Tuesday, December 11, 2018

Xarelto & Menstruation (or What I Learned as a Premenopausal Woman Having Periods on Blood Thinners)

This is an uncharacteristically personal blog post, but my hope is that the next active, menstruating person who is put on blood thinners and searches the internet for "blood thinners and periods" finds the info I wish I had in the beginning.

I'm also a science teacher (not a medical doctor), and I do get a little over-enthusiastic describing the physiology involved in these topics.

If you are a current or former student, or just squeamish about medical stuff: be forewarned, I'll be discussing my periods and a lot of bleeding, so if that creeps you out, don't read it. :)

And, finally, if you don't feel like reading the whole post, just know that Heavy Menstrual Bleeding (HMB) affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on anticoagulation (source). So, if you are still menstruating and are put on blood thinners (especially NOACs such as Xarelto which carry a high risk of HMB), do yourself a favor--keep a menstruation journal and check in with a gynecologist ASAP. From what I've experienced and read, your cardiologist is not going to ask you about your periods--so you will want to bring it up.

If you are interested in the scientific details, I recommend the journal article How I treat heavy menstrual bleeding associated with anticoagulants (Blood, 2017).

I also recommend this blog by another younger woman on blood thinners: Blood Thinners and Periods – What Your Doctor Failed to Tell You. She shares, "Out of the 7 doctors I’ve interacted with, only 1 mentioned menstruating on blood thinners being possibly different than without." My experience was similar, but with fewer doctors.

Here is an outline of this post:
  • PART 0: Varicose Veins and Blood Clots 
  • PART 1: Learning About Blood Thinners
  • PART 2: What I Wished I Knew From the Start
  • PART 3: Learning About Menstruation (on Blood Thinners)
      • How heavy is too heavy?
      • Where is this blood coming from?
      • Why (menstrual) clots?
      • What are my options?
  • PART 4: Solutions and Take-Aways (spoiler alert: it involves an IUD)
      • SOLUTION 1: Reclaiming my periods (mostly)
      • SOLUTION 2: Reclaiming my independence

PART 0: Varicose Veins and Blood Clots


I have a history of superficial venous thromboses (SVT). As their name suggests, these blood clots are superficial, located just below the skin’s surface and, unlike deep vein thromboses (DVT), are not life-threatening. Superficial vein thrombophlebitis (swelling associated with clots) is generally caused by an injury to the vein and appears in veins where blood flows slower than normal, such as varicose veins (this decreased blood flow is also called venous insufficiency). However, it is worth noting that most people with varicose veins do not develop thromboses (clots).
Even a slight injury can cause a varicose vein to become inflamed. Unlike deep vein thrombosis, which causes very little inflammation, superficial venous thrombosis involves a sudden (acute) inflammatory reaction that causes the blood cot (thrombus) to adhere firmly to the vein wall and lessens the likelihood that it will break loose. Unlike deep veins, superficial veins have no surrounding muscles to squeeze and dislodge a blood clot. For these reasons, superficial venous thrombosis rarely causes a blood clot to break loose (embolism). (source: Merck)
So, though they are painful and annoying, my superficial clots are not going to kill me. As stated above, they are not likely to contribute to a pulmonary embolism (PE), a life-threatening condition where a blood clot in the leg breaks loose and travels through the bloodstream to the lung. People show have a unprovoked DVT/PE can be put on blood thinners for life. I was only on blood thinners for three months.

Venous Ablation
I've had a lot of superficial clots, beginning in my late 20s. I had a venous ablation in my right leg 10+ years ago and wear 20-30 mmHg medical compression stockings on both legs most days--especially on airplanes, long car rides, or days where I do a lot of sitting (such as parent-teacher conferences). If you are interested, you can read more about radiofrequency ablation therapy for varicose veins here -- they basically use radio waves to heat up, destroy, and collapse your great saphenous vein (I recommend that link--it includes a very cool body map).

In August 2018, I felt a familiar pain and an ultrasound confirmed I had three new clots. This time, with my history of SVT, my vein doctor wanted me to go on blood thinners and follow through with the (previously optional) left leg ablation. So, that's how I ended up on Xarelto (generic name: rivaroxaban).


PART 1: Learning About Blood Thinners

 

I knew nothing about blood thinners except that "old people" took them. According to WebMD, "about 2 million to 3 million people take blood thinners every year."  According to doctors and pharmacists I talked to, the majority of these people are older adults--mostly men, and women who have gone through menopause. I imagine this is why heavy menstrual bleeding (HMB) seems to rarely be discussed at appointments or in the literature.

Blood thinners (or anticoagulants), despite their name, do not actually thin the blood; nor do they dissolve existing clots. They do interfere with blood clotting in general, they can help prevent new clots from forming, and they keep existing clots from becoming larger. This gives your body time to remove the clot on its own by activating a protein (plasmin) which breaks down the fibrin mesh (on the outside, we recognize fibrin in a scab). Anticoagulants are different than the so-called "clot-busting" drugs (thrombolytics) that are used in the case of heart attack, stroke, or massive pulmonary embolism--those drugs activate plasmin to actually break up the clot ASAP.

Here's a (rather complex) overview of how clotting works:
The coagulation cascade is triggered by tissue factor release from tissue trauma or vascular injury. Tissue factor in the presence of calcium forms a complex and cleaves clotting factors X and IX to their activated forms (factors Xa and IXa). The prothrombinase complex is then assembled and cleaves prothrombin (factor II) to factor IIa (thrombin). Thrombin is one of the most potent activators of primary (platelet-mediated) and secondary (clotting factor-mediated) hemostasis (stopping of blood loss, or clotting). (source)
Thrombin facilitates the conversion of a soluble plasma protein called fibrinogen into long, insoluble fibers or threads of the protein, fibrin. Fibrin threads form "an interlocking network of fibers and a framework for the clot. This net of fibers traps and helps hold platelets, blood cells, and other molecules tight to the site of injury, functioning as the initial clot." (source)
Xarelto is a direct factor Xa inhibitor.

I learned that blood thinners (anticoagulants in particular) generally include three types:

(1) vitamin K antagonists - these are perhaps the most well-known and work by reducing your body’s ability to make vitamin K. Without vitamin K, your liver has trouble making blood-clotting proteins. It is also necessary to have to have your liver monitored while taking these, and you have to be careful about what you eat--particularly around foods high in vitamin K.
  • Warfarin (Coumadin)

(2) Heparins - it is my understanding that this is administered through IV or injections at home. Heparins keep one of the clotting proteins, thrombin, from doing its job.
  • fondaparinux (Arixtra) , inhibits factor Xa
  • unfractionated heparin (UFH)
  • low-molecular weight heparins (LMWH) 

(3) non-VKA oral anticoagulants (NOACs) - These are newer, easier to take (pill form), and require no dietary restrictions or extra monitoring. (Us "younger" folks are most often put on NPACs now.) Plus, when you stop Xarelto, it is out of your system within 24 hours. NOACs keep your body from making fibrin, the protein the forms the clot’s mesh.
  • dabigatran (Pradaxa®)
  • rivaroxaban (Xarelto®)
  • apixaban (Eliquis®)
  • edoxaban (Lixiana [Europe/Asia], Savaysa [Nth Am]).

Some of these blood thinners, mostly older anticoagulants, have antidotes for when a person on anticoagulation has major bleeding, or when there is a need for urgent surgery (source). Most internet searches on Xarelto highlight that, for at least a long while, Xarelto did not have an antidote. This terrified me. (I was afraid to fall in a bike accident and bleed to death (irrational, but true). I didn't know what would happen if I was in a car accident.) Ends up Andexanet alfa was approved as antidote for Factor Xa inhibitors Xarelto and Eliquis in May 2018, under the trade name AndexXa. PHEW. 

Finally, you cannot take Ibuprofen, Naxopren (Aleve), or any other nonsteroidal anti-inflammatory drugs (NSAIDs) while taking blood thinners, as these medicines also thin your blood.

When you go on blood thinners, doctors seem to suggest getting (1) an electric razor and (2) a soft toothbrush, to minimize bleeding. I certainly wish my doctor had also added (3) an appointment with your gynecologist. One recent article clearly states, "Premenopausal women should be advised of the potential effect of anticoagulant therapy on menstrual bleeding at the time of treatment initiation." But that didn't happen in my case and I certainly did not expect what happened next.


PART 2: What I Wished I Knew From the Start


I never talked to my doctor in person initially about blood thinners. He prescribed them over the phone and scheduled a follow-up appointment in 3 weeks. Those three weeks were full of a lot of (scary) bleeding and anxiety. We'll get to the heavy periods later, but it ends up the symptoms of anemia - tiredness, dizziness, light-headedness, fatigue, shortness of breath, irregular or fluttering heartbeat - seem pretty similar to the symptoms of anxiety. So, it was hard for me to tell if I was losing too much blood, or just freaking out about it.

At the 3-week visit, the doctor stressed to me that Xarelto (or any blood thinners) do not make you any more likely to start bleeding. Rather, once I started bleeding, it would be harder to stop. (Apparently, older men often complain of blood in their urine when starting blood thinners, but that is most often due to a pre-existing, yet undiagnosed, condition.) I don't randomly start bleeding, I seldom fall off my bike--why would this be any different on Xarelto? (The light-headedness from blood loss/anxiety was one reason I did stay off the bike for a while.)

The doctor also confirmed that Xarelto did have an antidote (PHEW) and that he has only had to use it once in his career thus far. Xarelto is out of your system quickly (within 24 hours) making it different than the older blood thinners. (In fact, the doctor had me take my last Xarelto the day of my venous ablation, a minor surgery. Weird.)

Finally, and most relief-worthy, the doctor shared that Xarelto had a lower risk of cerebral (brain) bleeds than older blood thinners (like warfarin), though a slightly higher risk for gastrointestinal bleeding; BUT nothing I did from the neck down would be life-threatening. He said, "If you fall off your bike and skin up your legs, it's going to bleed for a while and look really scary, but it is not ultimately going to be a problem." He stressed that only if I hit my head, or fell super-awkwardly on a joint, should I take myself to the ER.

I'm not going to lie to you, when I got my first good cut on Xarelto (skinned my heel), I was a wreck, not knowing what to expect (spoiler: it bled a lot). However, what I learned next about periods made my superficial concerns laughable....

Finally, I also wish I knew what was "normal" and what was "too much" for a menstrual period. I don't typically talk to other women about how much they bleed. In hindsight, I've always had relatively heavy periods lasting 5-8 days. But when I found myself unable to change a tampon without blood running down my hands and dripping on to the floor on day 4 of my first Xarelto period, I figured I had a problem. The days following confirmed that this. was. not. normal.

I've since learned that "A normal menstrual cycle is defined in terms of frequency of 24 to 38 days (the regularity of which can vary between ± 2 and 20 days) with a duration of flow between 4.5 and 8 days and a volume of monthly blood loss between 5 and 80 mL per cycle."

Heavy menstrual bleeding (HMB) happens when you have:

  • Bleeding that lasts more than 7 days.
  • Bleeding that soaks through one or more tampons or pads every hour for several hours in a row.
  • Needing to wear more than one pad at a time to control menstrual flow.
  • Needing to change pads or tampons during the night.
  • Menstrual flow with blood clots that are as big as a quarter or larger.

Yep, I had all of that.


PART 3: Learning About Menstruation (on Blood Thinners)


Those first weeks, when I was worried about superficial cuts or unlikely head trauma, I severely underestimated how this all worked with menstruation (most people on blood thinners, as mentioned, are men or post-menopausal women). I realized later, despite being a science teacher, that I did not even really understand how periods worked. It was wild, kinda scary, and I learned a lot.

How heavy is too heavy?

On the aforementioned Day 4 of my first Xarelto period, I was scared. I made the mistake of Googling "Xarelto and periods." Don't do that--it's terrifying. I kept my Googling to more scientific search terms and learned a lot from this article Heavy menstrual bleeding: work-up and management.

The CDC page states, "Menorrhagia [now called HMB] is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. How do you know if you have heavy bleeding? If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding. If you have this type of bleeding, you should see a doctor."

Let's talk about clots for a minute. Normal menstrual clots are smaller than a quarter and only occur occasionally, usually toward the beginning of your menstrual cycle. Abnormal clots are larger than a quarter and occur frequently. (source) By day 5, I was passing some gnarly clots (I'll spare you the details). By then, I was also keeping a menstruation journal and documenting EVERYTHING (times, size and number of pads/tampons, percent filled upon removal, frequency and estimated diameter of clots. I calculated approximate volume blood loss using the measurements below--I was WAY over 80 ml for that first (and second) cycle.

Regular absorbency tampons: 6 to 9 grams
Super absorbency tampons: 9 to 12 grams
Super plus absorbency tampons: 12 to 15 grams
Ultra absorbency tampons: 15 to 18 grams

By the second week, I had made an appointment with a gynecologist. My vein doctor (a cardiologist) had been rather dismissive about the bleeding, asking (not unkindly) if I could just "tough it out." My primary doctor backed off all together, saying that it was not her area of expertise and that I should find a gynecologist who takes my insurance. I just wanted to bleeding to stop.

That first period was 10 days long, with three of those days (thankfully two on the weekend) involving setting a timer for every 1.5 hours (including throughout the night) to swap Super+ tampons before they'd leak onto the backup pad. Most of the time, I made it in time. Work (teaching middle school) was a challenge--it was hard to raise my voice without feeling light-headed, I occasionally I had to leave the room to lay down when I felt like I was going to faint, and I had to very strategically plan my bathroom access. And remember, you can't take Ibuprofen or Aleve ... Tylenol is better than nothing, but it just wasn't the same.

Where is this blood coming from? (or the shedding of uterine lining):

I did not know where all the blood was coming from. I asked my gynecologist that first visit, bewilderedly, "Is it coming from my veins?!" Her answer was "sort of." It was actually coming from my arteries.

Most of us learned that menstruation typically occurs in a 28-day cycle. Something like: "During the follicular phase (days 1 to 14) estrogen levels rise, the uterine lining (endometrium) thickens. During the luteal phase (days 14 to 21), the corpus luteum (CL) produces estrogen and progesterone. If fertilization does not occur, at the end of this 28 day cycle, the lining sheds." You've probably even seen a diagram like the one below:


Boy, did I not understand what was happening during that whole "shedding of the lining" part. Ends up, there are a lot of blood vessels involved, and those blood vessels need to clot in order to stop the cycle's bleeding.

I learned that the endometrium consists of two layers, the top being called the "functionalis layer." These layers are supplied by arteries.


image source (obgynkey.com)

As the menstrual cycle progresses, these arteries grow at a faster rate than the endometrial layer, resulting in coiling of the arteries. Near the end of the menstrual cycle (day 27), the coiled arteries get so coil-y that they constrict, and cut off blood flow (vasoconstriction) to that layer of the endometrium (endometrial hypoxia) and that layer dies. We experience the subsequent breakdown and and expelling of tissue as our period. Menstrual bleeding is generally arterial rather than venous bleeding. This source gets into waaaay more detail about all this, if you are interested in reading more.

I also had a scare when I remembered an embryology video I show in my science class... as the yolk broke from the follicle, a blood vessel burst (this is why you sometimes get those red dots on your egg yolks). I emailed my gynecologist and asked, "is there bleeding during ovulation?"  She said, "The risk of bleeding into the corpus luteum is slightly elevated, but your body should still be able to naturally stop that bleeding. Most people on blood thinners do not have issues with bleeding into corpus lutea. However, if it happens, symptoms include: Abdominal bloating, abdominal pain, lightheadedness, palpitations."  Once again, symptoms of the new IUD? Or anxiety over the blood thinners? Ugh.

So, here I was worried about a superficial cut on my heel, when my uterus was basically free-bleeding and there was nothing I could do about it. In fact, rivaroxaban (Xarelto) has a high instance of uterine bleeding occurrence (the bleeding rate was estimated at 29.8 percent) (source)


Why (menstrual) clots?

I was curious about the clots. I didn't understand... if I was on blood thinners, wouldn't I have fewer menstrual clots, not more? Turns out that "as the uterine lining sheds, it pools in the bottom of the uterus, waiting for the cervix to contract and expel its contents. To aid in the breakdown of this thickened blood and tissue, the body releases anticoagulants to thin the material and allow it to pass more freely. However, when the blood flow outpaces the body’s ability to produce anticoagulants, menstrual clots are released." (source)

If the bleeding is heavy, clots have time to form in the "pool," but the anticoagulants do not have time to act — so the blood clots.

What are my options?

Recently, HMB-related therapies (especially in anticoagulated patients) include hormonal therapy, tranexamic acid, anticoagulant management, and surgical interventions.  (You can read more details here.)

Basically, a thinner uterus lining will mean less bleeding.

Source: Management of Heavy Menstrual Bleeding on Anticoagulation

Surgical interventions

When in doubt, take it out. "Hysterectomy is the definitive treatment of HMB." (source) Apparently, if you were on blood thinners for life, the go-to option has been a hysterectomy (removal of the uterus) or endometrial ablation (removal of the thin layer of tissue that lines the uterus), both of which prevent your from ever having children in the future.

Tranexamic acid (US Brand name: Lysteda)
Tranexamic acid (an antifibrinolytic agent) works by blocking the breakdown of blood clots, which prevents bleeding. Apparently, it is taken three times a day for the first few days of the period. (People with the bleeding disorder von Willebrand’s disease are familiar with this treatment.  Side note: this disease is also under-diagnosed in men, since they do not menstruate or give birth.)

Anticoagulant management
Sometimes, doctors will recommend reducing the dose or skipping a couple doses during the start of your period. (Don't do this without consulting your doctor, as it may increase the risk for dangerous clots.) Or consider decreasing the DOAC blood thinner dose all together after the initial three months of full-dose anticoagulation

Hormonal therapy
It has been common practice to avoid prescribing hormone therapy and anticoagulants at the same time, but it is not well-studied. Many studies are now saying hormone treatments (like the birth control pill) are fine when taking a therapeutic dose of blood thinners (prevents clots anyway?).


There are a number of options but "the levonorgestrel intrauterine system (LNG-IUS, Mirena) is the most effective medical intervention for HMB and is recommended ... as the first-line option for HMB in women who also require contraception." This device diminished menstrual bleeding in more than 80% of women, but with intermenstrual bleeding in almost half of the women.

The Mirena (brand name) works by continuous release of 20 μg levonorgestrel every 24 hours, and reduces endometrial (the lining of the uterus) growth. The most common side effect associated with LNG-IUS and reason for discontinuation of treatment is menstrual irregularity, usually prolonged bleeding/spotting in the first 3 months. This may persist for a longer period in women with HMB. (Cohen, 2016) Levonorgestrel may also prevent ovulation (release of an egg from the ovaries) in some women." (source)

It's worth noting that some IUDs, such as the non-hormonal coper IUD, can actually make your periods longer and heavier. So, Mirena is the way to go. (Here's a nice IUD pros and cons list.)


PART 4: Solutions and Take-Aways (spoiler alert: it involves an IUD)



SOLUTION 1: Reclaiming my periods (mostly)

I had never even considered an IUD. I vaguely have heard negative things about it, and I wasn't all that interested in having a device in my uterus. Plus, the pill just always seemed an easier way to control my periods and provide birth control. (My doctors still do not agree if the pill actually triggered these most recent clots, since the pill is more commonly associated with the risk of unprovoked, life-threatening clots.  My clots were provoked by, presumably, my misbehaving veins. To be safe, we decided I won't take estrogen-containing pills again.)

14 days into Xarelto, I didn't care. I just wanted the menstrual bleeding to stop.

Despite there being many progestin-only options (here's a nice overview), the IUD seems to be the crowd favorite. "An advantage of the levonorgestrel IUD is that there is very little systemic absorption of the progestin. Nonetheless, menstrual blood flow is reduced 71% to 95%. Reduced menstrual blood flow has been confirmed in women with bleeding disorders and in women on anticoagulation." (source)

I met my (brand-new, internet-searched) gynecologist on a Tuesday; my Mirena was placed on that Friday during my lunch hour -- I returned to school and finished teaching that day.

My second period (post-IUD) was also 10 days long, but with slightly fewer clots. The third period (after a full month with the IUD) was only 5 days, I was bleeding less, and felt much less light-headed! However, the intermenstrual bleeding (presumable from ovulation, or as a side effect of the IUD) was pretty constant, I basically had my period all but 14 days over a 3-month time frame. It got old, let me tell you.  But, it also was a tolerable "new normal."  I even got to joking about it.

If you decide to go the IUD route, I also recommend not Googling "IUD insertion" before you go -- some women, especially those who have never had children, describe it as the "worst pain in their life" (What Getting an IUD Really Feels Like, According to 13 Women) whereas the mommy-blogs rate the pain a 1-2 on a scale of 10. (Not sure if that's due to physical changes in the cervix, but I suspect that, once you have a child, your pain scale is significantly and permanently altered.)

The insertion wasn't pleasant, but it wasn't that bad (for me). Through the insertion process, only the last step was biting-sharp, but over quickly. I also couldn't take the recommended dose of 600 mg of ibuprofen before insertion, so that was a bummer. My doctor also took a vaginal ultrasound to rule out uterine perforation--this would be bad news on blood thinners! As mentioned, it was quick and I went back to work that day. I even helped a friend pack on Saturday. It is still not always 100% comfortable, but it is better than bleeding all the time.


SOLUTION 2: Reclaiming my independence

After almost two months of worrying, I told myself I couldn't live like this. I picked up some gauze pads and bandage rolls and threw them in my bike bag, in case of a spill.

I also ordered a medical ID bracelet (here is the one I chose) to wear when I was out alone. Again there is not that much out there for younger, active folks, but I figured it couldn't hurt in the case of an accident. I choose "blood thinner" on the outside, since "Xarelto" is probably not a recognizable name. I added a label to the inside with the dosage, in case I was ever in need of emergency responders.




Finally, I switched my dosing to nighttime. After the initial 2x dosing, I continued to take my once-a-day in the morning, since the meds had to be taken at the same time each day, and with food. For convenience, I was taking it in the morning and the doctor said that wouldn't be a problem. However, with the periods, I would have liked to have been told that "maximal anticoagulant potency might be better tolerated during night, when the risk to experience accidents or injuries" (or perhaps menstrual bleeding?) "is lower." (source)


CONCLUSION

My clots dissolved and I had the ablation done earlier this month--I could write a whole other post about dealing with health insurance. The bruising (internal bleeding) was extensive but I now have been off blood thinners for the last few weeks and the bruises have just about faded. (My ultrasound tech said, three days after the procedure, that "You are lucky, some folks on Xarelto look like they've been hit by a truck after ablation!")

I still have the Mirena IUD and it will be interesting to see how it manages my periods long-term. So, far I am enjoying my 10th day in a row without bleeding.

Looking back, once the periods were under control, I had less light-headedness and, presumably, less anxiety. In fact, by the 2 month mark, it just became a "new normal." I feel fortunate that my experience was short-term and I hope my research can help other menstruating people learn about heavy menstrual bleeding and anticoagulation (periods and blood thinners!).

If you've read this far, you might also be interested in this other blood-clot-related news, published about one week after I got off blood thinners: Doctors Aren’t Sure How This Even Came Out of a Patient: somehow, a man coughed up an intact blood clot shaped like a lung passage (Atlantic, Dec 6, 2018)

Bodies are fascinating. 

Wednesday, July 12, 2017

Pruning, Procrastination, and Prioritization

It's been a couple of years and I've had a lot of jobs, but the dust is clearing and I've revisited this blog once again. I thought it worth running a post I wrote years ago. Looks like a lot has(n't) changed in 4 years--the pruning is long overdue.

Originally published 2.18.13:

So, my blog has been sorely neglected over the past few years.  Right now it is cluttered with draft posts, links and images in a private Tumbler of ideas.  Sprinkled throughout is the occasional posts, released in a burst of creative energy and prioritization.  However, my blog is mostly neglected as the demands of teaching relegate it to the back burner.

My blog is also competing with the immediacy of social media.  Share a link, or toss up a shortened URL on Twitter, and one quickly receives feedback and commentary from the crowd.  As immediately gratifying as this may be, it doesn't really take the place of blogging, a process that (at its best) forces me to consider multiple sources before assimilating those ideas with my own viewpoints, distilling them to what matters in my particular context, and then writing them down. I don't really blog for the crowd; I do it for me.

Public Domain
And, so, in resurrecting this blog, I've considered the analogy of the Phoenix - that mythical bird with its colorful plumage and a tail of gold and scarlet. The bird that, at the end of its 500 to 1000 year life-cycle, builds itself a nest of twigs that it then ignites; "both nest and bird burn fiercely and are reduced to ashes, from which a new, young phoenix or phoenix egg arises, reborn anew to live again."  (Wikipedia)  It's tempting to just destroy this blog and start anew, creating a new space from its ashes, but that analogy was not quite what I was looking for.

I've considered, instead, the act of pruning bushes. This seems more apropos to my goals.  The University of Rhode Island offers this Pruning Guide.  "Pruning is a regular part of plant maintenance involving the selective removal of specific plant parts."

CC-BY-SA by Hirvenkürpa
Why prune?  The site goes on to offer these reasons:

1) To improve the appearance or health of a plant.
2) To control the size of a plant.
3) To prevent personal injury or property damage.
4) To train young plants.
5) To influence fruiting and flowering.
6) To rejuvenate old trees and shrubs.

That's what my old blog needs - rejuvenation! I started blogging nearly 7 years ago, and over the years have more clearly focused my ideas and vision as a teacher.  I plan to start by pruning away those previous posts that serve as a distraction to my professional goals.

Then, perhaps, my blog will grow healthier and stronger than before.  Of course, this requires that I actually write.  And teaching tends to fill up my to-do list, leaving little time for much else.  However, it's good to have goals.

Friday, July 11, 2014

A few words on classroom organization

Like most teachers, I love teacher discounts.  And office supplies.  And containers. So, imagine my glee when I read about The Container Store's Organized Teacher's Summer Sweepstakes  (Unfortunately, it seems that "A total of one winner will be selected in a random drawing from all eligible entries received." but I'll write this post anyway.)
We’re honored to support teachers’ efforts through our Organized Teacher Discount Program. In fact, we’re going to give one lucky teacher a $1,000 organized classroom makeover from The Container Store!
Let's begin here.  This is a picture I recently took of my middle school science classroom. On Facebook, I included the comment "This is my classroom on July 6th, 2014. In an apocalyptic, time-capsule-y way, I have not touched it since the last day of school on June 6th. I suppose I should get in there and make some progress..."  This room is a busy place during the school year and is desperate for organization.


It's not for lack of trying.  All of the shelving in my classroom (see photo below) came from Berkeley Outlet or Urban Ore, both local and specializing in used/recycled furniture inventory. I've even used cardboard boxes and duct tape to "custom build" shelving underneath tables for more storage.  There are bins with raw materials everywhere - cardboard, computer keys, wire, LEDs, felt, batteries, styrofoam, duct tape - all the tools of art and ingenuity.  During science fair season, there are projects literally everywhere!  


My favorite repurposed item is this shelf unit (below) from my roommate - she was redecorating at home and I let her know I could put it to good use in my classroom. It has now become our makerspace (read the whole story here.)   I have put thousands of dollars (out of pocket) into materials this year, but my classroom is finally well on its way to being the creative, innovative space I've wanted and I truly believe kids need.  Students are constantly working on projects during lunch, recess, science class... they jokingly refer to my room as "nerdvana."  I spent $250 alone on those containers you see inside the makerspace.

Roommate's shelf turned makerspace
Transporting the desk piece
Having the materials in clearly labeled containers was just what I needed to allow the kids ownership over their workflow. They don't need to ask me where the soldering iron, snaps, or embroidery hoops are anymore - they just go grab what they need.  Our makerspace is a very busy, student-driven space.  With $1000 dollars to spend on organization, I would like to further develop this student centered strategy.  I would really like a solid shelving & bin system so that students can keep their many works-in-progress safe, yet easily accessible.  

I would also like to bring some order to what I affectionately refer to as our "fabrication studio."  Here's where the kids work with our 3D printers. I refurbished these tables from recycling and scavenged the various pieces of bins and shelving you see below.



I have many pictures of my science room (the kids often threaten to set up a time lapse in my room just to capture the ebb and flow of the creative chaos) but I will leave you with my favorite Container Store story.

In 2011, as I do every other year,  I hatched chicks and ducks as part of our embryology unit.  That year we ended up with a far better hatch rate than expected!  I knew I needed a bigger brooder.  Racing to the San Francisco store on my bicycle (I do not own a car) at 8:58 pm, minutes before closing, I asked for their biggest clear container. The sales person rang up my order, looked at my bike (propped inside the door) and asked quizzically, "How do you intend to get that home?"  I hadn't thought that far ahead; I was focused on the birds.  I figured I'd take the bus or something...

The saleswoman said, "Come here, I have an idea" and proceeded to strap the container to me like some sort of plastic turtle shell. She did such a great job, I put it back on in the morning to bike the nine miles to school the next day!   (She was pretty proud of herself and readily agreed to take a photo.)

(In case you want to see more pictures of ducks, check out our Flickr album - they don't get any cuter than our crew this spring!)





Recess in my room one day- kids from all grade levels tend to hang out here during free periods.


Monday, July 07, 2014

Embedding Slide Shows

So, I just finished my science bike post.  I was surprised to learn that I could no longer embed a slideshow from an album.  (Granted, I am a Flickr person and rarely deal with Picassa outside of the mandatory collections from this blog.)

Luckily, this blog post provided a solution. The author writes:

One of the great features of Picasa Web was that you could embed a Flash slideshow of your albums. Google would even give you the code to do it.  There was a button that said Embed and it would give you the code. Just cut and paste and you were done. 
With the migration to Google Plus Photos, this disappeared. 
Here's a work around. 
Use the following link to get back to the original PicasaWeb site:
https://picasaweb.google.com/lh/myphotos?noredirect=1
Hopefully the embed button makes a re-appearance, or Google leaves the old page up forever.

He also offers an alternate solution, if you want to go check it out.

Sunday, July 06, 2014

Science Bike

It has been six years since I've sold my car and relied almost entirely on my bicycle(s) for transportation.  (Occasionally, I'll still grab a Zipcar - like for this 10 foot gutter for science fair - see photo, right)  I am also very, very thankful for Amazon.

Bike commuting can get pretty interesting as a science teacher.  I rode with all of the bike loads below, except for the bike rack, science fair boards, ladder, and shelf/desk combo - it those cases, my bicycle served as my pack mule.

Thursday, June 12, 2014

Year-End To-Do List

School recently ended for our middle school - and another 10 months of blog post drafts piled up.  While I do believe in the benefits of pruning, there are a few posts of the posts that I will be working on over the next few weeks.  Here are some snapshots of the work in progress:
  • Impact of BPC in 3D: A 3D Printed Graduation Project (Tales of a 3D Printer, BPC STEAM)
  • BPC Visits 3D Robotics! (BPC STEAMspace)
  • More on Maker Faire (Tales of a 3D Printer)
  • 3D Printing Infiltrates the Science Fair (Tales of a 3D Printer)
  • Augmented Reality in the Classroom (Post-Its & Ponderings; BPC STEAM)
  • Ducks in the Science Room (BPC STEAM blog)
  • Tips on Hatching and Raising Ducks in the Middle School Classroom (Post-Its & Ponderings)
  • Ducks in my Makerspace (Post-Its & Ponderings)
  • Cardboard Arcade (Post-Its & Ponderings; BPC STEAM)
... plus whatever else I can publish in a timely manner.



Saturday, May 03, 2014

Science Fair with Maker Flair (and AR!)

Every year for the night of the science fair, I create a program that contains a little map of the projects plus a list of all the student abstracts. On the front of the program, I print a Wordle made from the text of the collection of abstracts.  You can see in the image below that this year's science fair had a distinct maker flair!  (For those of you who use Wordle, you might appreciate that this was my FIRST randomly-generated cloud!  Often I have to go through 25+ randomizations to find one I like for the cover.)

I've found it very valuable for the kids to write an abstract of their projects, especially for the relevance piece. (For some of them, this borders on creative writing... "My oobleck on a speaker will change the world because...")

     (1) what the objectives of the study were; [BACKGROUND]
     (2) how the study was done; [METHODS]
     (3) what results were obtained; [RESULTS]
     (4) and the significance of the results. [CONCLUSION]

I give my students a lot of freedom in choosing a topic that is personally interesting to them.  Many groups choose to do a traditional controlled experiment, but I always allow for more engineering-type projects as well.  It was exciting to note that this year (the first year we officially incorporated "Maker Mondays" into the science curriculum) that there were more maker-inspired projects than in previous years.



Here are some examples from this year's collection of abstracts 


Experiment Title: Parachute Shape Testing Eggsperiment   

Abstract:  We ran this experiment to see which parachute would work better. We made two parachutes: one out of a plastic bag, and one out of cardboard. We dropped them from 12.5 ft and timed how long it took for them to hit the ground. The plastic bag parachute average was 1.36 seconds and surprisingly lost to the cardboard parachute which had an average of 1.78 seconds before it hit the ground. We hope this will help future engineers build safer parachutes.


Experiment Title: The Radio 

Abstract:   We conducted a study to discover the antenna most practically shaped to receive millivolts and tried to build a working radio upon which to perform this test. Before working with the antennas, we had to assemble our radio. Then, we tried tuning into thirteen different stations and measured the millivolts each station received per antenna shape and recorded the results of the three best stations for each antenna. The results were unsurprising; the straight antenna had the best reception, followed by the spiral shaped antenna, and finally, the least functional antenna was the looped shape. Our radio was functional, and we determined that the straight antenna had the best and clearest range of stations. This project was significant because, although straight antennas were in use before, we confirmed that they are still the best shape to use commercially, saving future radio engineers time and energy designing new antenna shapes. 


Experiment Title: Measuring Electrolytes
Abstract: Our goal was to find out which of four drinks had the most electrolytes, by measuring volts. We did our project by creating a conductance sensor by using a multimeter, alligator clips, copper wire, and a 9V battery. We created a simple circuit so that when we put the two ends of our circuit into one drink, it would complete the circuit; we then recorded the voltage shown on the multimeter. We found out found that Powerade had the most electrolytes with 8.49V, then Odwalla Orange Juice with 8.4737V, then Powerbar Energy Drink with 8.4731V, and lastly Gatorade with 8.45V. The importance of this project  is that it will help athletes know which drink is best and which drink they should use to replace electrolytes after sweating and working out.  


Experiment Title: Pulse-Sensing Fashion
Abstract:  Our goal was to build a shirt equipped with LEDs that light up  up to the wearer’s pulse. We used the Pulse Sensor and the small Lilypad circuit board to achieve this goal. By programming the Lilypad and attaching the Pulse Sensor to it, we were able to make the LED read your pulse. Since we wanted to be able to display this in a cool and fashionable way, we decided to attach it to a shirt.  In the future, this technology could be used for heart patients in need of constant monitoring.


Experiment Title: The Multitasking Mind

Abstract:   We conducted a study to learn whether listening to music or other audio affects reading comprehension. We wrote four similar-length informational paragraphs about nonsensical things and questions to go with them. We took  subjects to a quiet place and gave them the tests in four conditions: no music, a pop song, a newscast, and a classical piece. After testing 32 subjects, we graded for accuracy on both spelling and content. We also measured the amount of time each subject took for each test. We have decided to disregard our data on the no audio condition because of the fact that we did all of the no audio tests first, and the practice effect affected the data.  The rest of our data showed that the subjects completed the worksheets fastest when listening to a pop song, and slowest when listening to a newscast. We believe this is because the pop song was musically the simplest and most predictable. We did not find any notable differences in the averages of the accuracy scores. The relatively small number of subjects and the wide range of scores may have obscured any differences that may have otherwise shown up in the data.


Another cool twist on this year's science fair was the addition of augmented reality (see recent post).  Using Aurasma, kids designed trigger images to add to their science fair boards.  When these trigger images were viewed through a device using the Aurasma app, videos appeared!

Of course, it is always best to hear from the kids themselves, but during the times they were not stationed at their board, family, friends and colleagues could hear about the project - in the voices of the kids themselves!  Very cool.





Plus, after the fair and long after the boards have been stripped and readied for next year, the trigger images live on in the hallway, available for anyone who would like to hear more about our science fair projects!

Pre-science fair prep of kids' trigger images!






Saturday, April 26, 2014

AR - Augmented Reality

At the 2014 Annual CUE conference, I was introduced to augmented reality for the first time, Holy.  Cow.  Here are the augmented reality apps I am familiar with so far.
  • ColAR - 3D coloring pages (Apple & Android) You download and print out the coloring pages from the website.  The bird, dot and another random one, along with the holiday pages, are free.  You can "unlock" sets of 6 other pages for $2.99 each. 

  • Aurasma - this app allows you to create your own AR attached to a trigger image of your choice. There is a library of 3D objects, or (theoretically) you can make your own.  Keep your eyes open for public "aura"s people have created for common symbols (NFL logo, the back of a $20 bill, etc)
Book(and other)-specific apps:

Want to make you own?  Explore Aurasma + the more hefty apps:
  • Daqri - an AR developer that has been around for a while (made the 3D Elements, Anatomy, etc)
  • Layar - also an AR dev for print images 

There are a lot of educators already doing cool things with AR and I hope to amass a collection of resources (like this slideshow - by @jstevens009& @Packwoman208 - and this list of integration ideas) soon!



Sunday, March 16, 2014

Cardboard Arcade using MaKey MaKey & Scratch

(blog post under construction as of August 2014)



From YouTube:  Published on Apr 9, 2012
I went to buy a doorhandle for my car and met this 9 year old boy who built an elaborate cardboard arcade in his dad's auto parts store. He invited me to play. http://CainesArcade.com
THANK YOU! Over $239,000 has been raised for Caine's Scholarship Fund! We also started the Imagination Foundation non-profit to foster the creativity of kids like Caine around the world (watch "Caine's Arcade 2"). Over 100,000 kids in 50 countries now take part in our annual Global Cardboard Challenge! 
Please share this story and lets foster the creativity of every child:
http://imagination.org
http://cardboardchallenge.com

Recently, inspired by Caine and his arcade, BPC's 7th grade students designed, built, and shared their own cardboard arcade creations.  We were able to add a bit of technology to the challenge, using Scratch for programming and MaKey MaKeys to incorporate some simple circuitry and provide input to the Scratch program.

Here is a snapshot:




Lesson Plan:

Preparation:








Cardboard Arcade Day(s)!:


Other projects with MaKey MaKey (not at our school):

Here's another great project we can't wait to tell you about (not us, but some other young makers)!

http://21stcscience.blogspot.com/2014/08/physical-computing-for-kids.html

Wednesday, January 01, 2014

Adafruit's Circuit Playground

Apparently, this has been around for a while, but it is new to me!  Adafruit's Circuit Playground "simplifies electronics reference & calculation so you can have more fun hacking, making, & building your projects!" This app is designed for both iPhone and iPad.



To go along with the app, Adafruit has started an educational YouTube series for kids.  I found it fairly useful for my own limited electronics background plus it's something short and sweet I can use with my middle school students (or maybe younger...)  The series is co-hosted by a puppet named Adabot and Adafruit founder Limor Fried.  It's clear, if a bit cheezy, and whenever Adabot says "accessing database"there are some interesting facts & animations on the way!

Here's Circuit Playground Episode 1: "A is for Ampere"


Circuit Playground Episode 2: "B is for Battery"



If you are wondering.. C is for Capacitor, but it doesn't appear to be published just yet.  And, apparently, you can get matching plushies!  If you want to read more about these cuddly components, check out this blog post.




Sunday, December 15, 2013

One Side Effect of Maker Mondays

I've noticed a strange side effect of our school Maker Mondays, which is our version of bringing making into the classroom.  I noticed it one day when I found myself disassembling my cordless vacuum.  Wait a minute - I don't do things like disassemble my small appliances!

To provide some context, I was raised in a world of planned & perceived obsolescence.  As a kid, I used Ziploc bags and plastic silverware, tossed aluminum cans and cardboard in the trash, and rarely saved plastic tubs for reuse, as my grandmother did.  As an adult, I consumed plastic appliances from Target that ultimately failed, and were tossed in the trash.  I pay someone to mend my clothes, fix my computer and do basic maintenance on my bicycle (my main mode of transportation).

But I am a teacher, and therefore a lifelong learner.  So I can't rely on apathy.

I am also expected to set an example for the kids I work with.  That's why, though I really, really hate piles of writhing worms, I take a deep breathe and try to handle them in science class like it is no big deal, as to not model the ubiquitous disgust reaction to worms.  I've held a tarantula, carried a (pet) rat on my shoulder, and held my tongue on camping trips when I was wet and cold and I wanted to whine, too.

Both of these responsibilities have come back to the forefront as we embark on our new Maker Monday adventures this year in my 7th grade classroom.  I have been fascinated with 3D printers since I saw my first Rep Rap in 2007, and bought my first Printrbot in 2011 to share with my classroom.  Since then, we have expanded the tools in my science classroom into a respectable little makerspace with various tools in traditional and digital fabrication, along with a variety of low- and high-tech physical computing options.

Let me be very clear, I am no expert.  And I am certainly not a digital native when it comes to the hardware side of tech.  In order to effectively implement out new program, I had to swallow a lot of pride and be very, very honest with my students.  We would be learning together.  It's been a slow process, as the whole full time life science teacher gig doesn't leave a lot of extra time for tinkering, but I am getting there, mostly thanks to my adolescent co-learners.  I've been right alongside them discovering the joy of soldering, assembling a soft circuit activated by snaps, or getting a potentiometer to control an LED.

Along the way, I have been noticing a shift in my attitude: I am becoming less fearful about breaking things, and I am gaining confidence that I can learn to fix things, or at least learn a lot as I am breaking them more.

Last spring, when I experienced my first filament jam on a Saturday afternoon, my first response was, "I'll just wait until Adam [8th grader] is here on Monday."  I remember admonishing myself - "Really?  You are going to depend on a 13 year old boy to solve your problems?"  So, I watched some tutorials and, heart pounding, disassembled, fixed, and reassembled my printerhead.

Now, I am sure many makers out there (and most anyone from my parent's generation) would laugh at my story, but it was a beginning.  Recently, our Cube had a filament error, and no amount of troubleshooting was working.  3D Systems approach would be to contact customer service for a replacement, this consumer-friendly 3D printer is not intended for tinkering.  However, I was not interested in taking it out of service yet again (we had to replace our first one for another failure).  The Cube community is not as vast as the Makerbot support community, but with a little research, I deduced the problem, fixed it, and shared my solution.

Recently, the bracket broke while I was retrieving my bike lock.  I reached under the nearby parked car to retrieve the pieces, hoping to save them so that when we do get our 3D scanner, perhaps I can scan and print myself a new one.

Then, a few days ago, I was trying to clean my room and realized my hand-held vac (it's a small room) wouldn't work.  Within a few minutes, the head was disassembled and I found & fixed the problem.

I feel a responsibility to model a willingness to tinker around my students, especially my girls, and it seems that practice may be making it a permanent part of my skillset.  But it is becoming more than just something "I do for my students."  I've been doing some more minor bike maintenance on my own, browsing TechShop classes, and even dreaming up my own projects!  I used to outsource my ideas (mostly bike-visibility-related), but now I am brainstorming ways to bring them to life using my own skills and the collaborative expertise of others.

As usual, teaching has taught me something important.





Friday, December 13, 2013

Tracking Classroom Software and Laptops

We've all seen the tchotchkes emblazoned with inspirational quotes. Well, I live by the lesser known quote of "do something that amuses you every day," combined with the middle-school-teacher mantra: "Laugh so you don't cry." (btw: Did you know this has been scientifically supported as effective?)

Anyway, in order to differentiate our motley crew of class laptops with their wide variety of operating systems and operational particularities, we could have opted for traditional numerical codes.  Instead, we opted to use chicken breed names.  Now, you may not find chickens as amusing as I do, so choose whatever category you'd like, but I can attest to how this creative labeling beats numbers any day.  Especially in context:
"Hey, can I have Leghorn?  I want to use the Arduino library I downloaded last class - Americana doesn't have it yet."
"Who has Silkie?  I want to use KISSlicer!"
"Let's try the Kinect on Orpington, cuz Wyandotte isn't as good."
Numerical or not, I have also found it helpful to set up a Google Doc to encourage the kids to track the software changes they make to each computer.  You can view our always-in-progress doc here, if you are interested.