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If the title of this post pulled you in, you’re likely part of the almost 50 percent of women aged 40 to 64 who have sleep problems. I’m sorry you’re a part of this club, but welcome! Sleep has been in the news a lot since—well, for as long as I can remember. It affects everything from mood and willpower to productivity and relationships. We all know how hard it is to gin up enthusiasm for romance when we’re sleep deprived.

Sleep also has implications for long-term health. Research shows that not getting enough sleep can lead to serious issues like diabetes and cardiovascular disease and a weakened immune system.

The evidence that we should make sleep a priority is pretty compelling. Perhaps you took the advice of our recent post on good sleep hygiene, and you have been going to bed at the same time every night, avoiding food, exercise, and alcohol several hours before bed, and keeping your bedroom cool and dark. Well done!

But if you’re still reading, those good habits may not be paying off for you. There are few things more frustrating to my patients than knowing all the reasons good sleep is important, following all the advice—and still not getting good sleep.

If you’ve tried all the normal ways to fix your sleep problems, and you don’t want to try medication, you might want to experiment with natural remedies.

As I’ve said before, herbal supplements are generally considered foodstuffs in the U.S., so manufacturers don’t have to conduct clinical studies about their efficacy or side effects. I can’t necessarily vouch for them, but few are known to be harmful. Some patients report one supplement or another has worked for them, and maybe one of them will work for you, too.

If you do want to try one, first consult with your doctor to make sure it’s safe for you, given your health and the medications you’re taking. I also recommend that you keep a sleep journal for a week before you begin and for 12 weeks after. Make a note of sleep hygiene factors, too, like when you ate and exercised and put away screens for the night.

Melatonin is a hormone that regulates when we sleep. When melatonin levels rise at night, body temperature falls and we feel sleepy. Melatonin seems to be most effective at helping people fall asleep rather than stay asleep. Calcium aids in the production of melatonin, which may be why some people find that drinking a glass of warm milk before bed makes them sleepy.

L-theanine is an amino acid that increases brain chemicals that are calming and reduces brain chemicals linked to stress and anxiety. Rather than acting as a sedative, L-theanine can improve the quality of sleep by lowering anxiety. It’s most often found in tea but can be bought in the form of supplements.

Valerian is an herb. Valerian root is thought to reduce anxiety by acting as a sedative, but research results on that have been mixed. It may help you fall asleep more quickly and improve the quality of your sleep, but you might need to use it every day for up to four weeks before it starts to help.

Magnesium is a mineral. Most adults get enough of it through their diets (leafy green vegetables, nuts, and whole grains are good sources), but it might affect the sleep of those who don’t; magnesium deficiency has been linked to higher levels of anxiety, which interferes with sleep. If you suspect you are low on magnesium, eat more of the above. Magnesium supplements often don’t play nicely with medications.

Lavender

Lavender is a popular natural sleep remedy. Many people say just the smell of it relaxes them and makes it easier to sleep. There is some research that shows that taking lavender oil by mouth for 6 to 10 weeks reduces anxiety and improves sleep.

Lavender—or any of the natural remedies above—may really work for some people. Or perhaps it’s just the placebo effect. If something is safe and it helps a patient get better sleep, I don’t care much about whether it’s “real” or placebo. And I suspect that you don’t, either.

Have you tried any of these or another that we haven’t included? I’d love to hear what’s working for you!

You say you’re using a vaginal suppository for vaginal moisturizing; the product you’re using contains illipe butter, coconut oil, vitamin E oil, apricot oil, meadowfoam plant wax, and carnauba plant wax. If you’re tolerating this product well, and it’s working for you, great!

Vaginal moisturizers

It’s hard to determine in advance which products will work for which women. For some women, oils can be somewhat occlusive and cause tissue breakdown. For others, oils increase risk of vaginal yeast infections. Other women can be sensitive to specific ingredients, like coconut and certain fragrances.

Feel comfortable with what works for you, and keep in mind that your body changes over time, too—which may mean you’ll need to rethink your routine.

Once again the yin/yang of hormone therapy (HT) is in the crosshairs. On the one hand, estrogen is the only truly effective treatment for vasomotor symptoms (hot flashes) during menopause. Estrogen also helps ease vaginal dryness, night sweats, and sleeplessness. It protects against osteoporosis and lowers the risk of heart disease. On the other hand, if you have breast cancer, estrogen may promote the growth of the cancer cells. Oral estrogen may increase the risk of stroke (although transdermal estrogen therapy doesn’t pose this risk).

This risk/benefit ledger has been totted and rejiggered for years as research adds to one column and subtracts from another. Overall, and with a few caveats, the level of risk inherent in HT is fairly low for the benefits conferred. Recently, however, a second iteration of a large Finnish “observational” study points to a new risk.

The study, which examined death records mandated by the government of Finland of over 300,000 women, found that postmenopausal women under age 60 who stopped HT were at statistically significant risk of death from heart attack and stroke in the first year after they stopped treatment. This elevated risk of cardiovascular death wasn’t found in women over age 60. And after the first year, these risks return to normal levels.

“This new study suggests that younger women may have a higher risk of heart disease and stroke during the first year of discontinuation,” says Dr. JoAnn Pinkerton, executive director of the North American Menopause Society (NAMS). “Thus, women and their healthcare providers need to consider the benefits and risks of starting and stopping hormone therapy before making any decision.”

Sobering, but let’s get some perspective. While the study’s results were fairly well-accepted, the data leaves some important questions unanswered: Because the data were drawn from government medical records, researchers weren’t able to determine whether women stopped HT abruptly or tapered off; they also couldn’t determine what dosages the women were taking or how the estrogen was delivered (pill or patch), which are areas that could affect outcomes and that need more study.

While a direct cause-and-effect relationship can’t be conclusively drawn in this kind of study, research suggests that the withdrawal of hormone treatment may jump-start certain processes, such as a creating an inflammatory reaction or causing a constriction of blood vessels.

Whether to begin hormone therapy, for how long to continue, and when to stop is a risk/benefit analysis that involves many factors unique to you: the severity of your symptoms, your quality of life considerations, age, whether you’ve had a hysterectomy, and other risk factors, such as osteoporosis, breast cancer, and stroke, in addition to your own preferences.

NAMS still recommends HT as an effective treatment for hot flashes and other unpleasantries of menopause, but it also recommends that estrogen be prescribed at the lowest effective dose for the shortest possible time. HT is safer and more effective when it is begun under age 60 and within 10 years of menopause.

What this new research adds to the decision-making equation is the potentially elevated risk when HT is stopped before age 60, essentially adding yet another element to the already loaded risk/benefit equation concerning hormone therapy. While this information adds urgency to the need for a thorough discussion with your doctor before starting or stopping hormone therapy, it doesn’t really change the necessity of having one. Nor does affect the need to revisit the decision annually while you’re on HT.

Yes, shortening of the vagina is a possible consequence of a hysterectomy, and that is clearly what you are describing. You say you were previously using an Estring vaginal ring to address menopausal symptoms; the Estring won’t work for you now, since having it inserted is uncomfortable. Oral HT isn’t an option for you because you’re a breast cancer survivor.

Please don’t lose heart. I’d recommend you consider using Intrarosa, a newer, very effective treatment for postmenopausal atrophy. It is a nightly vaginal insert, non-estrogen. Osphena is another non-estrogen oral option, or you could use a cream form of vaginal estrogen. Any of these is likely to be an effective treatment option, and all of them are considered safe for breast cancer survivors.

Amielle vaginal dilator setAfter restoring health to the vagina, you may then need to use vaginal dilators. Dilators are designed to increase vaginal “capacity,” whether in width or (as in your case) length. A healthy or “estrogenized” vagina should be distensible and elastic to get back the necessary length. Most women are very successful in regaining this function.

It would be very, very unusual for an old episiotomy scar to become problematic. You say you experience dryness, irritation, and a “tearing feeling,” which sounds to me entirely consistent with vulvodynia (also called vestibulodynia or provoked vulvodynia). Other ways the pain has been described are “sandpaper,” “cutting,” or “ripping.” The most common experience with vulvodynia is pain with intercourse, and usually not with other activities (although sometimes women have sensitivity when wiping after urination). There may or may not be vaginal dryness.

If the pain you’re experiencing is related to atrophy, which is very common and usually evident by vaginal dryness, the Premarin vaginal cream you describe using should be quite effective for that. A topical steroid, which you’ve also been prescribed, would be helpful if there’s an identified vulvar skin condition or dermatosis, but I’m not sure any of your descriptions indicate that the steroid is beneficial. You also asked about the Mona Lisa Touch, which has been shown effective for atrophy, but not vulvodynia, at least thus far.

For patients with vulvodynia, I use a compounded prescription of low-dose estrogen plus testosterone applied to the opening of the vagina (the introitus) two times a day for 12 weeks, tapering to once a day or less. Another option might be Intrarosa, a relatively new treatment for vulvovaginal atrophy, which I’ve begun using with some vulvodynia patients. Intrarosa is a vaginal insert, used nightly; it’s metabolized to testosterone (and estrogen) in the vagina, so I think this is going to help vulvodynia.

Note that vulvodynia can be difficult to diagnose, because the vulva and vagina may look normal. Describing your symptoms accurately will be extremely helpful!

 

A few years ago, I shared that the FDA had approved flibanserin, the first available treatment for those experiencing HSDD (hypoactive sexual desire disorder), low sexual desire that can’t be attributed to external circumstances like medical conditions or relationship difficulties. I said then that it made me optimistic that additional treatments would be developed.

I’m happy to say that my optimism wasn’t unfounded. The FDA is reviewing another treatment for HSSD called bremalanotide, which is self-administered through a disposable auto-injector. While it’s not a “pink Viagra,” it is designed to be used right before a sexual encounter, rather than on a daily basis, like the tablet flibanserin. HSDD results from an imbalance in chemicals, and bremalanotide works by changing the balance between “inhibitory and excitatory neural pathways in the brain,” according to its maker, AMAG Pharmaceuticals.

It could be approved early in 2019, and that would be good news for the estimated six million pre-menopausal women who have HSDD—about one in ten (and for post-menopausal women, too, but the study didn’t include them; like Addyi, this new drug is likely to be explicitly approved for the population included in the study). Most of those women likely don’t realize that what they are experiencing has a name, and that it’s now treatable. Instead, they may believe they have to accept low libido as part of “middle age.”

It’s true that it’s normal for desire and sex drive to fluctuate. Each of us decides what’s right for us and our partners. But if what you thought was a passing dip in desire lasts for longer than six months or so, then talk to a healthcare professional. It could be HSDD—and soon there may be one more way of treating it!

You say you’re considering pelletized subcutaneous testosterone as a response to flagging libido. I have seen good results with testosterone therapy, which you can read about in this blog post.

Testosterone, however, is one time that I never recommend pellets. It’s very difficult to manage levels and dosing in the pellet form, and I’ve seen plenty of awful outcomes of way-too-high doses, including masculinization that in some cases is irreversible (clitoral enlargement is one possible irreversible consequence, for instance).

While testosterone treatments are not FDA-approved for women in the U.S., we have plenty of data on transdermal, bioidentical testosterone use in women, and I think there is evidence those can be used safely if kept in female therapeutic ranges. I just don’t see pellets as allowing management in that safe therapeutic range. I use male pharmaceutical products at a fraction of the dose used for men.

Estrogen is fine in pellet form, but even there I rarely use pellets. We have such great bioidentical pharmaceutical products that are so much easier and flexible to use, with known, consistent dosing, which pellets just can’t provide. It’s hard to get too much estrogen delivered to women, in general. Although I have seen super-high levels with pellets, we don’t have information that this is harmful, and the only adverse side effect is usually breast soreness, which is reversible.

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