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Archive for July, 2012

Lichen Slerosis is a skin disorder that most often appears in the genital area. Early on, there are small white spots, which grow and become thin and brittle over time. We’re not quite sure of the cause; theories include immune system issues or hormone problems. It’s more common among post-menopausal women than those who are younger. Certainly it can cause discomfort during intimacy, itching and burning or even scar tissue.

I have found Neogyn Soothing Cream to be helpful for a number of different conditions, since it is, as the name says, soothing and it promotes healing. There’s been some limited research on using Neogyn in Lichen Sclerosis, and early indications are favorable.

Topical steriods are the mainstay of treatment for Lichen Sclerosis, but if something precludes your use (like active herpes, for example), Neogyn can be beneficial—or you might use it in addition for extra comfort and healing.

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Recently, I took a photo of my college-age daughter. I saw a beautiful young woman in a candid moment—smiling, long hair blowing in the breeze, everything youth should be.

Her reaction?

“Look how dumpy I am. Look at my belly. My boobs are so big.”

And at the other end of the generational divide, a grandmother in her early 80s complains about how fat she is and compares her breasts to “rocks in socks.”

Ladies, will we ever get beyond all this negative chatter and learn to accept, if not love, the only body we will ever have? Will we ever stop wasting valuable energy judging ourselves according to totally unrealistic cultural standards?

Unfortunately, I’m not that self-evolved. Are you?

Do you make love under cover of darkness (or maybe just under the covers) because you’re embarrassed by the cellulite and love handles? Have you avoided looking in mirrors ever since you saw your mother (and maybe now, your grandmother) looking back? Do you head for basic black and avoid wearing the colors and patterns you really like? Do you hate being photographed? When was the last time you wore a bathing suit?

In 2009, Glamour magazine repeated a survey it had conducted 25 years earlier. Sixteen thousand women were asked about their body image—how they felt about their looks; what they like and didn’t like. The results: “Sadly, more than 40 percent of women are unhappy with their bodies, a number virtually unchanged since 1984.”

Even more telling—women under 30 are now more likely to feel good about their bodies than older women, which is different from the 1984 survey.

It’s understandable, of course. We’ve been drinking the cultural Kool-Aid about youth and beauty since infancy. Now we’re staring down the final taboo: We’re growing old. Not only that, but those bodies we may (or may not) have reached an uneasy peace with are changing, too. They’ve developed bags and wrinkles, aches, pains, and excess avoirdupois. And no matter what we do to turn back the clock, this process will continue relentlessly and irrevocably.

This may be a good thing. This may allow us to finally claim who we are, undistracted and unburdened by the judgmental nattering all around us. When we can finally face down our shaky self-image and put our insecurities to bed. Perhaps we can appreciate and develop the things that really matters—our relationships and our own unique and beautiful selves. And maybe, having shaken off that critical voice, we can finally engage more freely in life and love and the world around us.

Sounds like a worthy goal at least.

Here are some ideas to get started:

  • Monitor your thoughts. To paraphrase an old saying: You are what you think. Do you cultivate a stream of negative thinking about yourself and others? Observe where your mind wanders and how you react to things. Try to turn negative thoughts and judgments in a positive direction.
  • Watch your mouth, too. Turn off the gossip and negative chatter—and that includes putting yourself down.
  • Cultivate friendships with joyful people who inspire you and are healthy to be around. Identify some unofficial life coaches who have experience, wisdom, and joy to share. Ideally, you’ll take your place among these mentors soon.
  • Identify things that make you feel good about yourself, whether it’s a massage, volunteer work, an afternoon with a special friend or an evening with your honey.
  • Don’t diet. Most people who diet gain the weight back anyway and are obsessed with weight, guilt, and counting calories. Instead, make your goal a healthy lifestyle. Focus on eating well and healthfully.
  • Do move. Getting active physically not only makes you feel better, but you’ll also feel better about how you look. “Being active in and of itself improves body image,” says Jim Annesi, PhD., in the Glamour article. And getting those joints moving increases flexibility and reduces the aches and pains, which incidentally helps with the next point…
  • Have sex. Paradoxically, the activity that is most likely to trigger our insecurities can also embolden us and restore our self-confidence. “Women who are able to get past those insecurities can find those fears are unfounded and realize how empowering it can be to experience pleasure and connection with another human being,” says gynecologist Hilda Hutcherson. So, after changing your thought patterns, developing a healthy lifestyle, and cultivating positive friends, the final payoff can be uninhibited sex with someone who ideally loves you just the way you are. With the lights on.

Have you noticed how attractive joyful people are? How age has its own special beauty? Have you noticed that beautiful woman with joy in her eyes and the wrinkles and lines of experience on her face?

That’s you.

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A Hot Time Tonight

Let’s face it. When you get to this stage of the game, and especially if you’ve been with the same partner for years, you may be wondering whether sex is really worth all the bother. Is it really worth the time, the mess, the mental energy? Why not just let it go the way of your vanishing waistline?

Well, you might consider that many couples in their mature years have discovered a kinder, gentler sex life that enriches their relationship and keeps their finger on this essential juiciness of life. You might think twice about closing the door to this most lovely of intimacies with a person you love. You might reconsider losing this thing that keeps you in touch with sensuality in the broadest sense. As Dr. Christine Northrup said in an interview, “Menopause is the fork in the road where one side says ‘Grow,’ and the other says, ‘Die.’ Menopause… like the fall of the year, is an open window.”

Libido is a fragile flame at this stage of life. We can snuff it out, or we can coax that flicker into a cozy fire. And like other parts of our life, with some nurturing, some honesty, and some practice, sex can become one of the delights of our mature years.

So, maybe it’s time to rethink attitudes and values you’ve carried with your throughout your adult life. Your body, your libido, and your responses—and maybe your partner’s vim and vigor—are changing anyway, so maybe it’s time to bring some open-mindedness, more compassion and patience (and maybe some new moves) to the bedroom.

First, you have to discover what pleases you sexually. You might have a hard time articulating or even knowing what turns you on. Maybe you haven’t thought about it, or you’ve focused on your partner’s pleasure, or you’ve never enjoyed sex all that much, or you’ve been too self-conscious for that kind of exploration.

Have you ever considered that the biggest turn-on for your partner is when you’re turned on? And that it doesn’t even take penis-in-vagina sex to turn you on? “The good news is, men do not need a penis to pleasure a woman,” says Dr. Northrup, “and it’s very important to a man’s self-esteem that he know how to pleasure a woman.”

So, the first order of business is to find out what pleases you and then to communicate that to your partner.

So—explore your sexual parts! Get to know yourself and what feels good and where. Practice. Masturbate. You’ll probably discover that, rather than a full-on attack, a gentle tease, a buildup of tension, then backing off is both effective and pleasurable. Consider using a vibrator if you need more stimulation.

Now, have a little tutorial with your partner. How is he supposed to know this stuff if you don’t show him? Maybe he can show you what pleases him as well.

Next, broaden your definition of sex. According to sex therapist JoAnn Loulan, sex should begin with willingness and end with pleasure, with or without orgasm in between. Lots of intimacies count as sex—cuddling, kissing, touching. As long as it’s emotionally pleasurable and fulfilling and keeps the spark alive, it all counts.

Your mind can be the pink Viagra that everyone’s looking for. Harness your creativity and imagination. Fantasize. Read or watch erotica. Many women are gathering ideas from the latest 50 Shades of Gray series. (More on that later.) Or read this for our own list of movies that turn us on.

Finally, a few wrap-up thoughts:

  • Don’t compare. Your sex life is unique and sacred. There’s no magic number of times or ways to do it. At this stage of the game, we can do it any way we want.
  • Your partner is a lot more accepting of your body than you are, so let go of the self-criticism.
  • If you have a hard time loosening up and you can’t turn off that judgmental voice in your head, try a glass of wine with sex. (As long as alcohol isn’t a problem for you.) It’s a nice way to release inhibitions.
  • Take belly dancing. I still remember watching a friend who had learned to belly dance walk onto the dance floor with her husband. That woman had the roll of the hips down pat—it was sexy even for me to watch. You’ll develop some great musculature, and you’ll learn a truly female art form.

And most important: Have sex! However it works for you, just don’t stop.

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Humankind has relied on medicinal plants for thousands of years. From that perspective, treatments like estrogen therapy (ET) are a flash in the pan.

And with insecurity about prescription oral ET because of rumored links to breast cancer and heart disease, are we back to leaves and roots?

Well, that’s an option. Maybe.

Many people choose nontraditional therapies, such as acupuncture, massage therapy, and homeopathy, either exclusively or in addition to traditional medicine. Botanicals—herbs and other plants—is just another of those nontraditional approaches. In fact, botanicals are still used in about half of the prescription drugs we take, according to an article in WebMD.

If you’re interested in trying botanicals for menopausal symptoms, like hot flashes, night sweats, and mood swings, here are a few options.

But first, a few caveats:

  • Herbs are drugs, just like pharmaceuticals. Don’t think that because they’re “natural” that they’re somehow safer or more pure. I often remind women that marijuana and cocaine are botanicals, too, so “botanical” does not always equal “healthful.” Botanicals can interact with other drugs, and they can cause side effects. If you have any medical conditions or are taking other medicines, do your homework and check with your doctor before taking any botanical.
  • Botanicals aren’t regulated. Dosages might vary and so might the quality and the efficacy of the remedy, depending on the manufacturer. So be sure to check the dosage you’re taking and buy botanicals from a reputable source.
  • There isn’t much credible research on the efficacy and long-term safety of most botanicals, so a lot of information is conflicting or based on hearsay from less-than-credible sources. For solid, current information, check out the National Center for Complementary and Alternative Medicine (NCCAM) website, which is maintained by the US Department of Health and Human Service.
  • No drug or botanical remedy replaces good health habits, like weight control, exercise, and a well-rounded diet.

So here’s the lowdown on the top botanicals for relieving some menopausal symptoms.

Black cohosh

Native Americans have used this member of the buttercup family to treat “female troubles” for hundreds of years. More recently, Germany’s Commission E, which is similar to our FDA, approved black cohosh for relief of menopausal symptoms. Remifemin is the commercial (and standardized) version of black cohosh. It’s also the version of black cohosh that’s been used in several studies.  As with most botanicals, however, the research is contradictory. It’s used to relieve hot flashes, night sweats, vaginal dryness and “other symptoms.”

Soy

While not an herb, per se, soy is one of those few plant-based substances that can only do you good. As a source of isoflavone—an estrogenlike hormone—it might relieve menopausal symptoms, although the North American Menopause Society stops short of recommending it due to inconclusive evidence. However, soy is known to control cholesterol and to help prevent osteoporosis, besides having several other health benefits. In any of its many forms—tofu, soy milk, roasted soybeans—it’s safe and good for you.

Chasteberry

Fruit of the chaste tree, which is native to central Asia and the Mediterranean, chasteberry has been used for menstrual and menopausal symptoms for millennia. While it might be more effective in treating menstrual problems, the jury is still out on how it works and how effective it is on menopausal issues. While it doesn’t have serious side effects, it might affect hormone levels. It might also suppress sexual desire (thus the basis of its quaint name), so if you’re experiencing that side effect of menopause, this isn’t the herb for you. It’s also knows as “monk’s pepper” for its libido-suppressing qualities.

Dong quai

Sometimes called the “female ginseng,” dong quai is another of those ancient remedies with conflicting and unproven results. Some sources unequivocally praise its ability to relieve hot flashes and night sweats; others that it has no benefit beyond placebo.

But everyone agrees that one side effect is increased sensitivity to sunlight, so be more vigilant about using sunblock if you take it.

Evening primrose

Evening primrose is a pretty North American plant with yellow flowers that blooms, as its name suggests, in the evening. Oil from its seeds is extracted to make the botanical remedy. It has few side effects, but it apparently isn’t very effective at treating menopausal symptoms. Maybe plant the seeds in your garden and enjoy the pretty flowers?

Ginseng

Not long ago, ginseng root was touted as an herbal tonic for everything from memory problems to erectile dysfunction to a general energy booster. It would be hard for any substance to live up to such hyperbolic claims, and ginseng doesn’t. “Research results to date do not support health claims associated with the herb,” states the NCCAM fact sheet.

As a magic bullet for menopause? Not so good.

It’s fairly innocuous, and might have some health benefits, but it isn’t the miracle cure it was cracked up to be.

St. John’s Wort

Another of those old-time remedies that has recently made a comeback as a sedative and treatment for mood disorders, such as anxiety and depression. While it may—or may not—be beneficial (a large NCCAM study found it no more effective than a placebo), it definitely has some powerful side effects.

St John’s Wort interacts negatively with a host of medications, including other antidepressants. It has a long list of side effects, including sensitivity to sunlight and sexual dysfunction. Yikes!

Have you tried any of these or other botanicals? How have they worked for you?

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Recently, Dr. Sheryl Kingsberg, chief of behavioral medicine at University Hospitals Case Medical Center, professor in Reproductive Biology and Psychiatry at Case Western Reserve University, and a MiddlesexMD advisor, was interviewed by Dr. Michael Krychman, another MiddlesexMD advisor, for an online feature about the state of testosterone therapy for women.

Since we were able to be a fly on the wall, here’s the takeaway:

Despite a few advances in the research, the general state of affairs surrounding testosterone therapy for women remains fairly untested and inconsistent.

Unlike in Europe, which has approved Proctor & Gamble’s testosterone patch for women, the US Food and Drug Administration has no approved testosterone therapies. Women who receive testosterone therapy in the US get it “off-label,” meaning that either products designed for men are prescribed in small doses for women, or it’s compounded by a pharmacist without regulation or oversight. And that’s the way it’s been done in the US for decades.

In the meantime, research on testosterone products for women proceeds in fits and starts, and there simply hasn’t been a lot of it. Two large efficacy trials of BioSante Pharmaceuticals’ new LibiGel testosterone product found no significant difference between it and a placebo. The company is continuing with five-year safety trials, however, to determine if long-term use causes adverse health effects in women—specifically, cardiovascular disease or breast cancer.

“They’re moving forward with the [safety] trial, so that is hugely exciting,” says Sheryl.

The goal of testosterone treatment is to return a woman’s testosterone to pre-menopausal levels; treatment protocols for clinicians are fairly undefined, although the North American Menopause Society has recently updated its practice guidelines. Most blood tests aren’t sensitive enough to pick up such low levels of testosterone, and there’s no correlation between blood testosterone levels and libido. That means that while blood tests to establish baseline levels can be helpful, a clinician has to rely on observation and the patient’s reported experience.

And determining whether a woman is a good candidate for testosterone therapy also remains something of an art as well as a science.

“Testosterone is an important option for women—but it’s not for every woman,” says Sheryl. “We know that testosterone therapy won’t necessarily be effective in all women, so it’s important not only to measure efficacy and safety, but also to think about other treatment options.

“The first thing a clinician needs to assess is which women would really make use of testosterone replacement, and which women have something else going on,” she adds.

Good candidates are women who have lost their biological drive for sex, which is the classic definition of hypoactive sexual desire disorder: They have no desire, no fantasies, no dreams, no “hunger for sex,” as opposed to women who may have lost interest in sex, but who may have relationship issues or other stressors in their lives.

Because of the dearth of research and treatment protocols, clinicians should monitor their patients who are on testosterone therapy to make sure that it’s both effective and at safe levels, although, as Sheryl points out, the amount of testosterone in most treatments is very low.

And despite the frustrating lack of options and research surrounding testosterone therapy, women who are troubled by low libido shouldn’t be embarrassed about asking for help. “Hypoactive sexual desire disorder is the most common sexual problem across all ages,” says Sheryl. “About 10 percent of women have it, and they deserve to be assessed and treated because sex is important to overall health and quality of life.”

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In an earlier blog post, Dr. Susan Kellogg Spadt, PhD, CRNP, a MiddlesexMD advisor, referred to vulvar discomfort that may be caused by contact dermatitis. Because this is a common condition, I asked her to come back to the topic in more detail, describing two types—irritant contact and allergic contact dermatitis—what causes them, and how they can be treated.

Irritant contact dermatitis is characterized by a burning sensation. When the burning occurs after contact with the irritant, it’s a sign that the top layer of skin has been “compromised” or broken (part of the job of our layers of skin is to keep harmful things out). Common vulvar irritants include propylene glycol (an ingredient in many creams and lotions), abrasive toilet paper, oxylate from urine, soaps, detergents, shampoos, powders, conditioners, baby wipes, panty liners and their adhesives, chemically treated clothing, spermicides, lubricants, alcohol, douches, and deodorants.

To address this type of irritation, first figure out and eliminate the irritant—whether it’s bath soap, topical creams, or powdered detergent residue in laundered clothing. Minimize contact with urine by using a spray bottle of water on the genitals during and after urination. Twice-daily application of a hypoallergenic emollient or skin moisturizer, or a “natural” product like vegetable shortening or mineral oil, can help to heal the skin and prevent irritation from recurring.

Allergic contact dermatitis (also called atopic dermatitis or eczema) is a highly prevalent vulvar disorder characterized by persistent itching. This form of dermatitis results from—here’s some medical talk—a locally dysfunctional cell-mediated immune response that inhibits natural skin microbicides, allowing for higher than normal colonization of yeast and bacteria. As a result of environmental and genetic factors, as many as 40 percent of adult women have a history of this type of vulvar dermatitis; most women are at risk of developing it at some time during their adult life. Women with a history of asthma, hay fever, chronic sinusitis, yeast infections, or eczema on other body parts are particularly at risk.

Recognized allergens or allergic triggers include a dry climate, exposure to latex, elastic, fragrances, fabric softeners, benzocaine, neomycin, chlorhexidine (found in KY Jelly and many other lubricants), and tea tree oil. Allergic dermatitis often involves flaking skin, because skin cell proliferation and exfoliation are stimulated.

Diagnosis of this type of dermatitis is most often based on history, but a biopsy can be done by a health care provider to confirm the diagnosis. After diagnosis, typical treatment is the use of topical low- to high-potency steroid ointments. It may take several weeks of treatment for a full layer of healthy skin to replace the irritated skin. We know the therapy is working when there’s a decline in itching (or “pruritus”) and incidence of yeast infection.

Contact dermatitis of the vulva is exceedingly common in women. These disorders are not life threatening, but can be very “quality of life threatening,” interfering with comfort during daily activities as well as with intimate relationships. Recognizing potential allergens and irritants and seeking care early from a knowledgeable health care provider are two important steps a woman can take to insure her vulvar health.

The bottom line? The less that comes into contact with your vulvar skin the better. And, if you even suspect you have an issue, the sooner you seek treatment, the better. I’ve seen women in my practice who’ve spent months in discomfort (assuming they had a “yeast infection”) when they didn’t need to.

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You say your physician is reluctant to prescribe any hormones because you had a pulmonary embolism 10 years ago. After a hysterectomy, you’re coping with physical issues reasonably well, but have vaginal dryness and pain with intercourse.

The clotting risks associated with estrogen use are documented to be with oral administration of the hormone. Oral estrogen is metabolized through the liver, which increases a clotting protein and puts women at greater risks for thrombosis or blood clots. Multiple studies suggest that other methods of administering estrogen—vaginal or transdermal applications—do not carry the same risks. I have many patients on non-oral estrogen who have had thrombosis.

As we get older, we have more risks for clotting: inactivity, weight gain, high blood pressure, and so on. We can’t eliminate all the risks, but we don’t increase that risk through non-oral extrogen—and your vagina is hungry for estrogen!

I’d call your OB/Gyn’s attention to the ESTHER study. The conclusion of that study:

Oral but not transdermal estrogen is associated with an increased VTE [Venous Thrombus Embolism] risk. In addition, our data suggest that norpregnane derivatives may be thrombogenic, whereas micronized progesterone and pregnane derivatives appear safe with respect to thrombotic risk. If confirmed, these findings could benefit women in the management of their menopausal symptoms with respect to the VTE risk associated with oral estrogen and the use of progestogens. [2007;115:840-845]

If your physician is still unwilling to work with you to address this issue, you can look for a certified North American Menopause Society health care provider in your area at their website, menopause.org.

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