BC Becky

Never thought I'd want to be a breast cancer survivor

Category: Surgery

  • Healing Notes

    Healing Notes

    I had my surgery follow up appointment with my surgeon Tuesday. Unfortunately, I’m still producing too much fluid for my drain to be removed. This means that I still cannot shower. However, they did remove the dressings over the incision except the steristrips. I now have the magic number – 30mL – when my drain gets to below that amount in 24 hours I can call the doctor’s office and they will book an appointment for me to see the nurse in ambulatory care who can remove the drain. At the same time, she will remove the steristrips and clean everything up.

    I also talked to the nurse about the nice flannel drain pouch they gave me after surgery. I can return it, but also, I can make more and give them to her. She will send them into the hospital laundry and they will be given out to the next person that needs them. It was such a nice gesture that helped me feel like I was being cared for. I’m going to try and sew up a few of them to give to the nurse when she pulls my drain.

    I decided to pull out my shower chair (glad I still have it), and use it to help me “shower”. I was able to sit in the chair, lean forward, and use my hand shower to wash my hair. Then I could stand up and wash all my body parts below the incision. Everything else got a sponge bath. I felt so so much better after washing my hair and my body.

    One tip that I failed to mention from when I returned from surgery – a friend who is living with us right now lent me her breast feeding pillow. It is long U shaped tube, where the stuffing (feels like little styrofoam beads), can be moved around to make some parts thicker than others. This in combination with my 10 inch wedge pillow was brilliant. It meant I could easily adjust it to sit and read and use the other side of the pillow to support my arm. It gave me enough options for support that I could find a comfortable position for both watching TV and for sleeping.

    At the drain appointment I asked about radiation. The surgeon said not before 6-weeks after surgery. She said that it would be coordinated with my oncologist. If chemo is needed that typically happens first. So the treatment order would be: (1) surgery, (2) chemo if needed, (3) radiation, (4) hormone therapy. Zometa is actually a bone treatment and it is unclear to me whether that would start in line with hormone therapy or if the first dose might happen before radiation. I won’t know anything further until I see my oncologist – which won’t be until the third week of September.

    Biopsy results take 2-3 weeks, so there is no information yet – although I’m meeting with my family doctor today and we will discuss the quickest and best way for me to get my hands on results. My oncologist is on vacation the first two weeks of September, so I will likely have an appointment to see him sometime the week of September 20 – where the remaining treatment plan will be made. The earliest radiation could start would be the first week of October.

    I’m healing well. I’ve not been taking pain killers since the day after surgery. Mostly I have decent range of motion – but I need to be careful not to pull anything while it is still healing. I’ve been using my arm enough that my shoulder is moving well (one of the biggest post surgery concerns is frozen shoulder).

    If the weather permits, I’m going to try and take a day in September to go camping. August weather has been pretty horrible, with at least one torrential downpour each week (where we get over a month’s rain in a 24-hour period). Things then dry out just in time for the next deluge of rain. Hopefully September weather will be kinder.

    One curiosity I’ve had is what to wear during and post radiation. I didn’t do radiation first time around, so I really have no idea what to wear. The day before surgery I went out and bought a couple of short sleeve shirts that button up, as I remember having difficulty getting things over my head from my last surgery – that turned out to be less of an issue, but useful for getting home on surgery day. Since it is only the one side, I can easily maneuver to put a T-shirt on.

    Any tips on the types of clothing that would make sense to wear during radiation treatment?

  • Five more years … and a back update

    Five more years … and a back update

    It has been a whirlwind over the last two weeks – with an appointment with my oncologist and an appointment with my back surgeon.

    I was pretty bummed out after my appointment with my oncologist. He again said that I was moderate to high risk for recurrence and that he wants me on some form of hormone therapy for another 5 years. We talked about options, since I really didn’t go through all the options when I stopped a couple years ago. When I stopped I was in pretty poor health. I had just been diagnosed with celiac and high blood pressure and was suffering from lymphedema in my left arm. There was just so much going on that I had to remove variables in order to figure things out, and the first variable was hormone therapy.

    In our prior visit my oncologist floated the idea of 5mg of tamoxifen. I think it is something they are testing for cases of DCIS and previvors (BRCA without a breast cancer diagnosis). Anyways, I agreed to give that a try. And so, for the last four days I’ve been taking 5mg of tamoxifen at dinner time. It causes a slight headache (or at least it did the first couple of days, last night went better). Fortunately, I’m usually pretty mentally burned out by dinner time, so it doesn’t have a hugely negative affect on my productivity. So far, it is something I can live with, so I’ll try that for the foreseeable future.

    I also had an appointment with my back surgeon. He confirmed that we would not do a fusion. He also explained that it would be a “partial laminectomy”. His goal is to remove the least amount of bone possible in order to still reach the nerves. Unfortunately, one of my disk herniations is on the side, which means he will need to move the muscle on the one side to get access. That is likely the part to cause the most pain, as it like spraining your back (ouch). I’ll have a 4 inch incision, but most of that will be superficial, as they will make a tiny hole in the area under L5 in order to access the nerve there and he will shave the disk herniation that is causing the pain. The other herniation at L4-L5 is lateral, so it means he needs to move the muscle to access it. As I understand it, it is about a 1-2 inch area.

    In the end, I feel a lot better about the surgery. He is being as minimally invasive as possible. He is also doing the minimum that needs to be done to clear the nerve pain. I am hopefully that after this I can get back to hiking. It has been a year since I’ve been able to go on a decent hike and I miss it more than you can image.

    What I wasn’t encouraged about is some of the degenerative changes in my back. These changes mean that at some point in the future, I’ll likely need a fuse – but he commented that if I’m careful to avoid lifting anything over 10 lbs and avoid too much strain in bending or twisting, it could be 25 years before the fusion is needed.

    I can hope to live long enough for that to happen. He commented on maybe needing it when I’m 75. This might sound rather morbid, but I just cannot think about being alive for that long. With both my parents dying in their mid to late 60s, and my history of breast cancer, I think it would be a miracle if I can make it to 75! That being said, getting back to hiking and regular exercise will go a long way to helping make that happen. It certainly won’t happen if I become immobile.

    Come January I ask for your prayers and healing thoughts as I do this surgery. I am not allowed to break a sweat for 6 weeks, as the surgeon wants to ensure the incision is fully healed before I do anything cardio related. I am also limited to walking about a 1/2 mile. I’m glad I asked the question, because all the paperwork says that walking is good, but that is written for people who generally don’t walk much. Had I not asked I likely would have been trying to walk 1, 2, or even 3 miles which would not give my body enough time to heal.

    And with that update, I need to get back to work … and back to focusing on dissertation writing and end of term marking.

    Happy Thanksgiving everyone.

    Feature image was taken at Cape Disappointment State Park in Washington.

  • Is this normal? Spinal laminectomy

    Is this normal? Spinal laminectomy

    Is it normal to have surgery booked after a short phone call with a surgical fellow outlining what surgery is being offered? Is it crazy to think that I might want an in-person appointment where the doctors show me my scans and explain exactly what the procedures they are suggesting entail? I’m finding it a bit crazy that I need ask for this appointment.

    The same thing happened with my mastectomy and reconstruction – I ended up booking an extra appointment so that my surgeon could go over what my scars would look like. I wanted to know what to expect so that I could prepare for it. I didn’t want to wake up and be shocked by it.

    I now have a date for back surgery – January 2nd. Luckly, the surgery will not be a fusion of my spine. I had a call with the surgical fellow who said something about a double laminectomy – Spine-Health has a great video that explains what a laminectomy of the lumbar spine is. In addition to the laminectomy, they are proposing a discectomy for the herniated disc. The spine-health video shows the minimally invasive discectomy, however, I don’t think that is what is planned, as they will already be in the area for the laminectomy, so if I understand it correctly, they would have access to the disk already and wouldn’t need to open a new incision. I think the lumbar laminectomy video by Blausen is closer to what would happen in my case.

    It just seems odd to me that a surgery this serious would not involve more detailed consultation. I wonder if it is just that people put blind faith in their doctors and are not so concerned? I just don’t get it. I want more information. That being said, I also want the surgery date that they have given me. The window for healing is ideal as it is in the window where I’m not teaching, so I can focus on healing and writing my dissertation.

    And so now I’m waiting to hear back – and find out when I’ll have that appointment where we run through the details of the surgery, and I can see my scans and picture it within my specific context. I’m guessing that I just misunderstood and that the nurse just forgot to tell me that there would be a follow up appointment. Either way, I’m not going into surgery without one.

    Did you have a detailed consultation before surgery? Did you need to ask for additional appointments with your surgeons or their support staff (fellow, physician assistant, or nurse)?

    Feature image by BruceBlaus [CC BY-SA 4.0] via Wikimedia Commons.

  • Normalization of surgery and toes

    It struck me the other day that the whole concept of surgery has been normalized for me. I knew this about breast cancer surgeries – where the talk of lumpectomies, mastectomies, and reconstruction are just normal part of my vocabulary, but I didn’t realize how that also influenced other areas of my health.

    When my big toe pain came back (I have osteoarthritis in my big toe – I had a surgery about two years ago to clean out the joint which did relieve some of the pain), I went back to see the pediatrist. He recommended a synthetic cartilage implant (www.cartiva.net) that has recently been approved. What is interesting to me is that the studies were done in Canada and the UK.

    What struck me was that the idea of the surgery didn’t bother me in any way. The whole idea of getting a cartilage implant seemed cool more than anything else.

    I’m finding myself wonder, if my willingness to do this is in part because the whole idea of surgery has been normalized for me? I’m not worried about it. It doesn’t feel odd in any way.

    It is also interesting that I didn’t want implanted breasts, but I’m OK with implanted cartilage in my toe. I think part because the alternatives aren’t any better. My toe pain is back. It can be problematic at times. The surgery I had two years ago relieved some of the pain, but not all of it – and my range of motion isn’t great. The x-ray showed that the arthritis grew back. The pediatrist doesn’t think doing the same surgery again makes any sense, because it will just grow back. We knew when we did it, that is was just a stop gap. The idea was that it would give me 5-7 years before needing to fuse the joint. I didn’t get that long, but this option is much better than fusing. It it doesn’t work, then fusing is still an option, so it doesn’t take that off the table. So, logistical me says this is the right choice.

    Do you find that breast cancer surgeries have made it easier for you to approach other health issues?

  • Memories of clear nodes

    Memories of clear nodes

    It was two years ago today that I got the very good news that the initial pathology returned that my lymph nodes showed no signs of cancer. It was a few days later when the final pathology report came in that it was confirmed that my lymph nodes did not show any signs of having had cancer – so no dead cancer cells. Since I did chemotherapy first, if the cancer had spread to my nodes, the chemo may have cleared it out. We will never know 100% for certain what the pre-chemotherapy results might have been. It doesn’t really matter.

    Scott told me that I asked him over-and-over again about the status of my nodes as I woke up from anesthesia. It was the biggest unknown in my treatment. I had known that I had tumors. Scanning gave us a pretty good sense of how big they were. Although scans didn’t show us any signs of lymph node involvement, I wouldn’t know for certain until they removed the sentinel nodes (the first couple/few) and tested them for cancer.

    The sentenal node dissection was only a small part of the surgery that I underwent on November 19, 2014. I also had three lumpectomies (which were not really that successful – in that one didn’t have clean margins and one missed the tumor altogether). I knew that my surgeons were not really concerned about the success of the lumpectomies. They knew that they would be going back a month later to do a full bilateral mastectomy. The primary reason for this surgery was a devascularization of the nipple and areola. This was the first stage in the nipple sparing mastectomy. In addition to doing a biopsy of the lump nodes, they also took tissue for a biopsy of the skin under my nipples. If that showed to have cancer, then they would remove the nipples during the mastectomy. Fortunately, the nipple biospies were also negative for cancer.

    This was the first of three surgeries.

    It is hard to believe that was two years ago.

    Feature image CC-Share Alike 4.0 by Cancer Research UK / Wikimedia Commons

  • Trivializing rather than educating … #breastcancerrealitycheck

    Trivializing rather than educating … #breastcancerrealitycheck

    Get your tickets today to meet our panel of famous judges: <redacted>, Olympic Gold Medalist and World Cup Champion, <redacted>, First Lady of <city> and <redacted>, head of <radacted> Center for BRCA Research as they judge our unique display of decorated bras!

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    <cancer charity> Board Member, <redacted> will discuss new breast reconstruction developments and a special patient will share her journey through breast reconstruction.

    This fun evening will also include appetizers, gift bags and some shopping opportunities, all to benefit <cancer charity>.

    This just crossed my inbox. Now, amongst the pinkness of October (Breast cancer awareness month in case you missed it), there are special days within the month. One key example is BRA day – or Breast Reconstruction Awareness Day. But I fail to see how a competition to decorate bras does anything other than trivialize the exact thing it is trying to educate about. Worse, it makes women who chose to undergo these procedures feel like they are doing so for pure frivolous vanity. It totally delegitimizes something that is a perfectly valid medical procedure.

    Reconstruction was one of the hardest decisions I had to make. What made the decision harder was that I had to overcome my personal self-doubt but also concern over sigma relating to how breast reconstruction is done for vanity reasons. For those who followed my blog, you know that I was convinced I was not going to reconstruct. That was the sigma talking. That was my self-doubt over it being an option that would feed my vanity rather than something that might be critical to my long term mental health. I did a lot of soul searching, and really a lot of self-reflection before I could come to the decision to do breast reconstruction. The surgery was hell (10+ hours under, 5 days in the hospital). I also did a lot of research. I wanted to be truly aware of what I was signing up for.

    For those that want to actually gain some awareness about breast reconstruction, how about you start here: 10 Reasons why breast reconstruction isn’t a boob job by Nancy Stordahl, or maybe watch this great video by Dr. Lee at Stanford that talks about What every women should know about breast reconstruction.

    Breast reconstruction is an individual choice. It can be really empowering and healing to a breast cancer survivor. It is certainly not an easy choice. It is rarely done from a pure vanity perspective – it is hugely more complicated than that. I don’t know of a single breast cancer survivor who would have chosen to get cancer for the opportunity to get a “boob job”. Ugg.

    What gets more even more is that the organization that is sponsoring this, a local charity that provides services to cancer patients. One of their biggest groups of clients are breast cancer survivors. So, why is it that even these organizations are contributing to this type of non-awareness campaign. Could they not think of a better way to fundraise?

  • What if patients made the recommendations?

    What if patients made the recommendations?

    I was reading through Caroline’s post about What I wish I had known before treatment. She mentions an article about recommendations from breast surgeons regarding prophylactic mastectomy. There is concern that more patients are opting for them, even though there is no oncological benefit (article is here – if you want a copy and don’t have access, email me).

    I see lots of these recommendations – and misinterpretations of them. I found this article to be interesting because of its emphasis on individual patient decision making. It wasn’t pushing a particular recommendation, just saying that this is the evidence to help you and your patient come to a shared decision.

    I do wonder, however, what would happen if the recommendations came from patient’s rather than “evidence” that has not been humanized. I wonder if instead of giving patients the “facts” you gave patients a booklet or video of stories from different patients who opted for the different treatment options. You let other patients describe the impact of the different treatment decisions.

     

    A lot of the decisions that breast cancer patients need to make are emotional decisions. They are not necessarily logical decision. The choice between lumpectomy and mastectomy (when it is a choice) is individual, but patients aren’t adequately prepared to make that decision. They are presented with facts from a medical system perspective. For example, in the tools to help you make your decision you are told that if you have a lumpectomy, you will keep your breast however, you’ll need to be screened (e.g. mammogram or MRI) every 6 months. If you do a mastectomy there is no systematic screening. It is very much a medical system oriented description of things to help you make your decision. However, the decision isn’t strictly a medical decision – it is an emotional one. It is a quality of life decision. There are also a host of emotional and practical side effects that are never discussed. They are things that the medical system doesn’t care about, but the patient does.

    Age also matters in these decisions – and yet most of the evidence that is used for recommendations does not take this into account. A young survivor (I’ll use under 50 at diagnosis, although most use under 45) has very different longer term life circumstances when making their decisions – and yet that isn’t often taken into account when looking at statistics to provide recommendations.

    So I wonder, what if there was a resource that was a series of concise yet down to earth patient stories, told from a patient perspective? A retrospective analysis of patient experiences – provided in both storied text format and in video format. Something that really helps patients make decisions from a patient perspective, not a physician perspective. Something that deals with the emotional and longer term health impacts of the decision – not just from a medical system perspective but from a human who has to spend the rest of their lives living with the decisions they make.

    What do you think? Would this type of resource have helped you make a decision? Would surgeons be willing to provide this type of resource for patients? Would this be a useful discussion topic for Virtually Connecting ePatients?

    Feature image CC0 from Pixabay

  • Ack my boobs are deflating

    Ack my boobs are deflating

    One of the selling points with the DIEP flap reconstruction surgery is that it uses your own body fat (belly fat) to reconstruct your breast. In the decision making process one of the “advantages” to this type of reconstruction is that as you gain or lose weight, your breasts will resize too. But what they don’t tell you is that the fat used to make your new breasts isn’t the same as breast tissue (OK that should be obvious), but what isn’t obvious is that as you lose weight, if you normally would have lost that weight in your belly first, it means you lose that weight in your breasts first.

    I’m finally starting to shed some of the chemo and surgery weight that I gained. I’m down 20 lbs from my post-surgery weight in March 2015. What I’ve noticed with the last 10 lbs is that my boobs are deflating. I can no longer fill the tops of my dresses. Unfortunately, I’m not lose any of the width around my thighs. This is making fitting into clothing an interesting challenge, as my upper body is not aligning with my lower body.

    It has me wondering about my vanity again. In some ways I feel shallow. I’m feeling the cultural pressure to not do anything, because in my circles getting plastic surgery for vanity reasons just isn’t something that is done. And yet I wonder. If my boobs deflate too much (I think right now I’m the only one that really notices the difference), I find myself wondering about fat grafting. My plastic surgeon could take some excess fat from my thighs and graft it to my breasts helping to balance things out again. But that feels like pure vanity. I’m not really likely to jump into another surgery anytime soon – well almost not, I’m going to have a procedure done on my arthritic toe to help resolve that never ending pain but that is another story – I’m not someone who would voluntarily chose to do plastic surgery. And yet, I did. I didn’t have to do breast reconstruction, but I am very glad that I did. Every time I put on a swimsuit or change at the gym, I’m happy that I had reconstruction done. I’m even OK with showing my scars, although I do try to be discrete about it.

    Just like when I reported that my body floated differently in the pool, I thought it interesting to share that as I lose weight the places the fat shrinks first has changed.

    Did you have a DIEP procedure? Did you notice a difference when gaining or losing weight?

    Feature image CC0 from Pixabay

  • Memories

    As my one year cancer free day is fast approaching (December 17, 2014 is the date the last of my cancer was removed from my body), I am finding myself having flashbacks to my diagnosis day. I am not remembering the storm the week before surgery, nor how low I was feeling. Instead I’m remembering some of my thoughts upon initial diagnosis.

    I am remembering how I thought to myself If I get treated at Stanford does that mean I get to buy the sweatshirt? Finding it tacky wearing university clothing for schools that I’m not associated with. Fortunately, I’m associated with enough schools that my sweater collection isn’t lacking.The answer to that question was a resounding yes. I wore my Stanford hoodie to almost every doctors appointment and chemo session. Now I’m wondering Now that I’m one year cancer free can I buy myself a new Stanford sweatshirt? Or do I move on and just get sweatshirts/hoodies for the schools I’m teaching at/studying at?

    As I write the question, I reflect on just how trivial it is. Not a big decision.

    The other memory I’m having is that of Window Shopping. I recall that morning (before treatment, while we were still waiting for pathology results), walking through Sausalito, finding myself staring at women’s breasts. Scared. Not knowing what was going to come next.

    In the midst of these flashbacks, Facebook reminds me of the rain storm at this time last year. It rained heavily for three days straight. The rain would mean that the emergency rooms were busier than normal for this time of year. It also meant that the hospital was a complete zoo when it came time for me to check-in for my surgery.

    Those are my memories for this time of year.

    Another lifetime ago, in December 2008 we were visiting Antakya Turkey. We were preparing to get back on our bikes and ride into Syria. That was a lifetime ago!

     

  • October – it’s just another month

    Last year, I found myself reflecting on all the pinkness of October. I recall thinking that October will always mean something different for me. I blogged about how I wanted to kill all the tacky fundraisers and really talk about what it means to experience breast cancer – it isn’t about pink ribbons.

    This year, my Pinktober experience has been different. I haven’t seen so many outwardly offensive advertising campaigns. No pink drill bits. No show your boobies for breast cancer advertisements – which is by the one, of the most offensive things one can do for breast cancer survivors, many of whom are suffering from severe issues with body image.

    This year, my Pintober actually began in September. First with my presentation at the Queens University of Belfast ePatient blogging and microblogging conference (#qubept). There, I gave a presentation on the impact breast cancer blogs have on those who read them. In that presentation, I weaved in my personal story with the data I got from the survey. I really enjoyed writing in that mixed paradigm – as both a cancer survivor and as an academic. You can read my presentation here or see the recording here.

    A couple of days after returning from Northern Ireland, one of the support groups that I’m a part of launched their new book “Shivering in a Paper Gown: Breast Cancer and its Aftermath: An Anthology”. One of the stories in the book (page 20) is based off of a couple of blog posts I wrote, titled “Breast that are not Breasts“. I read the story to a very packed room at the book launch.

    With that, Pinktober began and for the most part I ignored it. A friend asked me to write a blog post about what advice I would give for anyone going through cancer now – along the lines of a lesson I learned that I wish I knew before treatment. She wrote a lovely post that integrated the thoughts from six women – although I’d personally change the title to add the work survivors at the end, as the lessons are not from “breast cancer” but rather from breast cancer survivors: Six Lessons Learned From Breast Cancer. It felt more like what I was seeing this year in Pinktober – more useful resources and less tacky marketing.

    Another friend lunched an important project for research on metastatic breast cancer. If you have mets, I highly recommend you take a look at the Metastatic Breast Cancer project (https://www.mbcproject.org/). There is also a Facebook group for those who wish to follow using that media.

    The other aspect of October that I am much more aware of this year is BRA day (yesterday). More specifically Breast Cancer Reconstruction Awareness Day. The shorthand BRAday makes me think of all things tacky about breast cancer; however, I think the movement itself is an important one. I had someone reach out to me about I post I wrote last year where I struggled with the vanity of breast reconstruction. Early in my breast cancer treatment I was completely incensed about how I was informed about breast reconstruction. Perhaps it was because it was a male surgeon who said it? Perhaps it was because he just got finished telling me I had cancer, and needed a double-mastectomy, but the “good news” was the insurance had to pay for reconstruction. It wasn’t the message I was ready to hear – but for many women it is a message that needs to be heard, because they are not getting it. They don’t know that the option is available to them.

    For me, my breast reconstruction decision is every present when I swim (which is frequently). Every time I put on my bathing suit and walk out to the pool, I’m highly aware of how my reconstruction decision means that I don’t need to worry about prosthetics or how I look in the pool.

    I’ve joined a swanky gym (something I can only afford because of the deal I get from the wonderful folks at Sunflower Wellness). It is more of a country club then a gym. They do, however, have good cardio machines and a great adult swimming pool. Actually, they have two 25 meter pools, the one that is adult only is a couple degrees cooler and almost always available for lane swimming – plus it is a clean salt-water pool – truly wonderful! After my swim yesterday, I notice there were a lot of people tanning or just hanging out in the lounge chairs around the pool. I felt like all eyes were on me as I walked to the change room. Feeling like I didn’t ‘belong’ in this swanky club. But, the pool is great and open all winter (my condo pool closes at the end of the month). I’m going to continue going to the gym, but will probably try to get there a little earlier in the day when the pool is area is less crowded (the pool itself wasn’t that busy).

    The women’s locker room is a bit of a challenge for me. Many of the women walk around naked. I am very self-aware about my scars. I opt to be as discrete as possible when I’m changing into my swim suit or getting dressed after my shower. I don’t think that I would have had the inner strength to manage this had I not had reconstruction. Now I find myself wondering if the women in the club think that I did it strictly for vanity reasons?

    I also find myself contemplating nipple tattoos. A few months ago I bought some rub-on tattoos but haven’t had the courage to try them. Now I find myself wondering if putting them on would give me more confidence at the gym? My friend Stacey talks about how the rub-on tattoos help with inner confidence. In some ways, it is part of the healing process, and part of the reclaiming process. We are reclaiming our female bodies after cancer has taken parts away. I may seem vane or trivial, but it is not. It is a small thing that we CAN do. As a ‘young’ person being thrust into menopause, having all the estrogen in my body blocked in order to prevent breast cancer recurrence, I cling to the aspects of femininity that I can control. I try to fight the side effects by exercising, and strengthening. I need the self confidence that allows me to workout at the gym, and swim in the pool, and change in the women’s locker room.

    So this year, October is just a month, like any other month. It is one where I am working on both inner strength and outer strength. I am working on healing.

     

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