The American Cancer Society has released new guidelines for Mammogram Screenings. We know you’ve likely read a lot about it. I thought I’d hand it over to our old friend and writer Julie, a longtime MiddlesexMD blogging pal, who has breasts of her own and some thoughts to share on what to do when new guidelines hit the airwaves.

Guideline Headlines!!! Okay girls! Grab them and run! But which way! When? Where? But wait!!! No!

No! These guidelines are saying to maybe squish less often? For some of us? Really? To not start so soon? Who are these people?

I’m confused.

With the latest release of Breast Cancer screening guidelines from the American Cancer Society, it’s easy to feel a little—entangled—in questions of when and whether to handle our screenings. And no wonder. The discussions are very much in the air, and the experts are agreeing to disagree. Very politely.

It wasn’t the intention of the committee to create this confusion, of course.

They truly wanted to offer up more leeway in guidelines, particularly for women with average risk of developing breast cancer—and that’s most of us. But leeway is very hard for most of us to interpret. Most of us just want very clear direction. We want safety and assurance. We want to avoid unnecessary exposure to radiation and unnecessary medical procedures. That’s not too much to ask, is it?

Well, we can’t have absolute assurances from medical guidelines. It would be so nice if we could. We can only get the best advice from smart committees working from what data they have to keep the greatest number of us safe most of the time.

So the new guidelines ease up on the youngest women, aged 40-45, saying they don’t need to start screening if they have average to low risk of breast cancer. Of course we women in menopause are already screening our breasts, have already been at it for years by now. Now we are wondering what to tell our daughters. And we will be getting different advice from at least three of the six breast-cancer-guideline-writing organizations in the US alone.

In fact all of those concurrent guidelines exist out there already, in our doctors’ heads. And online. And in our restless heads and hearts. So what do we do with all of this various information?

First… We breathe.

Then…  We remember, that we are each in charge of our own bodies. Guidelines are there just as a framework of reference. In practice, we each are working on our particular realities, which must be dealt with in the particular, with a plan that takes in all of the unique, unusual, specific aspects of our own bodies, or our daughter’s, their daughter’s.

So, I’ll take me, for example.

Those guidelines would suggest, since my breasts have been around for 55 years (well, one of them. The other seems much, much older), and in my family there is no history of breast cancer at all, and I have no current cancer markers, good and good. But… I’ve had so many surgeries and lung problems my chest as been radiated enough in my lifetime to light up Tokyo on a moonless night, which is not so good, and I’ve had to have a few lumps biopsied here and there, which have markers they like to peek at now and again, so….. Yeah I’m signed up for annual scans. Am I worried? Not really. But I’m committed. My sister, with the same family history, may logically choose to scan less often. Because she’s been much healthier throughout her life.

A young relative in my family? Just turned 40. Did she need to go for her first exam? Not really, but she and her friends made a party of it at the local breast exam clinic. Wine and bites and breast squashing in paper robes. She could have put it off another 5 years, but she prefers to get this ball rolling. Preference plays a roll here. She is being cautious.

You see how this rolls. Family history + conference with your physician over your own medical history + your own ideas and feelings about medical tests at this time in your life, taken together with a careful review of the recommendations = your best plan for screening. That plan for screening? It changes year over year as you age. That’s how you do this. Review your plan each year for you. Discuss it with the women in your family. And your friends. Like. Discuss it. Out loud. Over coffee or tea.  Like, “What’s your breast scan plan, Mom?”

Like that.

It’s not rude.

No. It’s not.

Happy deciding, everyone.

It sounds like what you’re experiencing is “bridging.” There’s a “bridge” of tissue at the base of the opening of the vagina. When stretched, it will occasionally separate or tear. As we lose estrogen through menopause, those tissues lose elasticity; there’s also narrowing of the opening of the vagina.

A very successful solution is a “perineoplasty,” a surgical modification of that tissue. Like a small episiotomy (sometimes done in labor to ease childbirth), it involves a small incision and repair to relieve pressure. In this case, the repair is made from front to back rather than from side to side.

This procedure is done in the office, under a local anesthetic, with just a few absorbing stitches. In my experience, it’s very successful and much appreciated by women. Keeping things comfortable will often require some combination of localized estrogen, vaginal moisturizer, and a lubricant with intercourse.


Happy Vessels

We have a new product in the house, and our team is pretty excited about it. I’m asking some of my patients to work with it as well as trying it myself, and I’m hoping to see exactly the same success with us as the manufacturer has been seeing in their studies. The studies you can see here, in the Journal of Sexual Medicine.

This product, called Stronvivo, is a supplement for women and men.

And, before you worry about a doctor pushing Supplements, please hold on a minute. Good science backs this supplement up.

Stronvivo contains a stack of amino acids and minerals that are all essential to human life, but particularly helpful for supporting endothelial health—that is, strong blood vessels. These are amino acids and minerals that at our age we might not be easily getting or producing through our diets, metabolisms, or normal organ function.

And what are healthy blood vessels good for? They are great for the happy working of sexual organs. They are what make those organs go. Hers and his and theirs.

But, bonus! These same elements in these supplements are great for helping support the circulation of sexual hormones! Win-win! And especially a win for women who, because of cancer risk or preference, want to support what hormonal production their bodies can manage post-menopause without the aid of hormone replacement. This is a great offering for me as a physician. I love having a non-hormonal alternative I can present to my post-menopausal patients, and their partners!

And it plays out in the research of this formulation. The company tested their Informed-Choice, all-natural, US-manufactured product with women and men over 40 who have arousal issues. The results showed clinical improvement of the health of the endothelium, stimulation of nitric oxide production, reduction of platelet aggregation and adhesion, improved circulation, improved hormone production in the test subjects.

Clinical evaluations used the FSFI (Female Sexual Function Index), the PHQ-9 (Patient Health Questionnaire), the IIEF (International Index of Erectile Function, and the ADAM (Androgen Deficiency in the Aging Male) to measure female and male patients over 90 days. The women showed improvement in desire, arousal, lubrication, orgasm, satisfaction, and pain. The men improved in androgen levels and overall satisfaction.

And both women and men had improvement in mood, with less depression.

To understand the full potential, 90 days’ use is recommended for women; men may see full benefit after as little as 30 days.

Personally, I like the idea of a nutritional supplement that couples take together. It represents a kind of shared commitment to lovemaking and holding on to one another.

Also, from a purely medical point of view, keeping the smaller blood vessels of our sexual organs happy will keep your larger vessels happy. And that will keep your whole body working better through time.

And that makes this doctor very happy. If we’ve convinced you to give Stronvivo a try, you can order it here.

We have recently learned that women will live with incontinence 7 (seven) times longer than men will before seeking help for it.


I am the help, so I had to put this to my friends to help me understand why this would happen, because, well, frankly, I try so hard to be easy to talk with, and so do my colleagues, especially my colleagues and all their care teams in urogenital care.

So why, oh why would it take so long for anyone to come to us with such a difficult problem? No news could be more worrying.

As it turns out, it’s one of those problems many of us imagine is untreatable, undiscussable, more embarrassing because we imagine a leaking bladder makes us somehow… less. I just read the word on an incontinence forum: Unwantable. It broke my heart.

Then it sort of made me mad. Because nothing could be further from the truth! If a leaky bladder made us unwantable, most of us would be unwanted! Because here’s the truth! Humans Leak! I’m a doctor! I know this for a fact. We leak all over, all the time!

But particularly menopausal women leak. I hardly need to mention that, do I? Sneeze, leak. Laugh, leak. Giggle fit, leak. Dream about peeing, major leak.

Fully a third of us will experience some form of incontinence in our lifetimes. That’s way too many unwanted people, isn’t it? So of course that’s not right. Incontinence is just human. And it’s got lots of causes. And it’s treatable.

Today’s truth is, there are so many varied and layered causes, treatments and options for managing incontinence that we understand now so much better than before, it’s as if we have dozens of baseball bats we can grab hold of to smash that tired old stigma to bits.

But we have to do this out loud, and together, and among all of our friends and acquaintances. Let no one you know not help with the stigma smashing! It especially makes sense for us to pay attention to continence issues, and the great people who are helping us understand it and learn to manage it before it manages us. We look forward to sharing more on this and related topics from our friends at the Women’s Health Foundation, where resources are available for women of every age on all aspects of pelvic health.

Too, this month the National Association for Continence (NAFC) is gearing up with free classes all over the United States, and then continuing all year long with Twitter chats on bladder health to help you learn what you need to know to Stay Strong.

Their message: Kegels are important, yes. But we must learn to do them correctly. And they are not the only way to strengthen your pelvic basket. These coaches will teach us to get to know our whole anatomy and strengthen our entire pelvic arena by teaming up with physical therapists and pelvic floor experts across the country to help all of us learn and gain control that we may have lost or may have never had to begin with.

Knowledge is power. Partnering with a provider you trust can get you that knowledge quickly. Check out the Women’s Health Foundation and the NAFC website, where you can find classes, coaches, products, a forum to speak openly and honestly with other people who are experiencing exactly what you are, descriptions of different kinds of incontinence and lots of treatment options. It’s a whole new world for us. We don’t have to just live with any of it any more.

I’ve got much to catch up on, study up on, and share with you from my trip to the North American Menopause Society (NAMS) annual meeting a couple of weeks ago. It was a whirlwind of great talks, and such a marvelous time to catch up with colleagues who are doing wonderful work.

One of my all-time favorite people, Dr. Susan Kellogg-Spadt, who’s been a medical advisor here at MiddlesexMD, spoke at the conference! She was fantastic, of course.

She’s a nationally recognized expert in pelvic and vulvar pain and the Director of Female Medicine at the Bryn Mawr office of Academic Urology at the Center for Pelvic Medicine, in Rosemont, Pennsylvania. She treats patients throughout the United States as a vulvar specialist, sexual dysfunction clinician and therapist.

At her NAMS talk, Susan talked specifically about the sexual needs of menopausal women, and in some detail. We gain so much from having her in our field! But without further, um… gushing? Here are Susan’s top clinical pearls for our sexual health and happiness:

Add moisture daily. If we use a water-based, bioadhesive lubricant several times a week, regardless of sexual frequency, we can get a lot more comfort and satisfaction with sex and just make it easier to have an orgasm whenever we want to.

Nourish yourself. A Mediterranean diet has been shown to promote sexual function, (and, we just learned, perhaps lower breast cancer risk). And regular exercise improves mood and overall health, both of which contribute to better sex.

Talk it out. When we use “I” language to talk with our partners about sex honestly and in a non-accusatory way, we increase the chances of sexual success. Your NAMS doctor or therapist can help provide the vocabulary and communication tips.

Prioritize pleasure. Don’t wait for intimate time to just happen. Even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex. Putting it on your checklist may seem like a cold thing to do, but trust us, it gets hotter with practice.

Mindfulness matters. Reading or watching even the softest erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important. All mindfulness training can contribute to your ability to stay in the moment during your most intimate moments.

Intensity, baby. After menopause, many women need more intense stimulation to reach orgasm. Consider introducing vibrators into sex play. The term, “Doctor’s orders!” can be very useful here. You have our permission to use it.

Do try. Just opening up and talking about sex problems, and finding what can still be sexual successes, shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship. Mutual affection, honest attempts at exploring what is possible, comfortable, what still feels good, does amazing things for a relationship.

So my medical journals are telling me, again, that I need I need to eat better and keep moving. Gee, folks, thanks for the news!

But I rarely receive such specific advice as I have these past few weeks. They have handed me very, very clear directions:

  • Eat a Mediterranean Diet including extra-virgin olive oil.
  • Exercise 300 minutes a week.

Wait… Really?

Specifically….  for menopausal women… my medical journals are suggesting we do this to avoid breast cancer.

Well! That’s pretty specific! And pretty awesome when scientists are paying special attention to my favorite people!

So let’s look at these studies suggesting ways we just might, through diet and exercise, provide our bodies an optimal environment for fighting off breast cancer.

The PREDIMED study, published in JAMA, September, 2015, was conducted in Spain from 2003 to 2009, wherein more than 4,000 women at high cardiovascular risk, aged 60 to 80, were randomly placed on three diets: the Mediterranean diet, supplemented with extra-virgin olive oil (first cold-pressed), The Mediterranean Diet supplemented with mixed nuts, or a Low-Fat diet.

The results of this study have been coming out for some time, and have been fascinating. This latest release shows that those on the olive-oil-supplemented diet had a 68-percent lower risk of developing breast cancer than the other participants in the study. It’s one study, of course, and needs to be repeated, but it’s rather fascinating. Earlier outcomes of the PREDIMED study suggested the same diet resulted in a delay in cognitive decline for the same population. There will be more news from this cohort. We will stay tuned.

By the way, when shopping for olive oil, it is best to stick with first-cold-pressed, extra-virgin olive oil for your good health. It costs a little more, but that’s the healthy choice that this study is based upon. Cheaper oils have been heat-treated or chemically treated, and are no longer a healthy choice for your body.

The exercise link is a the Breast Cancer and Exercise Trial in Alberta, Canada, published in JAMA Oncology in 2015. The study followed 400 women. Half of them worked out for a half an hour a day, 5 days a week. The other half worked out for an hour a day, 5 days a week. They worked out at 65 to 75 percent heart rate for at least half of their workouts. All without changing their usual diets. The women were overweight, disease-free non-smokers, and they were followed for three years. Subcutaneous and abdominal fat and waist-to-hip ratio decreased significantly more in the high-exercise-volume group.

Since body fat increases postmenopausal breast cancer risk, this suggests this higher dose is a better dose of exercise for us to keep the weight off, the body fat down. Lower body fat is a better environment for lower breast cancer risk.

So I’m going to take a brisk walk to the grocery store, buy two big bottles of my favorite extra-virgin oil, and do biceps curls with them on the way home. Or maybe I’ll just stay a little longer on my treadmill and have a nice salad with dinner.

You say you’ve been using Replens regularly, and have noticed that hydrogenated palm oil is among the ingredients. You’ve heard that hydrogenated fats are unhealthy, and wonder whether you should be concerned.

You’re right to be concerned about ingesting hydrogenated palm oil in food products, especially if you have elevated cholesterol and triglycerides. As an ingredient for a topical product, though, like a vaginal moisturizer, the oil is safe and won’t affect your lipids. Applied to the surface of your skin or tissues, the moisturizer is not absorbed into your bloodstream.

Keep using that moisturizer! Keeping tissues health goes a long way toward comfort and enjoyment.


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