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Tantra is a Sanskrit word that means “woven together.” Hindu and Buddhist meditation practitioners use the sexual union of tantra sexology as a metaphor for weaving together the physical and the spiritual: weaving humanity to the divine. The Western form of this sacred sexuality called Tantra teaches slow, non-orgasmic sexual intercourse.

Couples in my practice who have tried tantric sex find that they cultivate great sensual pleasure and also a sense of “dissolving into each other” that is profound and loving. The purpose is to become enlightened, not to win an Olympic medal for carnal gymnastics. (Plus, there’s actually a scientific reason why you should have sex before you go to sleep.)

So, where do we start?

Begin by facing each other and gazing into each other’s eyes with your clothes on. Focus on one of your partner’s eyes; this keeps you intimately exposed. (Some people look back and forth between the two eyes to reduce the tension, but I think that’s cheating!) Eyes are windows to the soul.

Make sure you’re breathing the right way (yes, there’s a wrong way). Next, synchronize your breathing with your partner’s: Breathe in together, exhale together. Then move into breath exchange: You inhale when he exhales, then exhale when he inhales, as though you’re breathing each other in. Practice this for at least 10 minutes.

Then what? What does tantric sex for beginners look like?

To take this into sexual Tantra, try the same process but with clothes off. Sit on your partner’s lap, and wrap your legs around their waist. Do the breath exchange, but move into kissing and caressing. In time, begin slow intercourse, but continue caressing and kissing. Keep eye contact.

Here is where things get interesting; as you become more proficient, you can develop the ability for prolonged orgasm. For both women and men, this is a variation on multiple orgasms; you remain at the peak of ecstatic pleasure without climaxing. There are all the feelings of a typical orgasm, but it lasts for many minutes (or even hours), without a traditional orgasm. This leads to profound sexual and emotional merging.

Why should I try tantric sex?

In our over-scheduled lives, we rarely stop and intently focus on our partner. Practicing tantric sex can enhance your relationship and your sexual pleasure in several ways. First, emphasizing breath and connection creates a deep level of intimate contact. This alone can open your heart to feeling closer, more loving and more forgiving.

Second, the slow pace of tantric sex will allow you to explore the sensual range of your bodies and minds. Making love for an hour or more is like turning a fast-food meal into an epicurean feast. Both will satisfy your hunger, but the feast brings you more pleasure, delight and profound satisfaction.

Lastly, while you may balk at the idea of avoiding climaxing, these practices can help you both develop sexual ecstasy and connectedness far beyond that of a typical orgasm. If you feel that you need help getting in the mood, try these libido boosters.

Cheryl Fraser, Ph.D., is a psychologist and sex therapist who lives in Duncan, B.C. She teaches a couples’ workshop, the Awakened Lover Weekend.

Next: Are There Different Types of Orgasms? What Sex Experts Say

If you’re clocking somewhere between seven and nine hours, but still feel exhausted in the morning, sleep apnea might be the cause. This is a condition that causes your breathing to stop and start intermittently when you’re sleeping. It often results in snoring, gasping or loud breathing, and is most common in men and obese individuals.

However, regardless of sex or body type, certain facial anatomy puts people at higher risk for sleep apnea—narrow airways, dental causes and even the amount of fat on your tongue. (An enlarged or fat tongue may be related to a medical condition, your body type or a genetic predisposition—a doctor or dental professional can help you determine the root cause and recommend a course of action, if needed.)

Sometimes a partner can confirm that you’re displaying signs of sleep apnea, but other indicators may be a sore or dry throat when you wake up, morning headaches or difficulty concentrating during the day. Sleep apnea puts individuals at higher risk for a heart attack, stroke, dementia and other serious conditions, so it’s important to tell your doctor.

Next: I Get Enough Sleep—So Why Am I So Tired?

Shaving cream has long irked me. As a teen, I’d buy the men’s version for shaving my legs because it was cheaper than women’s, which meant there’d always be a hint of a masculine scent under my Ralph Lauren Ralph perfume (IYKYK). When I switched to women’s, I found the electric pink hue of the gel and the artificial scent (“Raspberry Rain,” anyone?) to be needlessly off-putting. And when the shaving cream can would inconspicuously run out of product and I’d have to shave one leg with just suds from a bar of soap, I always got razor burn. Needless to say, I’ve been all too happy to see a new shaving product on the scene—the shave bar.

By now, you’re probably familiar with the beauty bar trend (see: shampoo bars), which helps reduce the amount of single-use plastics that end up in landfills. A shave bar is no different. Instead of a gel or foam packaged in a metal aerosol can with a plastic cap (both of which can be recycled, but often aren’t), it’s just a bar in paper packaging—that can replace up to five bottles of shaving cream.

One of the shave bars leading the way is by Canadian company Good Juju. The brand’s Moisturizing Shave Bar is formulated with good-for-your-skin ingredients including natural oils (like coconut and jojoba seed) and butters (like cocoa and shea), all of which help boost skin’s hydration, reduce irritation and make it silky-smooth.

I’ve been using Good Juju’s shave bar for a few months, and unlike shaving cream, it doesn’t make my skin feel tight and dry, but hydrated and glowy. And unlike regular body soap, it hasn’t resulted in any razor burn. What’s more, Good Juju’s bar is made with rosemary and cedarwood essential oils, so it smells less like berry gummies (or fruity rain) and more like a high-end spa.

“Once you try our shave bar, you won’t ever go back,” says the Good Juju website. And I’m happy to confirm the brand’s right.

Good Juju Moisturizing Shave Bar, $15, thedetoxmarket.ca

Next: 6 Bath Products That’ll Help You Escape Reality and Relax

I recently started craving these morning glory muffins, which I used to make all the time. They are full of wonderful add-ins—which you can add in or not—and you can substitute similar ingredients (though I like to think that the bran helps make your morning glorious!). You don’t need any special equipment to make these, and if you don’t have a muffin pan, you can bake the batter in a 9-inch square pan and call them muffin squares (it may take a bit longer to bake).

Morning Glory Muffins

Makes 12 muffins

Ingredients

11/2 cups all-purpose flour (or half whole wheat)
1 cup bran cereal (I use All-Bran Buds)
1 Tbsp baking powder
1/2 tsp baking soda
1/4 tsp kosher salt
1 tsp cinnamon
1 egg
3/4 cup buttermilk
1/2 cup extra virgin olive oil or vegetable oil
1/2 cup light brown sugar
2 Tbsp molasses
1 apple or pear, peel on or off, grated
1 large carrot or parsnip, scrubbed or peeled, grated
1/2 cup chopped pitted dates (see note) or other dried fruit you like
1/2 cup chopped roasted walnuts or other nuts
2 tbsp toasted sesame seeds
2 tbsp roasted pumpkin seeds

Directions

Preheat the oven to 350°F. Butter or spray a 12-cup muffin pan. Or line with paper muffin cups.
In a medium mixing bowl, whisk the flour with the bran cereal, baking powder, baking soda, salt, and cinnamon until well combined.
In another, larger bowl, whisk the egg with the buttermilk, olive oil, sugar, and molasses.
Stir the dry ingredients into the egg mixture, and mix only until combined. Add the apples, carrots, dates, nuts, and sesame seeds. Stir well.
Scoop the batter into the muffin cups. Sprinkle with the pumpkin seeds. Bake for 20 to 25 minutes, or until the muffins have risen and are browned, and an instant-read thermometer registers at least 185°F when inserted into the center. Cool for 10 to 15 minutes in the pan, then remove. The muffins will keep for a few days, covered, at room temperature, and they freeze well.

Note: It’s easier to “chop” or slice dates or most other dried fruit by cutting them up with scissors.

Don't Worry, Just Cook by Bonnie Stern

Excerpted from Don’t Worry, Just Cook by Bonnie Stern. Copyright © 2022 Bonnie Stern Cooking Schools Ltd. and Anna Rupert. Photography © 2022 Tyler Anderson with additional photos by Mark Rupert and Anna Rupert. Food styling by Olga Truchan. Published by Appetite by Random House, a division of Penguin Random House Canada Limited. Reproduced by arrangement with the Publisher. All rights reserved.

Next: This Sheet Pan Chicken With Lemon and Olives Makes an Easy Weeknight Dinner

For some of us, it’s hard to let the tears fall, whether that’s simply because we’ve learned to hold back or it’s due to a medical reason (a decrease in tear production can be a side effect of many medications, including birth control, SSRIs, antihistamines and blood pressure medication). An SPCA commercial can induce waterworks for some, others find their eyes only well up when they chop onions, or on a high-pollen-count day. Sure, it’s all crying, but the tears are different; in fact, researchers have identified three main types. Basal tears, which keep our eyes lubricated and protect the cornea from infection, and reflex tears, which we cry in response to physical triggers like smoke, dust or pungent smells, make up the majority of the 50 to 100 litres we produce on average every year. Their content is 98 percent water.

And then there’s a third grouping called emotional tears. The crying that comes with strong emotions—whether it’s deep sadness and grief or extreme happiness and joy—may offer the biggest health benefits. It releases oxytocin and endogenous opioids, aka endorphins, those feel-good chemicals that help ease both physical and emotional pain. Emotional tears contain higher levels of stress hormones than basal or reflex tears, and they also contain more mood-regulating manganese, a trace mineral necessary for healthy brain and nerve function. When you release emotional tears, your parasympathetic nervous system is also activated, which lowers heart and breathing rates, lowers blood pressure and restores the body to a state of balance. Deep abdominal breathing can also do it, as can yoga and meditation practice—so if you can’t turn on your tears like a faucet, you should try to reap the benefits of releasing stress in other ways. But there should be no shame in an old-fashioned, middle-of-the-day, bathroom-stall weep: big girls do cry, and they’re better for it.

Did you know?

Women cry emotional tears on average 30 to 64 times a year, as compared with 5 to 17 times per year for men, according to a study of self-reports from more than 7,000 people in 37 countries.
A 2011 cross-cultural study of adult crying across 37 countries found that “individuals living in more affluent, democratic, extroverted, and individualistic countries tend to report to cry more often.” The study showed a lot of criers follow distinct trends: Australian and American men cried the most, while Bulgarian, Nigerian and Malaysian males cried least. Countries with the greatest gender equality reported crying more overall.
Tears are an essential communication tool for babies, and they may serve us well in adulthood, according to several studies. One showed participants images of faces dappled with tears and faces with tears digitally removed. Subjects judged the faces with tears as appearing sadder and rated the tearless faces ambiguously. “Tears add valence and nuance to the perception of faces,” says the study’s lead author. They become a sort of social lubricant, he says, ensuring the smooth functioning of a community by helping people communicate.
Tears help dogs, too. In a small 2022 study, researchers reported that dogs produce more tears when reunited with their owners than with other humans, and when dogs exhibit watery, shiny eyes, it “facilitates human caregiving,” according to Takefumi Kikusui, an animal behaviour and veterinary medicine specialist at Azabu University in Japan and one of the study’s authors.
The Japanese are such strong believers in the health benefits of a good sob that they have crying clubs. Rui-katsu (literally, “tear-seeking”) is where people come together to indulge in a communal weep. Hidefumi Yoshida holds workshops across the country, where he helps adults learn to cry. He’s also the subject of a sweet 2020 documentary, Tears Teacher. It may be just the thing to kick off your own sob fest.
Researchers from the University of Queensland ran an experiment to test whether emotional crying facilitates coping and recovery from unhappy feelings. They showed sad videos to groups of criers and self-described non-criers: the non-criers breathing rates went up, whereas the criers tended to maintain theirs. Criers also, right before crying, experienced decreases in their heart rates, seemingly in anticipation of the cry.

Next: Why Can Sad Music Help Us Feel Better?

Spring forward, fall back, feel tired for days? It happens to many of us—but most people who struggle with this transition have underlying sleep issues to begin with, says Mark Boulos, a neurologist and sleep health expert at Sunnybrook Hospital in Toronto.

This fall’s time change happens on Sunday, November 5 and even though you’ll technically gain an hour, some people will feel off their routines in the days that follow. (Then, in the spring, when you lose an hour? You’re even more likely to feel off your game.) Persistent tiredness after resetting those clocks can also be related to the duration of natural light rather than the time change itself—for example, driving to work in the dark when you’re used to having a bit of morning sunlight, or getting home from the office when the sun’s already set.

Try exercising in the morning to increase your energy, using a light box to simulate natural light on darker days, avoiding caffeine in the afternoon and evening and sticking to your usual bedtime. Melatonin may be helpful in this specific (and temporary) scenario, Boulos says. “It’s best used for jet lag and shift work.” While it might help you fall asleep, don’t count on melatonin to help you stay asleep. It’s not a prescription drug and research actually indicates that it has minimal effectiveness.

Next: I Get Enough Sleep—So Why Am I So Tired?

My post-shower ritual is a well-tuned performance. I am the conductor, my skin care products the orchestra. Each product is added at a pre-determined interval for maximum absorption and efficiency. It goes something like this: After I towel dry, I pat a vitamin C serum onto my face. As that dries, I brush my teeth. Next, I apply a hyaluronic acid serum. As that seeps into my skin, I slather on body lotion. Next comes an eye cream and moisturizer. As my face drinks those up, I swipe-on deodorant, and then, comes sunscreen.

Yet, as I look at my temperamental skin with its consistent dry patches and erratic blemishes, I have to wonder—is all this necessary? Am I even doing skin care right?

“Ideally, we’d all be able to pop into a dermatologist’s office and have the doctor provide a specially formulated skin care regime for us, but honestly, there just aren’t enough dermatologists right now to be able to do that,” says Dr. Marcie Ulmer, a cosmetic and medical dermatologist at Pacific Derm in Vancouver, B.C.

So, here’s the next best thing: I asked Dr. Ulmer to share advice on how to layer skin care products, which ingredients should (and shouldn’t) be paired together and the most common skin care mistakes to be aware of.

Why is it important to layer skin care products the right way?

The reason we guide our patients on proper ordering of their skin care is so they can get the maximum benefit from each product by maximizing the absorption of the active ingredient. For example, if you were to apply something thick, like an oil, first, it’ll sit on the surface of the skin. So if you apply something afterwards, you won’t get the maximum penetration of that second layer and it wouldn’t be absorbed.

What’s the proper order?

You should apply your products starting with the lightest product and progress to applying the heaviest products. For example, in the morning, start with your cleanser, then apply your lightest product, which is often a serum. If you’re using more than one serum, go with your lightest, first. Then moisturize, which will seal in the serum, and then apply sunscreen.

How should the order of skin care products differ in the morning versus at night?

The morning routine is for protection, and the night routine is for renewal. An antioxidant serum, like a vitamin C serum, is ideal to apply in the morning because it can help protect against sun damage, free radicals and pollution. And, obviously, sunscreen is also essential in the morning routine too. The night is when you’d want to use a retinol or retinoid since they can break down with sun exposure.

Are there certain products or ingredients that should always be paired together?

Vitamin C, vitamin E and sunscreen
Both vitamins C and E are powerful antioxidants, and we like to them pair with sunscreen. Products with these vitamins, when applied in the morning, can be your line of defence. As previously mentioned, they shield your skin from sun damage, pollution and harm from free radical damage.

Water, hyaluronic acid and moisturizer
Hyaluronic acid-containing products should be applied with wet fingertips or applied onto wet skin, because this ingredient draws water in, and wet fingers or face will increase hydration. A moisturizer needs to be applied on top of hyaluronic acid to lock in the hydration.

Dry skin, retinol and moisturizer
Retinol or retinoids can be irritating and drying and should not be applied immediately after washing your face. A moisturizer should always be applied before or after a retinol or a retinoid. For those with really sensitive skin, I suggest putting on moisturizer first and then the retinol or retinoid, then moisturizer again—so the retinol product is sandwiched in between moisturizer to prevent irritation.

What are the most common mistakes people make when layering skin care products?

Using too many products
If your skin is red, flaky, burning or irritated, or if you’re experiencing a flare-up of an underlying skin issue like rosacea or acne, you probably need to scale back to the basics. Sometimes that means just using a cleanser and moisturizer, and then adding back one product at a time. Then, if you develop an irritation, you know which product caused it.

Using irritating products together
Retinol and exfoliants can cause redness, flaking and burning and shouldn’t be used together. Instead, use, say, a glycolic acid only once or twice a week, retinol on the other nights of the week.

Applying too much of one product
Putting on too much of one product, such as 10 drops of a serum instead of the recommended three to four, can lead to irritation. Or, you could just be wasting money. You only need a few drops to lightly cover your face.

Copying someone else’s routine
Everyone’s skin care routine should look different—it’s not going to be the same as your sister or your bestie’s because that might not be right for your skin type. Customize your routine to suit your specific skin care needs. Learn what type of skin you have—dry, sensitive, acne-prone—and make sure to use the products targeted to address your skin concerns.

How long should you wait in between applying each product?

If you can, give each product a little time to absorb before applying the next one. If you have other grooming things to do, like brushing your teeth, do so in between applying products to give each one a little more time to be absorbed. But if you don’t have time, they’ll probably still absorb just fine—as long as they’re layered in the right order.

This interview has been edited and condensed for clarity.

Now that you know how to layer skin care, learn why cryotherapy-based skin care products are currently trending.

Sheet pan dinners have become extremely popular and I think they’re great. The idea for this recipe came from one of my favorite dishes, Moroccan chicken tagine with lemon and olives.

I started making this dish on a baking sheet because my tagine (the cooking pot) only has enough room for 3 or 4 servings but also because I love the way it looks when I serve it right on the sheet pan. I like to make it with chicken legs (thighs, or thighs and drumsticks), which have always been a chef favorite, as they have more flavor than chicken breasts and stay juicy and delicious even if overcooked. If you do use chicken breasts, use bone-in and skin-on to help them stay juicy, and be careful not to overcook them (use an instant-read thermometer and cook to 165°F). Serve with rice, couscous, or freekeh.

Sheet Pan Chicken with Lemon and Olives

Serves 6

Ingredients

3 lb chicken pieces (12 chicken thighs or 6 whole legs)
2 onions, quartered
1 head garlic, halved horizontally
1 bulb fennel, trimmed, halved, and cut into thick wedges
1 lemon, thinly sliced (or 2 if you don’t have preserved lemons)
1 cup coarsely chopped fresh cilantro or flat-leaf parsley + more for serving
1/2 cup large green olives, pitted by gently smashing or tearing apart
1/4 cup sliced preserved lemon peel (see note)
1/4 cup extra virgin olive oil
1 tbsp honey
1 tbsp kosher salt
1 tsp ground coriander
1 tsp ground cumin
1 tsp sweet paprika
1 tsp ground turmeric

Directions

Place the chicken pieces in a large bowl, along with the onions, garlic, fennel, lemons, cilantro, olives, preserved lemon peel, olive oil, honey, salt, coriander, cumin, paprika, and turmeric. Toss well to mix. Marinate in the refrigerator for a few hours if you have time, or cook right away.
Preheat the oven to 400°F. Arrange the chicken pieces in a single layer on a baking sheet lined with parchment paper or in
a large baking dish or shallow Dutch oven, skin side up. Spoon the fennel-lemon mixture over and around the chicken. Cover with aluminum foil and roast for 20 minutes.
Uncover and roast for another 30 minutes. If the chicken hasn’t browned yet, increase the oven temperature to 425°F and cook for 10 minutes longer or until the chicken and vegetables are nicely browned.
Serve topped with the cooked lemon slices and olives, and the fresh cilantro.

Note: Preserved lemons are a fantastic ingredient on their own. You can buy them, or make them yourself: Put about 1/2 inch of kosher salt at the bottom of a large preserving jar. The goal is to fill the jar with as many lemons as you can. Wash the lemons well, and cut each one into quarters, but keep the quarters attached at the bottom of the lemon. Fill the center of each lemon with salt and squish them down into the jar very firmly, pouring more kosher salt on top as you layer the lemons in. You can add spices or sugar, but I usually make mine plain. Keep pressing down so that you are wedging in as many lemons as possible and then pour lemon juice to cover just to the top of the lemons. Cover tightly and refrigerate for a few weeks before using, turning the jar over every few days to circulate the liquid. The peels of preserved lemons are often called for in recipes and are even easier to use when transformed into a preserved lemon paste, which is easily incorporated into soup, salad dressing, marinades, risotto, and pasta dishes.

Don't Worry, Just Cook by Bonnie Stern

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In the waiting room at the breast imaging centre, there is a sea of women in blue gowns. Some are seated. Some are standing, leaned against the wall, looking at their phones or just looking around. They are young and they are old. Tall, short, fat and thin – with hair and without. On this day there are no men, but I’ve seen them here because men get breast cancer, too. I close my eyes and my sisters in blue fade like waves on a horizon. I focus on the metallic chatter from the TV and the clamoring ring of a phone no one has answered. I want to hear music; I want to hear the street sounds. I don’t want to be here. None of us do. Yet all our hope lies here, in the waiting room.

One of the cruel aspects of this disease is that it hits us in such an intimate part of our bodies. Practically speaking, the breast is more expendable than some other parts of us. We can remove a breast and go on living. But they’re also an inextricable part of who we are. They’re a site of pleasure. They also feed our babies. They represent, in many ways, the cycle of life.

So, when someone takes a waterproof pen and draws a map across them or leads us into a dark biopsy room to remove a part of them, a part of us can go missing, too. When a patient is told she can potentially save her life by having a breast removed, it raises a complex array of feelings. Breasts, while not necessary for our lives, are far from vestigial. And it can be very painful when we have to say goodbye – in part or in full – to them.

Maybe that’s why in the past 50 years there’s been such an emphasis on reconstructive surgery to rebuild (or build anew) the breast that’s taken. The right to breast reconstruction has long been understood as an issue of freedom, bodily autonomy and choice. In Canada, breast reconstruction is funded as a part of our national health system because although it’s an aesthetic procedure, it has a positive impact on some patients’ mental health.

There is another option – aesthetic flat closure (going flat). Today, about one out of seven women in Ontario having breast-conserving surgery or mastectomy gets a flat closure. Google “going flat” and you’ll find Instagram selfies of lush, tattooed flat closures and coverage of fashion shows featuring women who chose to go flat, with an emphasis on body positivity. Through “Flat and Fabulous” blogs and social media groups, women share photos of the beautiful, flat-style dresses they’ve found for their weddings – and of date nights, smiling with their partners, no prostheses required. Judging from the community that’s been growing over time, going flat has been a positive choice for many women.

But most Canadian healthcare websites make only passing mention of the choice to get a flat closure – or no mention at all.

I’ve been wondering why.

When Abigail Bakan, a political science professor at the University of Toronto, had a bilateral mastectomy in 2016, she decided from the start she didn’t want reconstruction. “I said no. And they had it on my record,” she told me. But members of her cancer care team asked her, repeatedly, if she was sure. “That’s when I started thinking, ‘Why are they are continually asking the question and there’s only one right answer?’ The ‘right’ answer is you’re supposed to say yes.”

A social worker on Bakan’s cancer team recommended that she attend the Breast Reconstruction Awareness Day event in Toronto, known as BRA Day. BRA Days are held at various venues across North America, including community centres, convention centres and hospitals. It features seminars for patients about different reconstruction techniques as well as a Show and Tell Lounge where breast-reconstruction patients tell their stories (and show results) to women who’ve been referred to the event by their physicians.

The logo for BRA Day features a pink cancer ribbon with a symmetrical pair of loops resembling breasts and the tagline “Closing the loop on breast cancer.” The logo reflects the idea that constructing a new breast can be a liberating alternative to wearing a prosthesis or facing potential social stigma around appearing without a prosthesis. As Toni Zhong, a Toronto-based plastic surgeon and conference organizer, put it: “We now know that you don’t have to live with a mastectomy defect for the rest of your life and there are options available that can restore your breast to make you feel and look good or certainly better.”

But what if a patient doesn’t see her mastectomy or lumpectomy as “awkward” or a “defect?”

The women in the Flat and Fabulous movement are pushing back against the idea that they’re not whole without their breasts, blending online organizing around breast cancer care with image galleries that bring greater visibility to women who have chosen flat closure. One organization, Not Putting on a Shirt, uses social media to provide vetted information on topics such as body image, communicating with providers, emotional health and local community supports.

In this sense, the Flat and Fabulous movement has done more than introduce a new aesthetic option. It’s pushed for better shared decision-making and choice (two concepts that are key in the reproductive rights movement) in breast cancer care. This shift is needed. Across Flat and Fabulous platforms, women are telling their stories of recovery from botched surgeries or of “explanting” implants for various reasons, including serious health issues.

Yet many say that they were not made aware of risks, statements that are borne out in research. A cross-sectional survey in the U.S. in 2017 found that just 43.3 percent of breast cancer patients had made a “high-quality decision (about reconstruction), defined as having knowledge of at least half of the important facts and undergoing treatment concordant with one’s personal preferences.” Many hospital websites and most of the major American clinical breast-reconstruction decision aids do not include the option of flat closure (a notable exception being the Breast Advocate app, developed by plastic surgeon Minas Chrysopoulo).

This kind of information gap can have a negative effect on women’s quality of life. A 2017 study confirmed earlier research that patients are more likely to express decision regret when they have not been engaged in shared decision-making around post-mastectomy decisions, with this being true both for women who wanted reconstruction and those who wanted a flat closure. “Patients often felt pressure from their clinicians to choose one option or another,” according to the study, with some feeling that bias was at play and others feeling rushed to decide on the spot.

It may seem odd that some women must press their surgeons to get a flat closure, but it happens. A study of 931 women in 2021 by UCLA’s Jonsson Comprehensive Cancer Center found that 18 percent of recent mastectomy patients had been told there were no options for them to choose to go flat. In five percent of cases, women were given surgical results that they didn’t ask for, with the surgeons leaving additional tissue instead of a flat closure; what the researchers called “intentional flat denial.”

According to Deanna Attai, a California-based breast surgeon who co-authored the study: “Some patients were told that excess skin was intentionally left – despite a preoperative agreement to perform a flat chest wall closure – for use in future reconstruction, in case the patient changed her mind.” Attai notes, “We were surprised that some women had to struggle to receive the procedure that they desired.”

There is also the problem of a data gap, with little information collected on how satisfied women are when they choose to go flat. Recent data is interesting, however. A 2019 systematic review of 28 studies found that women who went without reconstruction fared no worse and sometimes better than those with reconstructed breasts, with no notable differences in terms of “quality of life, body image and sexuality.” Some of this was confirmed by results of the 2021 UCLA study that Attai co-authored, which showed that 75 to 90 per cent of women who underwent mastectomy without reconstruction were satisfied.

But in a data-driven field, there needs to be more research to form a better understanding about navigating the decision-making process.

(Related: How to Do a Self Breast Exam)

The history of breast cancer surgery is a grim chronicle of trial, error and slow progress. Lumpectomies have been performed since at least the 14th century. Rudimentary mastectomies are documented in the 19th century, including the mastectomy of Abigail “Nabby” Adams, the daughter of U.S. President John Adams, who underwent an early mastectomy while tied to a chair in her parents’ home with no anesthetic or antiseptic.

In the late 19th century, American surgeon William Halsted developed the radical mastectomy, removing the whole tumour in one piece along with the pectoral muscles, lymphatic vessels and axillary lymph nodes. While the procedure saved lives, it also led to pain and disability.

In the early 1930s, the modified radical mastectomy was developed, sparing some women pain by retaining muscle in the chest. Then, with advances in radiation and chemotherapy, research showed that some classes of patients who were treated with a lumpectomy (removal of tumour with an extra margin of tissue) and radiation had similar survival rates to women treated with only a mastectomy. As a result, in the late 1980s, the concept of breast-conserving surgery became more popular.

Before reconstruction became commonplace, women who had mastectomies were typically offered a range of prostheses – balls of cotton fabric and wool placed in the bra or bras with built in shelves and prosthesis.

Although surgeons in the first half of the 20th century experimented with reconstructions that used the woman’s own tissue (autologous reconstructions), it wasn’t until 1963 with the development of silicone breast implants that reconstruction surged in popularity. But these implants also created health risks and led to numerous recalls, explants and class action lawsuits.

They still carry risks and complications. Most recently, textured breast implants, which were used in thousands of procedures, were pulled off the market by Health Canada in 2019 because of a rare risk of lymphoma. Amazingly, some women have struggled to get provincial health coverage to have them removed. Women in the U.S. are similarly battling with insurers for coverage to have various types of breast implants removed.

In 1979, the first modern autologous breast reconstruction was performed, opening a door to alternatives for women choosing reconstruction. These procedures continue to carry risks, however, including limited mobility in sport as well as mastectomy skin flap necrosis (tissue death) that can cause scarring, deformity and lead to more interventions. A 2018 study of 2,300 Canadian and American women who had breast reconstruction between 2012 and 2015 found that women with autologous reconstruction experienced higher rates of complications than women with implants.

The choice to go flat has just recently begun to be normalized within the mainstream of cancer care. The term “aesthetic flat closure” was only adopted by the National Cancer Institute (U.S.) in 2020. And some of the loudest voices for a new approach have come from women who experienced flat denial. In Quebec, Marie-Claude Belzile wrote in 2017 that her experience inspired her to make change to health care in her community: “I had to fight with my breast surgeon to be flat. Even after I told him multiple times I wanted to go flat, he wrote on my surgery form ‘reconstruction, expanders.’ He finally respected my choice and did a good job, but the fight I had to go through should have never happened.” Belzile, who passed away in 2020 from metastatic disease, started a Facebook page called Tout aussi femme after being diagnosed with stage IV breast cancer. She also founded a French-speaking flat support group called Les Platines.

“Many women (opt out) for comfort, others are athletes and many women…want it to stay simple. Reconstruction is not a simple process,” says Attai, adding that in the past few years more of her patients, especially those with smaller breasts, are opting out of reconstruction.

Women who use their back muscles for work or athletics may be wary of latissimus dorsi flap surgery (which I was offered) because there is a risk it can compromise shoulder function. This and other procedures carry risks including infection and necrosis. Complications may lead to further interventions. In the U.S., one in three women develop a postoperative complication from breast-reconstruction surgery within two years and one in five require additional surgery. In five per cent of cases, reconstruction fails.

While a patient can give informed consent when knowing the risks, too often breast cancer patients have not been made aware of those risks. The UCLA study found that just 14 percent of patients were aware of potential complications of reconstruction – but 57 percent reported that they had been informed of the potential benefits to reconstruction procedures. The team concluded that: “Implementation of uniform surgical management and improved respect for patient consent in this population would result in significantly improved patient experiences.”

I was interested to see the word consent in the UCLA paper. While breasts are a part of gender, sexuality and reproduction, terms like choice, consent, shared decision-making and autonomy – common in the lexicon of gynecology – seem less common in breast cancer care.

I asked Todd Tuttle, a professor of surgery at the University of Minnesota, whether professional organizations in the field of breast cancer would be offering more guidance on fostering informed decision-making. “They’re going to have to,” he said, pointing out, “we’ve moved from paternalism, where the treatment plan was basically dictated by the surgeon often to the woman’s husband,” toward an atmosphere of greater choice and autonomy for patients. Tuttle notes that whether patients decide to have reconstruction or go flat, one key quality of life indicator is whether they felt they were able to have a real choice in the decision.

“If you give them enough time and enough information, they’re more likely to be happy five years afterward and they’ll feel like they made the right decision. Those people who are not satisfied often felt rushed or pushed,” he says. “I think time is probably one of the most important aspects of shared decision-making for breast cancer.”

In Canada, our underfunded systems lead to a different kind of rush. In seeking to care for everyone but with limited resources, our clinics lack capacity. Time often seems like a luxury – but with reconstructive surgery, waiting can actually help mitigate risk. A 2018 study found that patients who delayed reconstruction were significantly less likely to develop complications than those who chose to do their reconstruction immediately.

“I think we don’t talk as much with patients as we used to,” says Tuttle. “There’s all this documentation on electronic medical records and doctors are trying to get all that done instead of just talking to patients. The only way you can have those (important) conversations is by taking your time and listening.”

As we spoke, I thought back to the day of my diagnosis. I had brought a list of questions to the appointment (which I attended alone, due to COVID restrictions). My doctor pulled out a pen and wrote a series of quick notes about the specifics of my diagnosis … on the room’s examining table paper. After he rushed off to see other patients and I was alone in the room, I carefully tore the examining table paper, folded it and put it in my purse to read later with my husband. When I got home, it was inscrutable – an experience we would have again when results were posted in the online Patient Portal.

It was all information, to be sure. But it didn’t replace a conversation.

I switched to a different hospital, with a doctor who scheduled an in-depth introductory Zoom meeting about my care and choices. I remember being grateful that she took the time. I also recall that this conversation took place at 8:30 p.m. My new provider was making time for her patients by working after hours. Most likely, it was the only way she could.

“The problem with breast cancer is you have to make these irreversible life decisions in a really short time,” says Tuttle, “and you’re making the decisions at probably the most stressful point in your life.”

Throughout breast cancer treatments, our relationship with our bodies changes. During chemo our hair falls out, our weight fluctuates, bizarre things happen to our fingernails and skin. We get sick and sometimes can’t stay awake. The radiation burns us; those put into chemical menopause are doused in hot flashes. Pain and discomfort are part of the whole deal. And while there are some small decisions we have control over during treatment, most of us simply take the treatment plan handed to us if we want the best chance to get well. The choice of whether to reconstruct or go flat is different. This decision isn’t about fighting cancer; it’s about healing from the fight.

After my lumpectomies for synchronous bilateral cancer, I was offered a reconstruction. Because they removed more tissue from the right than the left, the plastic surgeon’s plan was to recreate a symmetry between my right and left breasts. But this choice would have involved a lot more than ticking off a box and signing a consent form (which I was offered in a flurry of papers before even seeing the consulting plastic surgeon) – and after months of cancer interventions that had too often kept me away from family and work, the thought of more surgeries exhausted me. I was ready to start reconnecting with my body, which already had become a site of multiple, difficult interventions. For me, rebuilding my relationship with my body didn’t involve rebuilding my breasts.

I was also not convinced by BRA Day’s claim that I could “close the loop on breast cancer” with plastic surgery. As I write this, I have a 20-year prescription for preventative meds in the hopes of staving off metastasis. Breast cancer is a part of my life now. What if, instead of “closure” through a facsimile of my pre-cancer body, I strive to accept the myriad ways that fighting cancer has changed me? Could accepting my post-treatment body help make the reality of survivorship easier, too?

Some of my concerns were like those of Isabelle (who chose not to use her last name), an Ottawa patient whose choice to go flat was supported by her health team. “I made the choice to have prophylactic mastectomies because I have a high risk of developing breast cancer, and I watched my mother die from it,” she told me. “That part of the choice was easy. What I had not really considered was the reconstruction.” In debating a post-mastectomy plan, she said, “I didn’t want to do anything that would require a long recovery, multiple surgeries, time away from the sports and activities I love … Going flat meant that I would not take any additional risks with my health.”

Isabelle echoed a common theme among women who go flat: a sense of wanting to move on with life. “I don’t feel like I am losing my femininity, that I will look like less of a woman,” she said. “My breasts fed my two babies … Now I want to be around for those babies for as long as I can.”

With all the aspects of cancer we don’t have control over, the aesthetic decisions carry an extra weight; they’re personal, yet they also have cultural meaning. As Belzile wrote: “My vision is that the more we speak out about our realities and our fights, the more it’ll change the culture and society … I see a way for getting visible to each other and to others and get validated for who we are. I see a future where women are respected and taken as the only person competent on what’s best for her.”

Back in the waiting room, my mind travels to my visit a year ago, waiting to go down the hall for surgery. X-rays of my tumours would be taken in surgery that day and sent to me later via a secure hospital server. I opened the images late one night and was struck by their appearance, like variegated blossoms in white and black – excised and sampled for cells to see if they got it all. They tried to get it all. We tried, all summer, fall and winter. Did we? I wonder: Did we get it all?

I open my eyes and look around the room. Every face tells a story and everyone here is waiting for some kind of news. Here, our breasts are imaged, mapped and ultrasounded, pressed in the mammogram machine, deconstructed in biopsy. We sit patiently, hold our breath; we bleed, blink back tears. Then at the end of the appointment, we take the elevator down and step back into everyone else’s world to find our way. To reconstruct, resurrect or rediscover who we are.

This story was originally published on healthydebate.ca

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For as long as I can remember, I’ve felt like I needed to catch up on sleep. That groggy, just-woke-up feeling many of us have in the early morning sometimes drags on for hours or even persists all day, even after a good night’s sleep, no matter how many coffees I down. Now in my late thirties, I feel like the word “tired” is a key part of my identity.

There’s a wide range of reasons people lack energy during the day, but we’re here to help you figure out why you’re so sleepy—and hopefully how to fix it.

What is “bad sleep,” anyway?

If you wake up feeling refreshed and able to carry out your daily activities without being too tired, that may be a sign that your sleep health is pretty good. But if you wake up feeling like you’ve run a marathon or were up all night (and maybe you were!), that’s a red flag, says Mark Boulos, a neurologist and sleep health expert at Sunnybrook Hospital in Toronto.

“People come with different levels of energy, and every one of us is very different—we all need a different amount of sleep,” he says. “But if you’re so tired that you don’t have the ability to carry out tasks, that’s obviously a big problem.”

Many individuals monitor their sleep using an app on their smartphone, a smartwatch or a fitness tracker—not a bad idea, Boulos says, but not the same as comprehensive testing in a sleep lab. “These products will give you a general idea of how well you’re sleeping, but not the nitty gritty of what sleep stage you’re in,” he explains. “They can’t tell you if you have sleep apnea.” If a formal sleep study is needed, your family doctor can refer you to a local sleep clinic.

I swear I’m sleeping eight hours a night. So why am I still so tired?

There are many reasons people feel tired, Boulos says, and both medical and psychological factors may play a role. A doctor may review your prescriptions and order several different blood tests, including checking your ferritin (iron) and various vitamin levels. If you’re found to have an iron deficiency, your medical professional can recommend different types of iron supplements to help reach the level that’s right for you with minimal side effects (iron supplements can cause an upset stomach for some people). They may also screen you for potential thyroid issues, like hypothyroidism, which can cause exhaustion as a main symptom.

To help a patient identify and treat their sleep issues, Boulos looks for signs of an underlying sleep disorder as well as physical markers. “Are you snoring?” Boulos asks. “If you’re a loud, noisy sleeper or you’re witnessed not breathing in sleep, it could be sleep apnea.”

Having the urge to move your legs constantly while trying to drift off can be a sign of restless legs syndrome—a condition that occurs in approximately seven to 10 percent of the population, and has been linked to anxiety and depression. Individuals who are dealing with long COVID may also experience sleep issues, as the virus can affect the part of the brain that manages sleep. “It’s unfortunate—but also uncommon,” Boulos says.

Should I be sleeping more?

While logging extra hours in bed to make up for poor sleep may sound good in theory, it’s not always a healthy choice. “Getting more than nine hours of sleep [on a regular basis] is harmful for you, and less than six hours is also harmful,” Boulos says, reiterating that most health associations recommend seven to nine hours of sleep per night for adults. “The extremes are not good.” Boulos also advises maintaining the same sleep schedule throughout the week—11 p.m. to 7 a.m., for example—so try not to stay up super late on Saturday nights (or stay in bed until noon the next day).

If you’re an active dreamer, you may feel like you’re not getting the kind of deep sleep you need—almost like your brain hasn’t rested properly—but that isn’t actually the case, according to Boulos. “Dreaming is not necessarily related to sleep quality,” he says. Dreams happen during the REM stage of sleep, which is particularly restorative and good for your body. Other indicators, like how tired you are during the day, or how often you wake up in the night, are more reflective of sleep quality.

“If you’re having poor sleep, get it checked out by your family doctor,” Boulos advises. “You may need a referral to a sleep specialist.”

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