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"What may seem like an ordinary love tangle is a very rich stew of contemporary mores and a great stage for both comedy and heartbreak." —Booklist (starred review)
"Touchingly conceived. . . . In the end we see that love unfulfilled still makes a difference." —Library Journal
Praise for Alexander McCall Smith:
"McCall Smith's generous writing and dry humor, his gentleness and humanity, and his ability to evoke a place and a set of characters without caricature or condescension have endeared his books to readers." —The New York Times
"McCall Smith's novels are beautifully precise and psychologically acute." —The Independent (London)
"A vivid observer and an elegant writer." —The Plain Dealer
"A virtuoso storyteller." —The Scotsman
"A writer who charms many readers . . . McCall Smith's characters are well-drawn and alive." —Providence Journal
"McCall Smith's accomplished novels [are] dependent on small gestures redolent with meaning and main characters blessed with pleasing personalities . . . These novels are gentle probes into the mysteries of human nature." —Newsday


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This store and it's owner are HORRIBLE. A year ago, they sold me $150 vaporizor that ended up working like crap and they didn't even give me the proper accessories, either.
Back in April 2012, I bought a mechanical grinder from here for and was charged $15. In Feb. 2013 the motor died, so, I went back for a new grinder and this time they tried to charge me $40 for it. I complained a bit, but, the complaints went nowhere,so, I bought the new grinder, anyway.
JUST UNDER 30 DAYS after I bought the new mechanical grinder, it stopped working too. Without a reciept, I took it back, but,...
This store has the most complete tobacco selection (and related items) you could hope for.
This store also has the largest vaporizer and ""alternative"" smoking ""devices"" available in Monroe County.
Giant/huge selection!! They also have tons of other goodies to browse through. PS if you don't like stores that carry these types of items - TOUGH TITTY
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City water main breaks
A water main break at the Bramlett Water Plant caused the Oxford Skate Park to be transformed into a pond and the Oxford Community Garden to be flooded on Tuesday night. (May 25, 2011, Page 2)
Curtain rises on Kayla Gala
The sixth annual endowment fundraiser for the Kayla Sue Mize Endowment opens on Thursday with the show "Cotton Patch Gospel."
Tickets are $10 at the door. A live auction will be on the final night, Saturday at 5:30. Performances are at 7:30 p.m. (May 25, 2011, Page 1)
Tennis effort may move forward
The University of Mississippi has committed $800,000 towards the expansion of the Leslie Tennis Facility. The city has also agreed to $1.5 million. The money is based on whether the Lafayette County Board of Supervisors will also agree to pay $1.5 million for the project. (May 25, 2011, Page 1)
GOP hopefuls in the middle of 'silly season'
The term "silly season" is probably related more to sports than anything else, but it could certainly be applied to presidential races and potential candidates. Editor Don Whitten says the political silly season is already in full force, and he takes a look at the ins and outs of Republican candidates to oppose Barack Obama in 2012. (May 25, 2011, Page 4)
The triangular negotiating table
Local columnist T.J. Ray takes a closer look at the ongoing negotiations and work on a Memorandum of Understanding for the new hospital to be built by Baptist, offering his take on different parts of the agreement and where he thinks things could be headed with local health care. (May 25, 2011, Page 4)
County Planning Commission examines subdivision regulations
The Lafayette County Planning Commissioners were given proposed changes to the county's subdivision regulations by County Engineer Larry Britt during their regular meeting Monday evening at the Lafayette County Chancery Building. (May 24, 2011, Page 3)
Former NFL, Ole Miss player enters senate race
Former NFL player Todd Wade has qualified to run as a Republican for the Mississippi 9th Senatorial District seat currently held by incumbent Democrat and Oxford attorney Gray Tollison. (May 24, 2011, Page 1)
OSD building projects begin
Work was approved to begin at Oxford High School, Oxford Middle School and Della Davidson Elementary on Monday with contracts going out to several local construction companies. OHS will begin site work. OMS will begin renovations and demolition of the current gym and DDE will begin class expansion. (May 24, 2011, Page 1)
Oxford makes mark on Freedom Trail
The University of Mississippi will be part of the freedom trail a new initiative by the state to celebrate its civil rights heritage. (May 24, 2011, Page 1)
Balducci testifies at judicial bribery hearing
The man who got the ball rolling that would eventually knock down several local attorneys testified for more than four hours Monday at the hearing where former attorney Zach Scruggs' hopes to clear his name
The hearing is expected to last several days. (May 24, 2011, Page 1)


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Phil Miller covered three seasons of Twins baseball, but that was at a different ballpark for a different newspaper. Now Miller returns to the baseball beat after joining the Star Tribune as the Gopher football writer in 2010, and he won't miss the dingy dome for a minute. In addition to the Twins and Gophers, Miller covered the Utah Jazz and the NBA for six years at The Salt Lake Tribune.
DETROIT -- The Twins just went 2-1 at Comerica Park in a span of about 30 hours, and the bullpen played a big role.
Things were looking pretty bleak when Samuel Deduno lasted just 2 1/3 innings Saturday. But Anthony Swarzak (3 2/3 innings, one run) and Luis Perdomo (two scoreless innings) kept things from getting too out of hand in that 8-0 defeat.
In Game 1 of Sunday's doubleheader, Scott Diamond gave the Twins a strong seven-inning start. With a 10-2 lead, Casey Fien pitched a 1-2-3 eighth (lowering his ERA to 1.39), and Alex Burnett would have had a scoreless ninth were it not for an error by Justin Morneau. Burnett allowed two runs, both unearned.
Game 2 was the bigger test. P.J. Walters held Detroit to one run over six innings. Brian Duensing pitched two scoreless innings (giving him a 0.73 ERA in 12 1/3 innings since moving back to the bullpen).
Jared Burton dazzled in the eighth, retiring Miguel Cabrera, Prince Fielder and Delmon Young (lowering his ERA to 2.01). And Glen Perkins pitched a 1-2-3 ninth (making him 14-for-15 in save chances since replacing Matt Capps as closer).
Burton just oozes confidence.
"It was one of those nights where I was pretty locked in," he said. "All my stuff was working; it's some of the best stuff I've had all year. And that energy with that crowd going helped a little bit, too."
There's plenty of talent in the Twins bullpen. If only the team has more leads to protect.
Twins spring training wrap: Rays 2, Twins 1
The Twins dropped to 2-1 this spring in a loss to Tampa Bay, but...


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Diamonds are Sparkling
- Posted by Greg Harmon
- on February 28th, 2012
Today marks the end of the end of February and time to step back and look at the longer term charts to gain perspective. Despite one day left in the Month, the monthly chart for the SPDR DJ Industrial Average ETF, $DIA, is not going to change character unless Monday closes under 125. Not only does this chart show the long bullish run off of the Triple Bottom near 60 since march 2009, but it screams that we are going to continue higher.
SPDR DJ Industrial Average ETF, $DIA
in January it broke above the Double Top and February is confirming higher. The first target on a Measured Move takes it to 138. It has support of the Relative Strength Index (RSI) bullish and rising and the Moving Average Convergence Divergence (MACD) indicator positive and rising. The second Measured Move takes it to 170. You could also create targets from the Fibonacci extensions of the retracement of the move lower from 2007 to 2009. These come at 151 (138.2%), 159 (150%) and 167 (161.8%). Need more ammunition? Well the Point and Figure chat measures a price objective of 154 from the Double Top break. Notice how none of these mention any kind of pause at the current 130 level? Still think that 150 on the $DIA or 15,000 on the Dow Jones Industrial Average, $DJIA, is pie in the sky?
If you like what you see above sign up for deeper analysis and trading strategy by using the Get Premium button above. As always you can see details of individual charts and more on my StockTwits page.
The information in this blog post represents my own opinions and does not contain a recommendation for any particular security or investment. I or my affiliates may hold positions or other interests in securities mentioned in the Blog, please see my Disclaimer page for my full disclaimer.
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Gregory W. Harmon CMT, CFA, has traded in the Securities markets since 1986. He has held senior positions including Head of Global Trading, Head of Product Development, Head of Strategy and Director of Equity. (More)
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"Spartans were known for never retreating. It was better to die on the battle field than to retreat."
Ron Pike
"Die, but do not retreat."
Joseph Stalin
"Follow me if I advance, kill me if I retreat, avenge me if I die"
Mary Matalin
"No retreat. No retreat. They must conquer or die who've no retreat."
John Gay
"It's almost universal that all glaciers are retreating. The signs of retreat are dramatic and accelerating."
Peter Clark
"Every person who wins in any undertaking must be willing to cut all sources of retreat. Only by doing so can one be sure of maintaining that state of mind known as a burning desire to win / essential to success."
Napoleon Hill
"Never retreat. Never explain. Get it done and let them howl."
Benjamin Jowett


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American Board of Urology
MD, University of Southern California
Residency, Surgery (General)
University of Southern California Med CenterResidency, Urology
University of Southern California Med CenterResidency, Urology
Henry Ford Health SystemsFellowship, Urology
Lac-Rancho Los Amigos Med. CenterFellowship, Urology/Oncology
UC Irvine Medical Center
Industry Relationships
Physicians and scientists on the faculty of the Icahn School of Medicine at Mount Sinai often interact with pharmaceutical, device and biotechnology companies to improve patient care, develop new therapies and achieve scientific breakthroughs. In order to promote an ethical and transparent environment for conducting research, providing clinical care and teaching, Mount Sinai requires that salaried faculty inform the School of their relationships with such companies.
Dr.Trop is not currently required to report Industry relationships.
Mount Sinai's faculty policies relating to faculty collaboration with industry are posted on our website at http://icahn.mssm.edu/about-us/services-and-resources/faculty-resources/handbooks-and-policies/faculty-handbook. Patients may wish to ask their physician about the activities they perform for companies.


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TransAm Hires Students and Experienced Drivers
TransAm's hiring area includes the states east of the Rocky Mountains. Whether you are an experienced driver or a recent graduate of truck driving school, TransAm treats you right. With TransAm's great pay scale, miles, stop pay and bonuses, first-year student drivers can earn over $40,000 per year and TransAm's Independent Contractors gross an average of $138,000 per year.
TransAm Trucking is pleased to offer its company drivers paid vacation time, health and dental coverages for employees, spouses and children, and a no-cost life insurance policy. Company drivers also enjoy eligibility in TransAm's 401(k) Profit Sharing Plan and Cafeteria 125 Plan.
All TransAm drivers have access to classroom training and can obtain personalized instruction when needed. TransAm student drivers acquire their knowledge from a professional staff of trainers who instruct them in over the road procedures, backing maneuvers, paperwork requirements and safety.


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What Happens When You Have a Bad MMA Referee The fight should have been stopped with the first knockout punch. 6/4/2014 11:27:02 AM 18,678 25
Drunk Falls Off Bridge and Slams Firetruck Drunk Falls Off Bridge and Slams Firetruck, Double fail! 7/5/2012 12:00:00 AM 18,655 30
Mountain Biker Takes a Very Hard Fall Medic! I must admit though, he did have nice form. 7/6/2012 12:00:00 AM 18,618 26
Best Fails of The Week 2 September 2013 A collection of all the best fails from this past week. 9/14/2013 10:33:40 AM 18,615 50
A Good Way To Fail Your Driving Test A fat woman from Hawaii flips out on her instructor during a driving test.... 3/24/2014 12:14:15 PM 18,613 68
Female Reporter Goes Overboard During Interview Fail Splish splash I was taking a bath... 4/8/2014 9:09:18 AM 18,556 54


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Wednesday, March 4th, will have an abbreviated schedule due to chapel at 11am. Classes in the morning will meet as follows.
8:00-8:55 will meet 8:00-8:35.
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Chapel will be from 11:00-11:55.
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Advising for the Spring 2015 semester began October 20. Please schedule a time with your advisor to talk about your schedule for next semester. Come by our office if you do not know who your advisor is. The schedule of classes for the spring semester has been posted under Resources.
Click here for Payment Deadlines and Purge Dates
All students must pay in full and confirm their registration by the purge deadlines to complete the registration process by logging into the MyLaCollege portal and following the procedures in the "Student Check-In" window located on the Registration tab.
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Team Newfoundland second Jen Cunningham,between ends during first draw action at The 2012 Scotties Tournament of Hearts, February 18-26, Red Deer, Albeta. The Canadian Womans Curling Championship. (Photo by: Andrew Klaver)
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The trailer of an 18-wheeler collided with a lift bucket at the Exit 28 interchange last Friday, swinging the worker into a traffic light pole and causing lacerations to his forehead. Meanwhile, police investigate a break-in at Feriba Place, where an unknown suspect stole tablets and jewelry valued at a combined $1550. Police were also called regarding multiple car break-ins and Hough High students camping in Glen Oak Green Park. Read on for details.
Read the full story


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Looking for Clues in All the Right Places: The Author in the Library
Date, Location
Thu, 04/26/2007 - 9:30am
Royal Oaks Country Club
8917 NE Fourth Plain
About the Event
Author Jo Dereske is a former reference librarian who ow makes libraries the setting for her Miss Zukas mysteries. Jo will talk about her experiences using libraries for writing research, and will share her thoughts on what makes libraries a great environment for authors. Bring along your questions and stories to share.
Presented by: Jo Dereske
Cost: $15
To Register:
(360) 921-2755
Event Website
http://www.altrusa.org/2007LibraryServiceAward-Events.pdfSubmitted by: hollyb on Tue, 04/17/2007 - 2:38pm Contact the person who posted this item.


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Kansas City Royals Gear
Kansas City Royals Mens
Kansas City Royals Mens Shorts & Pants
$20 to $40
(5 items)
Product ID: 1390298
Main Content
This item ships within one business day.
Order as many items as you like with our $4.99 flat rate shipping.
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No matter what you're doing, you always have to show some Royals spirit. These team-colored Fiery Fastball shorts by Majestic will make it easy with the Kansas City graphic on the left leg. With these shorts, you can show Kansas City Royals spirit every day of the week.
- 100% Polyester
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number, and/or designs. Some options may be limited by league rules.


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Willowdale Sports ClubPO Box 543, 3299 Bayview Avenue, Toronto, Ontario M2K 2Y5 Willowdale Sports Club |
willowdalesportsclub.com |
Congratulations to our Peewee Select team - 2015 Leaside Tournament Champions! |
See current and previous team photos on the Photo Gallery page. Use the button in the top right corner to see any photo in full size in a new window. |
HELP WANTED - contact firstname.lastname@example.com:
Stay in touch through Facebook
Go to the Willowdale Hockey - House League/Select page, and then "like" it.
2014-2015 Willowdale Select Program
2014-15 Willowdale Select Players Wanted PDF
NYHL (North York Hockey League)
Teams -- Minor Novice (2007 Top/Mid tier teams),
Novice (2006 Mid Tier teams),
Atom (2004-2005),
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2014-15 Willowdale Blackhawks Contacts PDF
Willowdale Blackhawks Apparel Program - through Ultimate Sports
Stormtech sizing chart
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Softball. Adult Mixed Slo-pitch Program.
For more information, please Contact us.
» Eulogy to AJ PDF


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Pentecostal Churches Accused Of Exploiting Cameroon's Poor
Pentecostalism is spreading rapidly throughout sub-Saharan Africa. Half of the world's Pentecostalists live there, and Cameroon's government has deemed the church a national threat.
Copyright © 2014 NPR. For personal, noncommercial use only. See Terms of Use. For other uses, prior permission required.
Pentecostalism is the fastest-growing Christian denomination in the world. It has spread swiftly through sub-Saharan Africa, which is now home to nearly 45 percent of all of Pentecostals. In Cameroon, a mainly Christian nation that sits in the crook of West Africa, the church's explosive growth has attracted government attention and ire. Andres Caballero reports.
ANDRES CABALLERO, BYLINE: The city of Bamenda sits near the lush green hills of northwest Cameroon. It's home to 400,000 people and a fast-growing number of revival churches. On my way through the outskirts of the city on a Sunday morning, I come across the Rhema Christian Center. It's a long, open structure covered by a giant tin roof. It looks even bigger from the inside, and it's bustling with nearly 5,000 worshipers. Several pregnant women wait to be prayed over. Cameroon has one of the highest infant mortality rates in the world, and these mothers believe the ministrations of Pastor Warah Solomon (ph) will guarantee that all will go smoothly.
WARAH SOLOMON: (Foreign language spoken).
CABALLERO: A pregnant woman who is three days late to deliver lies on the ground of a circular cement stage surrounded by dozens of people who wait in line to be healed. An usher wearing a red silk shirt brings Pastor Solomon a plastic bottle of holy or anointed water.
SOLOMON: Open up to cleanse all the complications. Drink. Watch as she drinks the anointed water. Watch. The anointed water is making the baby to be positioned. Baby, you cannot die, in Jesus name. You can't.
UNIDENTIFIED WOMAN: (Crying).
CABALLERO: The woman cries out in pain and apparently begins having contractions. She can't really stand on her own. People watch with their hands lifted up while the ushers carry her out and ask for volunteers to drive her to a hospital. Robert Akoko teaches sociology and anthropology at the University of Buea in the southwest region of Cameroon. He explains why the churches are so popular here.
ROBERT AKOKO: Cameroonians are faced with economic crises, HIV, AIDS - which cannot be cured - terminal illnesses and ones that themselves in such debt, they seek Pentecostal churches.
CABALLERO: But Akoko says, it's not just faith healing that's drawing followers. The church also claims to offer protection from evil spirits.
AKOKO: You hear people being exercised of spiritual husbands and spiritual wives.
UNIDENTIFIED SINGERS: (Singing) There is no one like you. You are the...
CABALLERO: In this quiet Bamenda neighborhood, the only thing that distinguishes King's Deliverance Ministries from the other buildings is the sound of women singing a cappella. Pastor Emanuel Ojei (ph) tells me he came from Nigeria and started this church less than a year ago. He calls himself a prophet.
EMANUEL OJEI: (Foreign language spoken).
CABALLERO: He paces back and forth with a Bible on his hand while the congregation repeats after him. Besides healing and prophecy, he says he specializes in casting demons out of people.
OJEI: Demons manifest. You see them screaming, crying and confessing. Some say they are spiritual husband, and some say they are spiritual wife.
OJEI: I don't want to know how long. The boy is dead and dying. I don't want to know how long they've been suffering.
CABALLERO: Mary Sabe (ph) stands up from her seat, lifts up her hands and reaffirms the words of the pastor. She joined this Pentecostal church after more than a decade as a Catholic. She says she was being tormented by what she called a spiritual husband.
MARY SABE: I couldn't sleep in the night. They always come have sex with me in the night, every night. So it was so tormenting. I didn't just know what to do.
CABALLERO: One of her friends told her about Pastor Ojei and this church.
SABE: So when I worship there, that is how I got my deliverance.
CABALLERO: Akoko has studied Pentecostalism and its growth amid economic hardship in Cameroon. He says that even though it originated in America, it's been what he describes as Africanized.
AKOKO: It addresses problems faced by Africans. It addresses the beliefs of Africans as far as supernatural forces may be concerned.
CABALLERO: But according to Akoko, it's the Pentecostal gospel of prosperity that draws Cameroonians, many of whom live on less than $7 a day. A branch of a Nigerian mega-church known as Winners Chapel has operated in Bamenda for several years. It's grown so fast recently that the church had to start having two Sunday morning services to accommodate nearly 1,400 members.
CABALLERO: During today's service, hundreds of people listen to members testify about how God has blessed them with material riches and with job promotions. This woman says she wondered why she always had to drive a rundown car compared to everyone else's. She says that after much prayer, God blessed her with a new Nissan. After the testimonies, young ushers in pressed suits crisscrossed the large concrete building collecting offerings from the congregation.
CABALLERO: There are more than 500 revival churches operating in Cameroon, but fewer than 50 are legally registered. Their rapid growth, as well as what the government views as questionable practices, has drawn attention. Last year, the government ordered the closure of nearly 100 churches claiming that some Pentecostals pastors engage in criminal practices, including extortion.
MINISTER OF COMMUNICATION ISSA BAKARY: (Foreign language spoken).
CABALLERO: That's Cameroon's minister of communication, Issa Bakary. He says these so-called awaken churches take advantage of people who are in tough situations. Professor Akoko says there are genuine Pentecostal churches.
AKOKO: But the problem now is identifying the good ones from the bad ones.
CABALLERO: For NPR news, I'm Andres Caballero.
SIMON: And Andres is an NPR Above the Fray fellow, sponsored by the John Alexander Project. That's a group that supports young journalists to find stories like the one we just heard. Tomorrow on WEEKEND EDITION, we'll look into the Cameroonian government's crackdown on hundreds of revival churches. You're listening to WEEKEND EDITION from NPR News.
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Report: U.S. came close to nuclear disaster in 1961
Published 09/21/2013, Associated Press
A hydrogen bomb nearly detonated on the East Coast of the United States in 1961, with a single switch averting a blast which would have been 260 times more powerful than the device that flattened Hiroshima, a newly published book says.
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Purchasing Article: H. Habara, G. Xu, T. Jitsuno, R. Kodama, K. Suzuki, K. Sawai, K. Kondo, N. Miyanaga, K. A. Tanaka, K. Mima, M. C. Rushford, J. A. Britten, and C. P. J. Barty, "Pulse compression and beam focusing with segmented diffraction gratings in a high-power chirped-pulse amplification glass laser system," Opt. Lett. 35, 1783-1785 (2010) |


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Kolor Labs: Measurement using Panoramas by Alexandre Jenny
Friday, September 7th, 2012
Prepare for the impending launch of Panobook 2012 panoramic competition! The contest will open in a few days and this year, you will be able to win beautiful prizes!
Kolor Panobook is an annual panoramic photo contest open to all and that leads to the publication of a unique book composed of the winning panoramas. Everyone's invited to join the contest! No entry fee, no obligation to use a particular image-stitching application ; all you need to have is to prepare a selection of your most beautiful, original, inspired panoramas. (read more…) |


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A few tips for you: Vince Wilfork's last name is not pronounced "Wil****." Rob Gronkowski's last name is not pronounced "Grabowski." It is ill-advised to refer to him as "Gonk." Wes Welker is not pronounced "Wes Wecker" and he no longer plays for us. Our kicker is Stephen Gostowski, not Jason Varitek. Tom Brady is not a point person or a point leader. He is a franchise quarterback. There is no such thing as a World Series Cup. Extra credit: Boston is not an "arousing" city. It may be a "rousing" city, but not the former.
Also ... the holiday on January 20th IS NOT: Martha Luther King day ... Also Bring and Bing are not the same ... BING .... :rofl:
I know I might be a little late on this, but supposedly Mayor Walsh is a huge die hard Pats fan! Been a season ticket holder for quite some time. Unlike mayor mumbles who hated the team


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WRT549SZDB 30" Top-Freezer Refrigerator with 19.2 Cu. Ft. Capacity, LED Interior Lighting, Frameless Glass Shelves, Electronic Temperature Control, Flexi-Slide Bin and Humidity Controlled Crispers, in Black
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14 foot boards tend to dominate the downwind lineup. But the reality is, a 12'6 can perform just as well and be easier to manage in the wind. We asked our friend Misako to take the 12'6 Dennis Pang for a run to give us some feedback for how a 12'6 can perform in the Gorge. Here's what she discovered….
SUP 'n Pub
The Crew at Gorge Performance is excited to announce the Summer SUP 'n Pub Race Series beginning Tuesday, July 1st through August 19th from 6:00 – 7:30 pm. This no cost race series is designed to offer courses in various locations around Portland that will be fun and laid back for anyone who loves to SUP. You can be as competitive or carefree as you'd like. Then join us for a cold summer time beverage at a local pub near the race site.
In my search to find a SUP for surfing the Oregon coast I recently tried the Boardworks Infinity carver 9'10". The board is marketed for "for bigger guys who are experienced SUP surfers looking to step down in size/length and step up their performance." And, that is exactly what I was looking for.
There are several boards to consider for paddlers who want to go from an all-around board to a touring board with a flatwater-optimized displacement hull. But, the minute they say, "… I think I might want to race someday" I immediately introduce them to the Amundson TR-2.
Thanks to Gorge Performance, eFit's first annual Stand Up to NF event was a huge success!! Last Sunday, Gorge Performance donated the use of 33 SUP boards for the SUP Paddle relay so that we could have more than 30 four-person teams relay up and down the Willamette River on the SUP boards. Read More
The first time I saw the Bark Appleby Race board it was easily passing me on the East side of Ross Island during a SUP race. My initial thought was, "Wow, that's a good looking board!" My second thought was, "Why is that woman going so much faster than me when I feel like I am working twice as hard?" It was that day I realized the impact a good board for the right conditions could make and that my 11′ all-around SUP was never going to out run a true race board regardless of how hard I paddled. Not long after, I added the Appleby to my quiver and have been thrilled with it since.
For years (30 to be exact) Gorge Performance has been a hardcore surf shop with an emphasis on stocking a ton of surfboards and wetsuits for men and women, and less focus on apparel. Sure, boardshorts and tees for guys have been staple items at Gorge, but not much for our surfer girls. Now that flatwater SUP – a sport not requiring a full wetsuit like surfing does – has firmly staked its claim in the Gorge board-dom, it's only natural we expand our women's clothing selection to include functional fitness apparel intended for paddling (and surfing, yoga, rock climbing,… living!). These items are meant to move, like you do.
Late last season the CGKA developed a new launch at Cascade Locks (directly across the river from Bob's Beach in Stevenson, WA.). Blackberry Beach emerged from the nasty thorns and bushes and is the first significant new launch location in years thanks to the assistance of countless volunteers. It went from blackberries to beach and the crew at Gorge Performance are stoked to have another launch just 45 minutes from Portland, sans bridge toll! Read More
We've declared the 2013 SUP season officially open. Time to get out on the water and put those hibernating paddling muscles to work again. It's also a great time to evaluate your gear. If you've been considering making a change (paddle or board) you're in luck in terms of many, many options to choose from. Our team at Gorge has been testing boards and paddles over the last few months to provide you, our customers, with hands- and feet-on practical reviews to help you narrow your options. First up, Matt Spencer puts the 14′ Amundson TR-X through its paces. Here's what he has to say: Read More
The elves at Gorge Performance have been busy, but not with sleigh repairs, reindeer maintenance and toy making. When the guys at Gorge aren't providing the best customer service in Portland, they are outside ready for the next swell, gust or dump. So who better to provide you with a little holiday shopping insight than the elves who ride and wear our products every day.
While my usual ride, a 12'6″ Tahoe Bliss, was in the shop for repair, I borrowed the Lakeshore Betty in powder blue. So to be fair, this review of the Betty is a comparison to the board I know and love.
Remember the El Camino? Truck bed in the back, car in the front. I never thought it was a good looking vehicle, but I always admired it for trying to take the best from both rides. I am relying on that dual-purpose concept from Chevy for my fall paddling gear, but unlike the iconic 70's ride, Dakine and O'Neill got the looks right. Mix and match these two items with your board shorts or wear them solo, it works!
We all have friends who want to try SUP. We run into people on the water who say "That looks fun!" or "Is that hard to do?" or the typical "Isn't it cold?" Now there is a way for you to share your love for SUP without your $2k race board bumping into the dock as you stand nervously on the shore. Send them to Gorge Performance for a stand up paddle lesson. The Gorge Crew has been busy this spring perfecting their techniques and becoming certified ASI instructors.
I really don't think Jimmy Buffet was thinking about stand up paddle boarding with his 1979 hit "Fins" but the collection at the Gorge Performance shop is certainly song-worthy.
If you are paddling around with the stock fin your board came with, it is time to consider your options.
Two recent tragedies involving stand up paddlers this past weekend should be a reminder to all of us that no matter how easy and fun SUP can be, the power and danger of water still exists. Closest to home, a 39 year-old woman died in Gold Beach, Oregon on the Checto River when her surfboard leash caught on a snag and she was trapped underwater. A 50 year-old Tampa, Florida man went missing while paddling on Saturday night. His board washed up on shore along with his wallet, car keys and cellphone.
Here are a few things to consider before you head out on your next paddle to ensure it's not your last. Read More
Portland's occasional sun breaks have us all dreaming about the spring stand up paddle season. The problem is many of our boards have not seen action since late last fall. You could put the board back in the water on the next sunny day and hope for the best, but why not try these three simple steps to get ready for spring.


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It is not hard to uncover Shoulder Holsters On Sale. If you visit OpticsPlanet.com the sales find you! This is especially true if you stop by our Shoulder Holsters sale page! We carry a wide range of Shoulder Holsters, and our normal prices are fantastic, so at times it's difficult to figure out which products have the very best deals. That is what this page is all about. We want you to enjoy our sales on Shoulder Holsters. We work hard to get the best possible prices, and whenever we have the opportunity to take a few additional dollars off some of our Shoulder Holsters we don't want those awesome savings to go unnoticed because of all the options available. That's why we developed this page of our On Sale Shoulder Holsters. Whenever you're in the market for one or two new Shoulder Holsters, make sure you remember to check this page 1st so you can see our sale items. We may have the model you're looking for at the right price! For Shoulder Holsters On Sale, you've found the perfect place.


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If you could only use 5 flys to fish a western river with 'bows to 8 lbs which would they be?
What about lakes?
What about lakes?
mickey 07-23-2004, 12:15 AM If you could only use 5 flys to fish a western river with 'bows to 8 lbs which would they be? What about lakes? juro 07-23-2004, 06:27 AM One would be a sculpin pattern in my 5... 8# rainbows have a 'dark side'. Dble Haul 07-23-2004, 08:49 AM I would also include a freshwater scud/shrimp pattern....many of the fish out there get that big buy feasting on such creatures. Skilly 07-23-2004, 10:01 AM #3 would have to be a woolybuger, probably black and olive. BigDave 07-23-2004, 10:34 AM What time of year would this be? dewey 07-23-2004, 12:41 PM bugger, muddler, stimulator, hare's ear, dark stonefly John Desjardins 07-23-2004, 02:35 PM I'm similar to Dewey: Bugger, muddler, PT nymph, Stone fly & a bushy dry that can be trimmed to match almost any profile. flytyer 07-23-2004, 06:30 PM Sculpin or muddler, black stonefly nymph, tan (or better yet golden brown) elk hair caddis, grasshopper, Royal Wullf. This assume you will be fishing during mid-June to mid-September. Brad 07-23-2004, 06:52 PM SJW, RS2, midge stuff, BHPT, copper john NateSmith 08-04-2004, 01:05 AM A mix of small and big big: double bunny, sculpins, hoppers small: zebra midges, small emerger patterns to match the hatch ie PMD...ect... |


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Menorrhagia in Patients With Type I Glycogen Storage Disease.
ABSTRACT To evaluate menorrhagia in a cohort of women with glycogen storage disease type I because it appears to be an under-recognized problem in females of reproductive age.
A retrospective chart review was performed on 13 menstruating patients with glycogen storage disease type I (age 23-48 years) for a diagnosis of menorrhagia.
Nine (69%) (confidence interval 0.39-0.91) women had development of menorrhagia. Median hemoglobin values in these patients were generally low (range 9.5-12.85 g/dL) but not different from those of the nonmenorrhagia group (hemoglobin range 9.55-11.0 g/dL) with glycogen storage disease type I. Four patients with menorrhagia required hospitalization or emergency department visits for treatment of menorrhagia. Two of the four patients hospitalized required blood transfusion, with an additional patient requiring a transfusion during pregnancy. Eight patients (89%) either were recommended to have or required medical or surgical treatment of their menorrhagia.
Glycogen storage disease type I is associated with menorrhagia. The evaluation should include assessment of coagulation functions and referral to a gynecologist, hematologist, or both, because bleeding diathesis and polycystic ovary syndrome are common in patients with glycogen storage disease type I.
- Citations (30)
- Cited In (0)
- Blood 03/1973; 41(2):235-47. · 9.78 Impact Factor
- Acta Obstetricia Et Gynecologica Scandinavica 02/1966; 45(3):320-51. · 1.99 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: There has been much debate concerning the relative contribution of insulin resistance to the development of polycystic ovaries (PCO). We therefore aimed to assess ovarian morphology and insulin/androgen status in females with the hepatic glycogen storage diseases types Ia (GSD-Ia) and III (GSD-III), disorders associated with abnormalities of insulin secretion. A cross-sectional study of ovarian ultrasonography, oral glucose tolerance tests (oGTTs) and single measurements of gonadotrophins and androgens were performed. Twenty-seven patients were evaluated: 13 with GSD-Ia, median age 11.2 years (range, 3.3-26.7) and 14 with GSD-III, aged 13.2 years (4.2-31.3). None had clinical signs of hyperandrogenism and only two of the 13 adults (15%) had menstrual irregularities. They were compared to 9 normal adult female controls, aged 21-28 years. Ovarian morphology and volume were measured. Blood glucose and plasma insulin concentrations were measured at the beginning and end of a 2-hour oGTT. Single measures of LH, FSH, testosterone, dehydroepiandrosterone sulphate, androstenedione, IGF-I and SHBG were made on samples taken at the beginning of the oGTT. In both GSD-Ia and III, all those older than 4.8 years of age had a polycystic ovarian appearance. Pre-pubertal GSD-Ia patients had lower basal and 2-hour blood glucose and plasma insulin concentrations than pre-pubertal GSD-III patients. In adults with GSD-Ia and GSD-III, although basal and 2-hour blood glucose concentrations did not differ, both basal and 2-hour plasma insulin concentrations were significantly higher than controls. Serum gonadotrophins, androgens, IGF-I and SHBG were mostly normal. A polycystic ovarian appearance is a common finding in patients with glycogen storage disease even before puberty. In GSD-III and adults with GSD-Ia, this ovarian appearance was associated with hyperinsulinism, suggesting an aetiological link, but this was not the case in pre-pubertal children with GDS-Ia. Inborn errors of carbohydrate metabolism may act as useful models for examining control mechanisms of ovarian physiology and development.Clinical Endocrinology 07/1995; 42(6):601-6. · 3.35 Impact Factor
Page 1
Menorrhagia in Patients With Type I
Glycogen Storage Disease
Original Research
Stephanie L. Austin, MS, MA, Areeg H. El-Gharbawy, MD, Vellore G. Kasturi, MD, Andra James, MD,
and Priya S. Kishnani, MD
OBJECTIVE: To evaluate menorrhagia in a cohort of
women with glycogen storage disease type I because it
appears to be an under-recognized problem in females
of reproductive age.
METHODS: A retrospective chart review was performed
on 13 menstruating patients with glycogen storage
disease type I (age 23–48 years) for a diagnosis of men-
RESULTS: Nine (69%) (confidence interval 0.39–0.91)
women had development of menorrhagia. Median hemo-
globin values in these patients were generally low (range
9.5–12.85 g/dL) but not different from those of the non-
menorrhagia group (hemoglobin range 9.55–11.0 g/dL)
with glycogen storage disease type I. Four patients with
menorrhagiarequired hospitalization
department visits for treatment of menorrhagia. Two of
the four patients hospitalized required blood transfusion,
with an additional patient requiring a transfusion during
pregnancy. Eight patients (89%) either were recommen-
ded to have or required medical or surgical treatment of
their menorrhagia.
CONCLUSION: Glycogen storage disease type I is asso-
ciated with menorrhagia. The evaluation should include
assessment of coagulation functions and referral to
a gynecologist, hematologist, or both, because bleeding
diathesis and polycystic ovary syndrome are common in
patients with glycogen storage disease type I.
(Obstet Gynecol 2013;122:1246–54)
Mendelian Inheritance in Man 232200) is caused by
a defect in the glucose-6-phosphatase system. The effect
is profound hypoglycemia with fasting attributable to
inability to make glucose by gluconeogenesis or glyco-
genolysis. Two subtypes of glycogen storage disease I
are type Ia, which accounts for 80–90% of glycogen
storage disease I cases and is caused by defective
glucose-6-phosphatase enzyme, and type Ib (which
accounts for most of the remaining cases), in which
translocase, the enzyme that transports glucose-6-phos-
phate across the microsomal membrane, is defective.
The majority of patients with glycogen storage
disease type I present with hepatomegaly, symptoms
of hypoglycemia, seizures, or a combination of these
during infancy. Secondary metabolic abnormalities
include lactic acidemia, hyperuricemia, and hyperlip-
idemia. Individuals with type Ib additionally have
neutropenia and impaired neutrophil function, and
can have recurrent bacterial infections.1
During the past decades, improved dietary and
medical management have significantly improved
survival, resulting in an increased number of patients
reaching adulthood.2–4This has led to recognition of
the effect of glycogen storage disease type I on repro-
ductive health. Puberty often is delayed in males and
females.5Lee et al6reported that women with glyco-
gen storage disease type I commonly had a polycystic
appearance of their ovaries even before puberty.
Although adult women (n56) with glycogen storage
ype Iglycogenstoragedisease(glucose-6-phosphatase
From the Departments of Pediatrics, Divisions of Medical Genetics, Duke
University Medical Center, Durham, North Carolina, and University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and the Department of
Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottes-
ville, Virginia.
Supported by the Children's Fund for Glycogen Storage Disease Research and the
Association for Glycogen Storage Disease, United States.
The authors thank the glycogen storage disease type I patient population who
participated in this study.
Presented in part at the American Society of Human Genetics Annual Meeting,
Philadelphia, Pennsylvania, November 11–15, 2008.
Corresponding author: Vellore Kasturi, Duke University Medical Center,
GSRB1, 905 La Salle Street, DUMC 103857, Durham, NC 27710; e-mail:
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2013 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
Page 2
disease type I had polycystic ovaries that were associ-
ated with hyperinsulinism, manifestations of hyperan-
drogenism such as acne and hirsutism did not occur.
There is not much information available regarding
anovulatory bleeding in these patients. It is not clear
how the features of polycystic ovary syndrome affect
fertility because successful pregnancies have been
Glycogen storage disease type I has been associ-
ated with a bleeding diathesis attributable to impaired
platelet function,9a von Willebrand–like defect,10or
both. Commonly reported symptoms include epi-
staxis, easy bruising, bleeding gums, and excessive
bleeding after surgery. In a report by the European
Study on glycogen storage disease type I (age range
0.4–45.4 years), 19% of the patients had recurrent or
severe epistaxis, 3% had prolonged bleeding after sur-
gery, and 2% had urogenital tract bleeding, gastroin-
testinal bleeding, or both.5Although, heavy menstrual
bleeding, or menorrhagia, is the most common symp-
tom that women with bleeding disorders usually expe-
rience, there has been no specific reference to
menorrhagia as a bleeding manifestation of glycogen
storage disease type I in the literature we reviewed to
Menorrhagia is defined as prolonged or excessive
bleeding (more than 80 mL of blood loss per
menstrual cycle).11Several circumstances correlate
with this amount of blood loss, such as soaking
through one pad or more during 1 hour, soaking
through night clothes, clots larger than 1 inch in diam-
eter, and low ferritin.12Of note, ferritin is not a reliable
indicator of menorrhagia in women with glycogen
storage disease type I, because it could be normal or
elevated and does not correlate with anemia noted in
these patients.13Most data regarding the prevalence of
menorrhagia in women with bleeding disorders come
from reports of women with von Willebrand disease,
but menorrhagia has also been reported in hemophilia
carriers, women with factor XI deficiency, women
with rare factor deficiencies, and women with platelet
dysfunction.14Because glycogen storage disease type I
has been associated with a bleeding diathesis attribut-
able to impaired platelet function, a von Willebrand–
like defect similar to that in women with bleeding
disorders, or both impaired platelet function and
a von Willebrand–like defect, the likelihood of men-
orrhagia in this population should be considered. In
this clinical report, we evaluate and characterize the
features of menorrhagia in menstruating females with
glycogen storage disease type I who attend the Duke
Metabolic Clinic to determine whether menorrhagia
was an under-reported symptom in these patients.
After receiving Duke University Institutional Review
Board approval and patient consent through a natural
history study, a retrospective chart review was per-
formed on 13 patients between the ages of 23 and 48
years with glycogen storage disease type I for a diag-
nosis of menorrhagia.
If information regarding the menstrual cycle was
not available, then the patients were asked to respond
to a set of questions (reviewed by a gynecologist A.J.),
which included the following menstrual cycle infor-
mation details: frequency; duration; quantity of men-
strual flow; and age of onset. Examples of the
questions included the following: "Do you soak
through one pad or more in an 1 hour?"; "Do you
soak through night clothes?"; "Do your periods last
more than 2 weeks?"; and "Do you have clots larger
than 1 inch in diameter?" This occurred either during
an outpatient visit or through a telephone call or
e-mail. The study used a positive response to one of
these questions to define menorrhagia or a previous
documented diagnosis of menorrhagia.
Patients attending the Duke metabolic clinic are
evaluated and followed-up on a yearly or bi-yearly
basis. Routine evaluations include a comprehensive
history, physical examination, and dietary consulta-
tion by an experienced metabolic dietitian, during
which adherence to dietary intervention is encour-
aged but not formally assessed. Laboratory evalua-
tions include electrolytes, blood glucose, liver and
kidney functions, and complete blood count, in
addition to secondary markers of metabolic control
(lactic acid, uric acid, triglycerides, and cholesterol).
Based on glycogen storage disease type I guidelines,
alpha-fetoprotein and carcinoembryonic antigen also
are assessed in this age group.15
An additional evaluation for menorrhagia assess-
ment included thyroid function, which was evaluated
to exclude abnormalities that may contribute to
menorrhagia. Coagulation studies were available for
some, but not all, patients. These included platelet
aggregation studies in response to collagen, adenosine
diphosphate, arachidonic acid, and ristocetin, and
a von Willebrand factor panel, which includes FVIII
and von Willebrand factor antigen (von Willebrand
factor:Ag) and activity (von Willebrand factor:RCo).
Blood type was obtained to guide interpretation of
von Willebrand factor studies. Patients usually have
regular liver imaging studies consisting of an ultra-
sound examination, magnetic resonance examination,
or computed tomography scan to evaluate liver size,
presence of liver adenomas, and liver architecture. At
VOL. 122, NO. 6, DECEMBER 2013Austin et al Menorrhagia and Glycogen Storage Disease I
Page 3
Table 1. Clinical Summary of Patients
Age (y)
Age at
of GSD 1
Age at
Diagnosis of
(y) Mutations Noted
of Disease
or Risk
Factor for
Other Bleeding
1236 mo20Homozygous for
(p.Arg 83Cys)
None knownEpistaxis
2483 y40Homozygous for
Hepatic adenomas, long-standing
hypothyroidism on synthroid, renal
transplantation at age 38 y
Epistaxis, easy
bruising, gum
3426 y 22 Homozygous for
(p. Gln347stop)
Hepatic adenomas, history of
nephrolithiasis, arthritis requiring
large doses of aspirin
Epistaxis, gum
bleeding during
Easy bruising,
bleeding after
4 362 y 11 Compound
for c.371C.A
(p. Ala124Glu)
and c.1039C.T
Hepatic adenomas
53210 mo16 Compound
heterozygous for
and c.1039C.T
heterozygous for
and c.1039C.T
Hepatic adenomas Bleeding during
6 3114 mo 22 Hepatic adenomasNone
72818 mo 15 NA HypothyroidismEpistaxis, easy
bruising, gum
8 368 mo11 or 12NAHepatic adenomasEpistaxis, easy
bruising, gum
36NA Mid 20sNA None Epistaxis, easy
bruising, gum
GSD 1, glycogen storage disease type 1; p.o. t.i.d., orally, three times per day; ED, emergency department; IUD, intrauterine device; NA, not
* Only one time point available.
†Glycogen storage disease IB.
Austin et al Menorrhagia and Glycogen Storage Disease IOBSTETRICS & GYNECOLOGY
Page 4
Severity of Menorrhagia
and Duration
Need for
Because of
Vaginal Bleeding
Level Median
(g/dL) and
Range (Normal,
Need for
Past Treatments
for Menorrhagia
Treatment for
and Outcome
Soaking 4 pads in an hour and
soaking through night clothes
at approximately age 20 y
Heavy and irregular periods
beginning at age 23 y and
lasting for approximately 5
mo before initiation of
Yes9.5 (8.0–10.7)YesNorethindrone acetate 5 mg
p.o. t.i.d.
Ethinyl estradiol
Uses progesterone
as needed for
heavy bleeding,
ablation is
Yes9.9 (2.6–13.0) Yes Transvaginal estrogen
treatment, cyclic
acetate (not responsive),
estradiol or norethindrone
acetate transdermal
No response to
Soaking through menstrual
pads and bed sheets,
occurring inconsistently
since kidney transplantation
Passing clots larger than 1 inch
in diameter, soaking through
night clothing, soaking
through more than one pad
in an hour, lasting for
approximately last 14 y since
age 16 y
Passing clots larger than 1 inch
in diameter and requiring
iron supplementation, lasting
for approximately 7 y since
age 22 y
Yes (bleeding
10.7 (8.7–12.3) No Endometrial
None, no
after liver
Yes (ED x 3 visits)10.45 (6.3–14.9)No Ethinyl estradiol and
No10.2 (9.5–11.1) Yes (during
Irregular menses with cramping
and sometimes heavy
menstrual bleeding, started
oral contraceptive pill at age
13 y because of menorrhagia
that often required
emergency department visits
Menses often lasting 2 wk or
more with moderate
bleeding (3 tampons per day)
Yes12.85 (10.9–14.0) NoNonePatient plans
ablation or
Yes11.7 (11.0–12.5) NoMedroxyprogesterone
acetate, did not respond
to progestin-only pill, for
8 mo beginning at age 23
Did not respond to oral
norethindrone, responded
to combined pill but had to
discontinue with the
diagnosis of hepatic
adenomas, dilatation and
Ethinyl estradiol and
norethindrone but
stopped soon after
starting because of fear of
risk of liver damage
Irregular periods every 6 wk,
bleeds through night clothes
and tampons
No11.6* NoNone, stopped
Heavy period with clots lasting
7 d; soaks through night
No 9.8 (9–10.6) NoNone,
VOL. 122, NO. 6, DECEMBER 2013Austin et al Menorrhagia and Glycogen Storage Disease I
Page 5
our center, regular abdominal imaging studies are
usually extended into the pelvic area to evaluate for
leiomyomas, polyps, endometrial hyperplasia, and
cancer. The patients treated at our center were offered
care for their menorrhagia by a gynecologist with
experience in glycogen storage disease type I (A.J.);
other patients were referred to a local gynecologist
with advice from our center. Interventions included
noninvasive (hormonal therapy) procedures, invasive
surgical procedures, or both.
Descriptive statistics were used to characterize the
patient population and laboratory results. Mann-
Whitney test was used to differentiate median values
groups. Metabolic and coagulation parameters were
reported as mean6range values. P#.05 was consid-
ered significant. A 95% confidence interval was used.
and nonmenorrhagia
In this study of patients with glycogen storage disease
type I, we evaluated 13 for menorrhagia. Their ages
ranged from 23 to 48 years. Nine women (69%;
confidence interval 0.39–0.91) had manifestations of
menorrhagia; results are summarized in Table 1.
Menorrhagia or other menstrual abnormalities have
not been documented in the remaining four patients.
Most of the patients with menorrhagia experi-
enced abnormal bleeding in their late teens to early
20s (average age of onset was 18 years). Participants
described their periods as heavy, with significant
bleeding lasting from 1 to 3 days per period. Four
women described their cycles as lasting more than 28
days. Six patients were not using hormonal therapy
before the onset of their heavy periods; documenta-
tion regarding hormonal therapy before the onset of
menorrhagia was lacking for three patients. The
menorrhagia was severe and even life-threatening in
some instances, because four patients required hospi-
talization or emergency department visits and three
patients received blood transfusions. One patient has
been hospitalized and received transfusions several
times over the past 8 years. Leiomyomas, polyps,
endometrial hyperplasia, and cancer were excluded.
Hemoglobin was documented to be as low as 2.6 g/dL
in the menorrhagia group, in which all patients were
anemic during at least one time point (data in Table 1).
Median hemoglobin in patients without menorrhagia
was as low as 9.55 g/dL (range 9.55–11.0 g/dL; data
not included). There was no difference in median
hemoglobin levels between patients with and without
menorrhagia; however, there were three patients in
the group with menorrhagia requiring a blood trans-
fusion, including one patient during pregnancy, and
four patients required hospitalization for vaginal
bleeding or menorrhagia. Platelet counts were normal
for all patients.
Tables 2 and 3 show the results of metabolic pa-
rameters for women with and without menorrhagia,
respectively, expressed as median value and range,
obtained during the reported period of menorrhagia.
Both groups of patients with glycogen storage disease
type I had hyperlactatemia and hyperlipdemia. How-
ever, the group of patients with menorrhagia showed
a more adverse metabolic profile in the form of lower
blood glucose levels (the median was in the hypogly-
cemia range) and higher lactate levels and triglycer-
ides when compared with the nonmenorrhagic group,
although the difference was insignificant (P#.05).
Tables 4 and 5 show the results of coagulation
parameters in patients with and without menorrhagia,
respectively, expressed as the median value and
range. Coagulation studies showed that median values
for adenosine diphosphate–induced platelet aggrega-
tion, von Willebrand factor:Ag, and von Willebrand
factor:RCo were generally lower in the menorrhagia
group compared with the nonmenorrhagia group, but
the difference was not statistically significant (P#.05).
The lack of statistical significance is likely secondary
to the low statistical power given the small sample
sizes because of the limited number of patients who
had available study data during that time. Of note,
seven of nine patients with menorrhagia and four
of four patients without menorrhagia (data not
shown) also reported other symptoms indicative of
a bleeding disorder, such as easy bruising, excessive
bleeding after surgery, or gum bleeding and nose
bleeding (Table 1).
Six of the nine patients with menorrhagia had
documented liver adenomas. Two of the four patients
without menorrhagia had liver adenomas. Eight
patients with menorrhagia (89%) in our study used
hormonal therapy. For seven of nine patients, hor-
monal therapy was prescribed for management of
menorrhagia. Patient 3 had an endometrial ablation
after medroxyprogesterone therapy was not sufficient
enough to correct her bleeding, and another woman
(patient 8) was treated with dilation and curettage in
addition to failed progesterone only therapy. This
patient (patient 8) had success with combined estrogen
and progesterone therapy but had to discontinue the
use of estrogen because of development of liver
adenomas. Patient 4 was initially treated with ethinyl
estradiol and norgestrel and medroxyprogesterone
acetate therapy, but she reported that her menorrha-
gia and metabolic parameters did not improve until
she received a liver transplant. Patients 8 and 9
Austin et al Menorrhagia and Glycogen Storage Disease IOBSTETRICS & GYNECOLOGY
Page 6
eventually discontinued hormonal therapy as a result
of hepatic adenomas and patient anxiety regarding
liver damage.
As patients with glycogen storage disease type I live
longer, newer perspectives of the natural history of the
disease are emerging. Menorrhagia is an under-
reported problem that should be evaluated in these
patients and added to the list of causes of anemia in
females with glycogen storage disease type I.
Possible causes of menorrhagia in glycogen
storage disease type I are related to an acquired
bleeding diathesis attributable to von Willebrand–like
defect,10platelet dysfunction,9or both. Autoimmune
hypothyroidism, which may be particularly more
common in glycogen storage disease type Ib, could
be another contributing factor.16The platelet defect in
glycogen storage disease type I has been described as
an acquired qualitative platelet abnormality manifest-
ing by decreased prothrombin consumption, abnor-
mal aggregation reactions, prolonged bleeding time,
and low platelet adhesiveness.9In the patients with
menorrhagia, metabolic control seemed inadequate
compared with that in the group without menorrha-
gia; however, the sample numbers are small. These
findings combined suggest that patients with glycogen
storage disease type I and menorrhagia had a more
significant bleeding defect related to platelet dysfunc-
tion and von Willebrand factor abnormalities.
Patients with glycogen storage disease type I are
already at risk for chronic anemia. The anemia can
occur for several reasons, such as restricted diet,
bleeding within liver adenomas, and renal involve-
ment. Additionally, Roy et al13found that anemia,
often iron refractory anemia, in glycogen storage dis-
ease type I was related to the production of hepcidin
from large hepatic adenomas. Six of the nine patients
with menorrhagia in this study had adenomas; unfor-
tunately, a measure of hepcidin is not clinically avail-
able. As a result of the anemia, the episodes of
menorrhagia these patients experience add additional
burden to their already strained hematopoiesis.
In our study, eight patients were prescribed
medical or surgical intervention for management of
their menorrhagia at some point in time despite
attempts to optimize dietary control. In patients with
Table 2. Metabolic Parameters in Patients With Menorrhagia
mg/dL) (n59)
Triglycerides (mg/dL)
(Normal\150 mg/dL)
Lactic Acid
(Normal 0.5–2.2
mmol/L) (n58)
Uric Acid (mg/dL)
(Normal 2.5–8.0
mg/dL) (n59)
Glucose (mg/dL)
mg/dL) (n59)
Median range
261 (216–443) 647 (507–1,194)8.2 (5.1–12) 6.2 (2.6–10.7)
* Glycogen storage disease Ib.
Table 3. Metabolic Parameters in Patients Without Menorrhagia
(mg/dL) (n54)
(mg/dL) (n54)
Lactic Acid
(mmol/L) (n54)
Uric Acid
(mg/dL) (n54)
(mg/dL) (n54)
Median range (minimum–maximum)
288 (164–349)535 (363–580) 4.9 (2.6–6.9)7.3 (6.8–10.8)97 (61–151)
* Glycogen storage disease Ib.
VOL. 122, NO. 6, DECEMBER 2013Austin et alMenorrhagia and Glycogen Storage Disease I
Page 7
glycogen storage disease type I, the role of dietary
management is well-known, and its effect on meta-
bolic control is maintained through patient compli-
ance. Metabolic compliance can be a challenge,
especially in children and young adults with chronic
illness. Adherence to a treatment regimen is compli-
cated and dependent on many factors.17Improved
metabolic control may improve the hemostatic abnor-
malities.5,10For patients with glycogen storage disease
type I who have not shown improvement with dietary
management alone, referral to a hematologist with
experience in coagulation abnormalities is indicated
for further management because they may benefit from
other forms of hemostatic therapy such as 1-desamino-
These agents have side effects that need to be moni-
tored carefully.
Our recommendation is that a gynecologist
should perform a full gynecologic evaluation and
use usual gynecologic therapies to manage menorrha-
gia. Given the risk for adenomas in glycogen storage
disease type I,20,21special considerations have to be
taken into account when prescribing hormonal treat-
ment for menorrhagia. Estrogen is known to contribute
to both benign and malignant hepatocellular tumors.22
As a result of the increased risk of adenomas in patients
with glycogen storage disease type I, estrogen should
be avoided whenever possible.23Progestin-only contra-
ceptives do not pose the same risk and may be used;
however, with long-term use of medroxyprogesterone
acetate, there is risk for reduced bone mineral density,
which needs to be monitored in this population.24
Because of neutropenia, there is increased risk of infec-
tion in patients with glycogen storage disease type Ib,
and whether this infection risk extends to intrauterine
devices is unknown.
Experience with treating menorrhagia in other
bleeding diathesis has suggested endometrial ablation
as a promising option since the early 1990s.25Endome-
trial ablations are less invasive and quicker than hys-
terectomies. A review of the Cochrane database by
Lethaby concluded that the newer second-generation
Table 4. Coagulation Parameters in Patients With Menorrhagia
von Willebrand Factor
Antigen (Normal for O Blood
Type Group 40–150; Not O
55–190) (n55)
von Willebrand Factor
Antigen Ristocetin Cofactor
Activity (Normal for O Type
Blood Group 45–130; Not O
65–150) (n55)
ADP Aggregation
(Normal[60) (n54)
Median range
46 (34–84)43 (25–81)45.5 (33–88)
ADP, adenosine diphosphate; NA, not available.
Table 5. Coagulation Parameters in Patients Without Menorrhagia
von Willebrand Factor
Antigen (Normal for O Blood
Type Group 40–150; Not O
55–190) (n54)
von Willebrand Factor
Antigen Ristocetin Cofactor
Activity (Normal for O Blood
Type Group 45–130; Not O
65–150) (n54)
ADP Aggregation
(Normal[60) (n54)
Median range
66.5 (41–101)60.0 (22–109) 62.0 (45–95)
ADP, adenosine diphosphate; NA, not available.
* Glycogen storage disease Ib.
Austin et alMenorrhagia and Glycogen Storage Disease I OBSTETRICS & GYNECOLOGY
Page 8
techniques of ablation, which treat the whole cavity at
once, are easier to perform and safer.26In 2005, au-
thors from the Mayo Clinic concluded that endome-
trial ablation appears to be a safe procedure that
improves the quality of life in patients with von Wille-
brand disease–related menorrhagia.27However, its
long-term efficacy appears to be lower in patients with
von Willebrand disease when compared with women
with menorrhagia without von Willebrand disease.
Subsequently, a 2012 study by Huq et al28showed that
endometrial ablation appears to be a safe and effective
long-term treatment for heavy menstrual bleeding in
women with inherited disorders of bleeding. They
found that it significantly decreased menstrual blood
loss and improved quality of life.28
The limitation of this study includes lack of
knowledge of the exact pathophysiology of menor-
rhagia. Further analysis of ovarian function and
endometrial pathology is required to determine
whether the menorrhagia in these patients is attribut-
able to bleeding diathesis, poor metabolic control,
endocrine dysfunction, or other factors. These pa-
tients are also at risk for development of other
gynecologic pathologies prevalent in the general
population. Given the increased incidence of poly-
cystic ovarian syndrome and insulin resistance as
described in the study from 1995 by Lee et al, they
are more likely to have anovulatory bleeding.7,29
When anovulatory, these patients are at risk for devel-
opment of endometrial hyperplasia and endometrial
carcinoma because of unopposed estrogen.30Endo-
metrial ablation in the setting of hyperplasia can mask
the detection of superimposing cancer, and therefore
is not a good therapeutic option in this situation.
Treatment with an intrauterine levonorgestrel device
or oral progesterone and close monitoring is a safe
option in these patients because they address the issue
and can prevent progression to endometrial carci-
noma.31However, if the bleeding is attributable to
a bleeding diathesis, these patients are good candi-
dates for endometrial ablation or for strategies to treat
the underlying coagulation defect.18,32Careful risk
benefit evaluation is necessary because of the risk
for infection in patients with glycogen storage disease
type Ib. There is no available literature to guide in this
decision-making. Thus, we recommend further stud-
ies addressing pathophysiology of menstrual bleeding
in glycogen storage disease type 1b and safety of lev-
onorgetrel intrauterine devices.
Menorrhagia is a clinical manifestation of bleed-
ing in a subset of females with glycogen storage
disease type I that warrants further systematic study
in the future, perhaps as a collaborative effort with
a larger group of patients. The lack of statistical
significance in this study is likely attributable to the
low statistical power given the small sample sizes. In
a given patient, it is necessary to evaluate whether the
cause of the bleeding is attributable to an endocrine
issue, hematologic factors, metabolic control, or other
factors. Specialists treating females with glycogen
storage disease type I need to be aware of this
condition. The multidisciplinary management team
approach for females with the disease should include
the expertise of a gynecologist and hematologist
familiar with the condition.
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