absolutely. So we talked a little bit about some of the risks. I just mentioned injection risks certainly are something to always think about. But making sure that whoever is injecting your face is intimately familiar with those muscles and the other things in the area that could get affected by your injection is so important.

So one of the other common things that can happen if you're injecting around the eye, and especially if you're injecting in certain areas, is that toxin can diffuse and affect one of the upper muscles in your eyelid and basically give you a droopy eyelid. So that's something called ptosis.

And especially for cosmetic things, it's a little bit less common, but you want to make sure that your injector is injecting in places where that's a much lower risk. Certainly, we can treat that with eyedrops, and often it only acts for a few weeks even.

But yeah, that's a small example of you want to make sure you're going to someone who knows what they're doing and can provide the treatment in the places that you want it, giving you the effect that you want, and the dosage that you want.

So yeah, Botox injectors come in all sorts of varieties. I've even seen dentist office offering Botox. Have you guys seen that?

Mitch: What? No.

Scot: No.

Dr. Akkina: I mean, I think if you're well trained and have good results, okay, for sure. But yeah, you just never know and I think it's safer to make sure you're going to a place where the person knows the face, knows the muscles, knows what they're doing.

While it's safe in general, you can have unwanted consequences. You can freeze out a face. You can cause droopy eyelids. You can affect things like the smile overall. If you're doing masseter Botox, sometimes that can diffuse in different places. So you just want to make sure someone's really knowledgeable when they're doing it.

Scot: Those are some really good tips on how to look for a professional. And also, I love the fact that you said you should have a conversation and make sure that you feel comfortable with the person . . .

Dr. Akkina: Yes, absolutely.

Scot: . . . that's going to do it for you.

So I'm not going to pass judgment, I guess. I think the Scot of 10 years ago, and certainly the Scot that is the son of a South Dakota Rancher would. But we're in a different world, right? Botox is super useful for a lot of reasons beyond just appearance. If you want to get it for appearance too, and I've considered it, so I would completely understand.

So I want to find out where we are after our conversation. We started out with the association game. Troy, Botox.

Troy: Teeth grinding.

Scot: Okay. Wow. So we did change perception there.

Troy: That was my takeaway. And as we talked about it, I was grinding my teeth and I thought, "Maybe I need this."

Mitch: Oh, my. I've been struggling with this forever. I have a little mouth guard thing that I wear most nights, and I've still got sore muscles. It's like, "No duh, we have something out there that can turn those muscles off for a bit."

Scot: All right. Mitch, Botox.

Mitch: Toxin, my eyes. I don't know. What I'm thinking now is just, "Maybe I . . ." If it's for the most part relatively short term, maybe I could try it and see if it's worthwhile to have those muscles near my eye frozen. I didn't fully realize that it was kind of a temporary thing. So I don't know. I feel very different about it.

Scot: You're more open to it now?

Mitch: Oh, very much so.

Scot: All right. Very good.

Well, thank you very much, Dr. Akkina. We appreciate having you on the show.

And if you're listening, where are you about Botox after this episode? Have you ever used it for other procedures, for your appearance, or any of the conditions we talked about? And how did it work for you? Then finally, is it legit for a man to care about their appearance and want to use Botox?

If you have thoughts on any of those topics, you can email us at hello@thescoperadio.com.

Thank you for listening, and thank you for caring about men's health.
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Interviewer: After getting COVID-19, some people can lose their sense of smell or also suffer a condition called parosmia, which is a distortion of smells that can turn once-pleasant odors into unpleasant ones. Not being able to smell or smell accurately can be an inconvenience and not enjoyable, especially if things like fruit, coffee, chicken, and other foods and things in your environment smell like garbage or chemicals like ammonia. But can it impact a person's physical or emotional health?

Dr. Kristine Smith is a rhinologist, which is a nose and sinus expert, at University of Utah Health. Dr. Smith, is a decrease in the ability to smell or an altered sense of smell dangerous?

Dr. Smith: You know, kind of shortest, simple answer is that losing your sense of smell or having a change in your sense of smell is not going to directly cause you harm by not having it, but it does increase your risk of some other potential harmful things. The ones that I try to really emphasize for patients is when your sense of smell comes back wrong, or when it's decreased long term, this does actually put you at an increased risk for experiencing food poisoning over time because you might not be able to tell when something has gone bad in your fridge. And so a really careful attention to the expiry dates on food in your fridge and labeling your leftovers so you know how long they've been there for, or having someone in your home who has a normal sense of smell check them before you eat them is actually really important.

And then similarly, you might not be able to detect smoke or natural gas in your home with your altered sense of smell, and so ensuring that you have up-to-date smoke detectors and natural gas detectors is really important. Even if you have a natural gas stove, potentially getting a handheld natural gas detector can be really important because it might be that you went to light your stove, the lighter didn't work, and then the gas is kind of spewing out of the stove, and you try to relight it, and there's been an accumulation of that gas in your home, which can potentially cause a small explosion. And so it's something I'm very careful to talk to patients about so that they're aware of that potential risk. Barbecues are another area where that can be really problematic.

Similarly, we can see occupational disruptions in our patients that are experiencing parosmia, particularly people that work in the food industry, like chefs, or potentially in other areas like florists or firefighters, who are dependent on their sense of smell to do their job well, and so this can be very impactful for patients.

Outside of those kind of like lifestyle risks that we talked about, changes in your sense of smell actually has the potential to significantly impact your mental health. So your ability to smell, your ability to enjoy food from the flavor that comes from your sense of smell is really important for our well-being long term, and these types of alterations have a really significant impact in the quality of life of our patients.

They do feel very bothered by these symptoms, and they do affect their enjoyment of life on a day-to-day basis. And so having persistent parosmia, having persistent hyposmia can increase your risk potentially for things like anxiety or depression. And I think making sure that our patients are aware of this is really important so that if they start to experience those symptoms, if they start to think that maybe they're being affected by this, we can help to treat those associated issues, those associated anxiety and depression, so that we can mitigate the impact that this is having as much as we can.

Interviewer: I can see how the mental impacts could be very real, especially with I've heard patients reporting that other people in their lives have a hard time understanding what they're going through. Have you experienced that with your patients?

Dr. Smith: Yeah. I would say that's absolutely true. Parosmia, phantosmia, hyposmia are extremely difficult to understand unless you've lived them. And I think most people have had a cold or an upper respiratory tract infection where they've had a weird sense of smell or taste for a short period of time, and they're like, you know, "Nothing tastes good. I don't want to eat while I'm feeling sick." And now imagine if that's what your life is like every day forever. And it can potentially cause real distress when patients can't enjoy things that they normally would enjoy.

So, you know, I personally had COVID-19 in April, and when I was recovering, I actually did have some parosmia phantosmia as I was recovering, and one of the things that I no longer enjoyed was coffee. And I'm a big coffee drinker. I love my morning cup of coffee. And it got to the point where I could not drink my coffee and keep it down because the smell that was associated with it was so terrible. It was making me so nauseated, I couldn't drink it anymore. We had to take all the coffee beans out of our espresso machine and put them away for a while because I just couldn't tolerate them being in the home, and I was really upset about that. I was really bothered about that, and I thought, you know, "This is going to last forever. I'm never going to be able to have a good cup of coffee again." And, you know, fortunately for me, slowly over time that improved, and now I can have my morning cup of coffee again.

But for some patients it's not restricted to one food or to one drink. And it's very bothersome for them. I think it's important that we acknowledge how severely this can impact their life and their day-to-day living because it is a real problem.

Interviewer: And as far as not getting the nutrients that somebody needs because of parosmia, is that a threat? Is that something that maybe somebody should see a dietician about?

Dr. Smith: I think that's a great idea. So if you find that your trigger foods are leading you to eliminate an entire food group from your diet, like meat, this is really going to significantly impact your intake of proteins, of vitamins and minerals, and as you start to restrict your diet using those avoidance measures, you want to make sure that you're still getting a well-rounded diet.

This can be particularly disruptive in an older generation of patients. As you get a little bit older or wiser, one of the things that happens is that your sense of smell starts to diminish naturally over time, and this can be particularly bothersome to patients when it comes to their enjoyment of food. And so if you get an additional disruption to that with COVID-19, it kind of adds a stepwise worsening to that process.

And so one of the reasons that we see folks eating less as they get older and wiser is because their enjoyment of food has decreased in addition to their appetite, and it can be really hard to motivate someone to eat when everything tastes really bland or when it tastes bad. And subsequently, you can have potentially an increased risk of anxiety and depression associated with those things. And so this is something that I think it's important to be mindful of in our older generation so that we can keep an eye out for it and help to manage it as it's becoming a problem.

Interviewer: What would you say to somebody who has parosmia and they're listening to this? What would be the most important message you could give them?

Dr. Smith: Honestly, I think there are two things. The first and most important is that you are definitely not alone. There are so many other patients who are experiencing this. There is a whole growing community of people like you that can help you to kind of get through this stage of your life. It's unfortunately common. We are seeing a lot of it. You are not alone.

The second thing is that it seems to get better. The vast majority of people, you know, 90% plus, within two years of having their COVID-19 infection report that these alterations in their sense of smell go away despite doing nothing about it. And so, for the vast majority of people, it is going to get better with time. It is very slow. We used to think that nerve healing kind of whatever you had one year after the injury, or one year after your episode of COVID-19, was what you were going to be stuck with long term, and we know now that that's not true. It keeps improving two years, three years after you've had the infection, and things seem to slowly get better over time. So don't lose hope. It is very slow. I know that it's hard and it's disruptive, but it does seem to get better for the vast majority of people slowly over time.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Interviewer: Were you aware that lack of knowledge about colorectal cancer causes a significant percentage of adult deaths from colon cancer every single year? So that means just by listening to this podcast today you are going to reduce your risk of colorectal cancer.

Dr. Priyanka Kanth is from Huntsman Cancer Institute and here are the bullet points that we're going to talk about today to help inform you so you are less likely to get colorectal cancer.

So, first of all, it's one of the most common cancers, and it causes a significant percentage of adult cancer deaths. Colorectal cancer impacts men and women equally. You need to have screening even if you don't have a family history and by the time you have symptoms it can often be too late, that's why screening is so important. So let's start with the first one Dr. Kanth, colorectal cancer I didn't realize this, one of the most common cancers and causes a lot of deaths.

Dr. Kanth: That's correct. So colon cancer is the third most common cancer in the U.S. And so number one being lungs and number two being breast and prostate in the respective gender. And then third is colon cancer, and that's pretty high. And it is also the second most common cancer to cause death in the U.S. So the first is lung cancer, leading the highest deaths from a cancer, and the second is colon cancer. So it is surely that the burden of disease is very high.

Interviewer: Yeah. I think that surprises a lot of people. A lot of people don't realize that and, as a result, maybe don't take screening as seriously. Another misperception is that men . . . It's a man's disease, but it actually impacts men and women equally. Tell me more about that.

Dr. Kanth: Absolutely. So there is no separate recommendation for men and women. Both genders can get this cancer, and both genders should start at the same age. So there is no difference in recommendation. It is a disease for anyone. So anyone should get screened and now at age 45, yes.

Interviewer: And another perception is, well, my family, nobody in my family had colorectal cancer. So I'm probably going to be okay. Maybe I don't need to get screened at 45, which is the new recommendation. Maybe I can wait till I'm 60. But that's false too.

Dr. Kanth: Absolutely, you're very correct about it. A lot of time we don't think that it is a problem for us because we don't have anyone in our family, but that's not correct. It can happen to anyone. In fact, 70% of all colorectal cancer patients don't have a family history. So that's a big number. And that's why it's so important to have this screened because screening is the best prevention.

Interviewer: I also understand that there's a misperception that colorectal cancer just happens to older people, like in their 60s, 70s, and 80s, so I can put off my screening.

Dr. Kanth: Again, a very, very good point. It can happen to anyone. So age is a number. It surely can happen more in older age, but even young people can get it. And we have seen a rise in incidents in less than age 50. So it is not a disease of only old age. It is a disease for anyone to be worried about.

Interviewer: And then the other misperception that I've heard is, oh, I'll go in and get my screening when I start to show symptoms. But that's very dangerous and inaccurate.

Dr. Kanth: It is. It is very dangerous because colon cancer, especially early stages will not have any symptoms. Even sometimes late stages you'll have symptoms, very minimal symptoms. This is a disease where you don't produce symptoms, you don't think about it and it is inside you. So you have to be very, very aware of this. That don't wait for symptoms. Go ahead and get your screening.

Interviewer: And how difficult is it for treatment if a patient comes to you is at the point where they have symptoms?

Dr. Kanth: Absolutely. So if the symptoms are already there, we are worried it is a late-stage disease. And treating a late-stage disease when it has spread beyond colon is much more difficult compared to treating a stage one or two disease, when it is just in the colon. If it's just in the colon, we take your colon out. We all can live without our colon believe it or not. We can have some change in quality of life, but we can have same life expectancy. So treating an early-stage colon cancer is way easier compared to treating a stage four, late-stage colorectal cancer, yes.

Interviewer: And the two options you've got the stool test, or you've got a colonoscopy. Tell me the advantages and disadvantages of each one of those, because, you know, we know that 45 is the number we should be screened at, but some of us don't necessarily want to take, you know, the day off before and after to get a colonoscopy, so talk me through that.

Dr. Kanth: That's correct. So colonoscopy is gold standard. The reason we call it gold standard is this is the only preventive tool where we can go in, we can see a precancerous lesion, which is a polyp, and we can take it out.

Interviewer: And so it's a diagnostic tool.

Dr. Kanth: It's a diagnostic.

Interviewer: In addition too, if there's a problem at the same time, you can take care of it.

Dr. Kanth: You've taken care of it. It will never turn into cancer. Stool test are very, very, very good tests to detect colon cancer. They may not detect polyps, but they will detect colon cancer at a very high sensitivity. So it is a very good option for patients who are worried about colonoscopy. Now, colonoscopies are not without risk. It's an invasive procedure. We give you sedation. You have to go through a prep as well. You have to take time off, like you mentioned, and yes, some risks associated with the procedure itself, like bleeding or perforation. Those risks are very small, very, very small, but can happen. Stool tests on the other hand, are very safe, can detect colon cancer readily, may not be polyps, but it's a very good tool, once we find that you have blood in stool. Now remember this, if your stool test is positive, you have to get a colonoscopy. That is the next step. So just to keep in mind, any screening test result like we said, best screening test is the one that gets done. So we should consider screening whatever option works for you.

Interviewer: And the advantage of a colonoscopy too, is once you have that done, if no polyps are discovered, you're good for another 10 years.

Dr. Kanth: Absolutely. If your prep was good, if you did a good exam and no polyps were found, you have no family history, you don't have to repeat it for 10 years. So even with small polyps now we don't have to repeat it for 7 to 10 years. So the recent recommendation has changed and become more relaxed for even if you had one or two small polyps, you're okay.

Interviewer: And the stool test is yearly.

Dr. Kanth: So stool test, there're a couple of stool tests. One stool test, where you have to do pretty much yearly is called fecal immunochemical testing. The other stool test is called FIT-DNA, which is commercially called Cologuard which you may consider doing it every three years. But it is surely more frequent to do it than getting a colonoscopy done.

Interviewer: And let's talk briefly about barriers that keep people from getting either one of the two screenings. So maybe we can help talk them through and encourage them, you know, if they have average risk to get screened at 45, because that is really the best way of preventing death from colorectal cancer. So what are some of the barriers and how can people overcome those?

Dr. Kanth: Absolutely. So the biggest barrier, I think, is the knowledge. They should know that they have to get screened. So there is a provider and patient education involved either away. So if no one told them, or if they did not hear it on the radio, say they don't know. So that's the biggest barrier. So education is very important from both aspects. The other barriers are, I would say another very big barrier is, of course, insurance coverage, if you don't have insurance. But there are other tools, there are other ways, like I said, stool tests, they are very cheap. So things can still be done even if you don't have insurance. Apart from that, other barriers are just being worried about getting a procedure. A lot of people think colonoscopy is painful. I have to go through this. It's not true. Colonoscopy is a very smooth, painless procedure, honestly. So those kinds of things that this is going to hurt me, that's not correct. So those are the main things. I would say if I have to pick any, I would say education. If you're aware you're going to do it, you will do it.

Interviewer: And sometimes it's just getting it on the calendar, right?

Dr. Kanth: Absolutely.

Interviewer: Whether it's the colonoscopy or whether it's the stool test, just talk to your primary care provider. Have that discussion find out where it works out for you.

Dr. Kanth: Absolutely. Yes. And that's for average risk screening, you can choose anything, colonoscopy or stool test. There are other tests, other modalities too, but these two are the most common. If you've family history, we recommend colonoscopy, that's the usual tool is recommended. So the best way is to contact your primary care provider, talk to them what's best for you.