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Archive for October, 2012

The North American Menopause Society (NAMS) has just published its seventh position statement about hormone therapy in the ten years since the Women’s Health Initiative (WHI) linked a whole bunch of unpleasant side effects, notably breast cancer, to hormone replacement therapy.

Before that groundbreaking study, estrogen was the wonder drug that alleviated menopausal symptoms, such as night sweats and hot flashes, and kept our sexual parts juicy. Once a woman reached “that age,” hormone replacement began.

The WHI study was like yelling “fire” in a crowded theater—everyone ran for the exit. From the fountain of youth, estrogen therapy became the disinherited stepchild, suddenly viewed with anxiety and suspicion.

But with ongoing research over the past decade, the effect of hormones is understood better, and the role of hormone therapy is more refined, nuanced—and safer.

Thus the need for all those updates. “In reviewing the recent scientific publications, NAMS determined that there are enough differences now between the effects of combined estrogen plus progestin (EPT) therapy versus estrogen therapy (ET) alone that it was time to make some changes,” said Dr. Margery Gass, executive director, NAMS, in an interview with The Female Patient.

Plus, as NAMS reasserts, hormone therapy is still the most effective treatment for those pesky, and sometimes debilitating, menopausal symptoms. (Hormone therapy shouldn’t be confused with localized hormones in the form of a cream, tablet, or ring that are used in the vagina to treat dryness and discomfort. These aren’t absorbed into the bloodstream, but they don’t treat other menopausal symptoms, either.)

So here’s the takeaway from the latest NAMS position statement:

  • Hormone therapy for women who have NOT undergone a hysterectomy (who still have a uterus) is usually estrogen plus progestin (EPT) because progestin protects against endometrial cancer. If therapy is started early in menopause and continues for less than 3 to 5 years, the risk of complications from breast cancer is low. The increased risk of side effects found in the WHI study was in older women (above age 60) or after long-term use of hormone therapy.
  • There is no greater risk of heart disease from hormone therapy for healthy women under 60. Risk of blood clots or stroke is a little higher—“less than 1 in every 1000 women per year taking HT,” according to the NAMS position statement. That risk can be further reduced with non-oral or transdermal estrogen therapy.
  • Estrogen alone, which is prescribed for women who have had a hysterectomy, has no increased risk of side effects, even after 7 years of therapy.
  • Hormone therapy comes in several forms—a low-dose pill or by patch, gel, skin spray, or cream. These may have fewer side effects than the regular-dose pill, but more research is needed to determine that.
  • It’s important to consider hormone therapy for the right woman, at the right time, and via the right products to maximize benefit and minimize risk. A careful consideration of your own history as well as your family history will help in making that decision.

Because the issue is complex and research is ongoing, NAMS will undoubtedly continue to update its position, but the bottom line, according to Dr. Gass, is that “both these therapies (EPT and ET) are relatively safe for women who are bothered by symptoms of menopause, and who would like to use hormone therapy for a while.”

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Did you know that the whole idea behind MiddlesexMD is based on a recipe? You could call it the MiddlesexMD formula for really juicy sex. Officially, we call it “our recipe for women’s sexual health.”

We think our recipe is so important that our entire website is organized around what we’ve identified, after a lot of thought and research, as the five necessary ingredients for a satisfying love life at midlife. You can add your flavor of whipped cream and lingerie, but if those five ingredients aren’t in place, sex just won’t work very well.

These ingredients may be surprising (knowledge? emotional intimacy?), and some are unique to our stage of life (vaginal comfort, genital sensation, pelvic tone). We try to help you understand why they’re important and to give you tools and tips for understanding what they are and for incorporating them into your life.

Here’s a tool someone at a recent conference told us about; it reaches the same destination by a different path. It’s a fun quiz put together by the Association of Reproductive Health Professionals (ARHP). Sounds like place to get blood drawn, I know, but behind that bland façade is a sexy little quiz that reinforces a lot of the thinking behind our recipe.

To start, click on your age in the circle that says, “It [sex] could be better…” The questions cover a range of life issues, from physical health to libido to emotional well-being—because, as we’ve said, sex involves all our parts, including our psyche and our emotions.

While the assessment tool is meant to be light and fun, it also delivers good advice. Be honest with your answers (who’s looking, anyway?), and you’ll get some targeted, useful information to improve your sex life. And maybe the rest of your life.

You’ll discover, for example, that about 20 percent of women (of all ages) have a hard time getting turned on, and that it’s one of the most common sexual complaints. That a woman’s sexual response is complicated and affected by things like self-image and stress. (Click on the right-side box that explains how men and women are different.) The tool reassures you that most women can’t orgasm with penis-in-vagina sex alone, but need clitoral stimulation as well.

Nothing earth-shaking, but some nice reinforcement and some good tips. Take the quiz. Read the results, then dig around in MiddlesexMD for more in-depth information. We have lots of information about pain during sex. And we’ve certainly explored the female sexual response cycle. We’ve clarified the difference between moisturizers and lubricants, and we sell them both in our shop.

So, use the assessment as a fun way to pinpoint areas you might need to work on in your sex life, and then dig into our blog and website for the meat and potatoes.

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One of the advantages of having an advisory board is the different perspectives we bring to the same set of problems. In our last conversation with Mary Jo Rapini, the issue of body image came up: the fact that we women are sometimes our own worst enemies when it comes to nurturing our sexuality. The topic clearly hit a chord with Mary Jo–she’d also been coming across examples of it–and she offered to write this blog post.  

I was recently at a meeting that explored the literature and dealt with issues of sexuality, dysfunction, and relationships. The most popular theme in each educator’s presentation, no matter what their field of study, was the importance of body image in influencing women’s libido. Although many of the diagrams and graphs were complicated, the message was not. How women feel about their bodies influences their libido.

It makes sense, especially if you are a woman yourself or are close to one. You know how it feels when you feel bloated or fat and your partner wants to get naked. There is a sense of dread and duty; either you acquiesce or you find an excuse. It doesn’t matter how beautiful your partner tells you they believe you are, or what you’re wearing; if you don’t feel good about your body you don’t look forward to being vulnerable or wanting pleasure. Both of these are important when making love.

MiddlesexMD_RumiWhen I see women who are struggling with their body image I find myself reciting things I have heard or read that help. For example, experts tell women to focus on an area they like and to appreciate and dress in to flatter that feature. For many women, this may be helpful, but my practice is full of women who can only admit to liking a very small limited area. Let’s face it; if you tell me your favorite area is your eyebrows, I’m going to struggle with how to help you build a better body image using your eyebrows–any expert would.

Body image can include areas that aren’t exactly body related. For example, many professional women boast a high body image and self esteem due to their careers. They may not like their body or parts of it, but they don’t let it hold them back sexually.

What we say to ourselves is much more important than what others say. A recent report I read said that women routinely say over twenty derogatory things about their bodies each day. These same women suffer from how they view their body emotionally, physically, and sexually. It doesn’t matter if their husbands love their bodies, comment on the beauty of their bodies, or tell them how attractive they are: These women are destroying their concept of themselves from within. Media is an easy target to blame, but media is not the entire problem. What we say to ourselves is the problem. What we think to ourselves is the problem. What we say to our friends about our inadequacies is a problem. All sex talk begins with what we say to ourselves. No sex talk will make women feel sexier, hotter, or more desired if they have destroyed their sense of sexiness from within. Hormone therapy can make you feel more like having sex, but if you don’t feel good about your body, you will be reluctant to act on your feelings.

Since this is an inside job we do to ourselves, the work to stop perpetuating a poor body image is also up to us. It means you have to take a stance and begin by advocating for yourself, for your intimacy/sex life with your partner. That means sitting down with your partner and directly addressing what happens to you when you talk to yourself. Usually loving men will do anything to help their partner if they understand the mission.

  1. If you are highly suggestive and seeing a photo of a taut, scantily dressed woman with sex appeal makes you feel and talk badly about yourself, then rid your home of these types of magazines, TV shows, or whatever you are currently seeing.
  2. Movement is linked to many sensory areas of our brains. Movement makes our mood better, our affect more animated, and our sense of sexuality healthier. You don’t need to run marathons to feel and be sexy, but you do need to exercise each day. Ten minutes is better than no minutes. An hour a day split up any way you want is best!
  3. Begin a journal to yourself listing derogatory comments you remember being said to you prior to the age of eight. These comments may have been made as “jokes” by warped people, but they weren’t jokes. They are wired into your brain, and you may be repeating these to yourself as part of your negative mantra.
  4. Catch yourself. Whenever you make a derogatory comment about some part of your body, picture a stop sign and say aloud, “No.” Ask yourself, “What right do you have to abuse anyone including yourself?” Then think of who in your life made you think this was okay. Sometimes you will remember things your dad said, but more likely your mom used to insult herself as well.
  5. If anyone in your life right now insults your body, that is a huge red flag. Tell them they are waving a red flag, and abusing you with negative comments is not okay. If your kids hear this message, they will begin early protecting their body image.
  6. Women are much more critical of their bodies than men are. Part of this is due to the fact that women are more sensitive and do not abuse men’s bodies with negative comments to the degree men do with women. One way men will learn how to treat women is if a woman stands up to them when they make a derogatory comment instead of joining them in their taunts.

Couples will spend money to enhance their sex life with products, medications, and exotic vacations. However, the least expensive and perhaps most effective is to begin changing how we talk to ourselves. The first sex talk you get is not the one you get from mom or dad during a formal birds and bees lecture. It’s the mini body image lectures we give ourselves when we are children. These mini body image insults we say each day to our bodies are more potent than any sex product, medication, or exotic vacation we could ever afford.

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Sometimes we medical people get to hear about medications and treatments before they hit the doctor’s offices and pharmacies. Recently, MiddlesexMD advisor Dr. Michael Krychman interviewed Dr. James Simon, a well-connected expert in women’s sexual health, about new treatments that are under development to treat vulvovaginal atrophy (VA).

If you recall, VA is the thinning and inflammation of your delicate genital tissues, including the vagina, which is caused by loss of estrogen after menopause. As you can imagine (or already know), it causes genital irritation, an increase in minor infections, and uncomfortable—or downright painful—sex.

VA doesn’t go away, and it doesn’t get better by itself—it requires treatment, usually in the form of estrogen, whether taken internally or applied topically. Topical estrogen creams, tablets, and rings can be very effective in treating the effects of VA.

But a few new approaches are also under investigation. They are:

  • DHEA suppositories. DHEA (which, if you must know, stands for dehydroepiandrosterone), is a steroid that, according to Dr. Simon, is “taken up by the vaginal cells themselves, which convert them to testosterone and estradiol.” The estradiol eases symptoms of VA, and the testosterone improves muscular function and makes the vagina and clitoris more sensitive, so it also gives the libido a little boost. None of it is absorbed into the system, so the medication should be safe for women with breast or ovarian cancers. Don’t expect to see this little number on pharma shelves too soon. Dr. Simon advises patience, since the treatment in still in clinical trials and then must be approved by the FDA.
  • Treatment for VA in pill form. Because many women (and their partners) find topical treatments for VA—creams, rings, suppositories—messy, unpleasant, and a sex inhibitor, a new drug that is readily absorbed by the estrogen receptors in the vagina, but not in other places, such as the endometrium, is being tested.
  • Very low-dose estrogen tablet. In an ongoing effort to find the lowest effective dose of estrogen, Novo Nordisk, the manufacturer of Vagifem, recently found that 10 micrograms is effective in treating symptoms of VA. “It seems to work extremely well, even at these extraordinarily low doses,” said Dr. Simon. And even after taking it for a year, he points out, this dosage amounts to just over 1 gram of estrogen, an amount that is probably safe even for breast cancer patients. The disadvantage, warns Dr. Simon, is that, while the medication treats vaginal symptons well, it might not be as effective for the vulva (the external genitalia). In this case, women may still need an estrogen cream for the very important vulvar care.

Since over 40 percent of post-menopausal women experience symptoms of VA, an effective treatment that doesn’t increase our cancer risks would make us—and our partners—very happy. Take heart. “Many companies are dedicated to innovative treatments without rise in systemic hormones,” said Dr. Krychman.

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Friends in Florida

The MiddlesexMD team and I have just come back from representing what we do at two conferences in Orlando. The first was the gathering of the North American Menopause Society; the second was the Nurse Practitioners in Women’s Health.

These events are both exhausting and exhilarating. It’s great, as a medical professional, to learn from the presentations by my colleagues on topics I’m dealing with every day, whether in my office or by responding to questions on or researching products for MiddlesexMD. Both physicians and nurse practitioners are enthusiastic about what we offer—a safe place for both solid, reliable information about sex after 40 and private purchases of products that can help address changes many of us face. We met other people who share our mission of making sure women know that they can continue (or start!) to have comfortable, satisfying sex, no matter what their age.

We’ve been doing these events for a couple of years now, in a variety of places. We’re reminded—as I certainly know, investing in my continuing education—that medical professionals always have things to learn—and are eager to do so. They’re surprisingly up front about wanting information for themselves as well as for their patients. We love the women who come back to our booth on day two of a conference, having discussed their sex lives over dinner the night before! And we’re also touched by the woman who steps away to call her husband before she chooses a vibrator. We love to see all that conversation about our sexuality!

There are, of course, a lot of professionals at these conferences—people who talk about body parts and processes all day long. But we’re especially happy to talk to hotel employees who happen by, who may have fewer opportunities to have their questions about sexuality answered. We met Linda, who picked up information for her friend who’s just recovering from a hysterectomy, and Tony, who was deputized to pick up information for his coworkers to share with their midlife wives. Our fellow exhibitors are also welcoming; we exchange information about how we support women and are often able to share resources.

As some of our new relationships develop over the next few months, I’ll share details here. For now, just know there’s a whole community of people out there who are ready to help you maintain your sexual health. And we at MiddlesexMD are pleased to be a part!

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As we saw in the last post, vibrators were developed by doctors in the late 1800s to replace the “pelvic finger massage” they routinely administered to female patients. The massage was intended to relieve symptoms of “hysteria” or “neurasthenia,” such as anxiety, sleeplessness, and general malaise. Done successfully, it induced a “hysterical paroxysm,” which offered temporary relief to patients. By some estimates, over 75 percent of women suffered from these symptoms.

By the early 1900s, small electric vibrators had a comfy niche in middle-class homes right on the shelf between the toaster and the electric iron. At the time, they were perceived as medical devices that had nothing to do with sex.

The porn industry, however, was not so easily deluded. In the late 1920s, early porn films embraced the gadget for its own version of “doctor.” In this context, the “hysterical paroxysm” looked unmistakably like (gasp!) an orgasm. Once that connection was made, the veneer of the vibrator as a nonsexual treatment for a medical condition became uncomfortably hard to sustain, and the vibrator quietly disappeared from respectable society and doctors’ offices.

It became so utterly invisible, in fact, that in the 1970s only 1 percent of women had ever used one, according to the Hite Report, a famous study of female sexuality. “This was perhaps unsurprising, given that most vibrators by then were modeled on a very male notion of what a woman would want–a supersized phallus–replicating, in other words, the very anatomy whose shortcomings had precipitated the invention in the first place,” writes Decca Aitkenhead, in the Guardian.

At the heart of the matter was that:

  • At the time, women (of a certain social class) were simultaneously idealized and condescended to. They weren’t supposed to be sexual, to want sex, or to enjoy it.
  • The only “real” sex was penis-in-vagina penetration until the male reached orgasm.
  • If this didn’t satisfy a woman, the fault was hers. She was either defective, frigid, or “out of sorts” (in Victorian parlance).

Rachel Maines, author of The Technology of the Orgasm, the seminal work tracing the history of the vibrator, commented in an article in the Daily Beast, “In effect, doctors inherited the job of producing orgasm in women because it was a job nobody else wanted. The vibrator inherited the job when they got tired of it, too.”

That many women were not completely (or at all) satisfied by ordinary coitus was a source of confusion, frustration, and threat to some men. According to the Hite Report, most women can reach clitoral orgasm through masturbation. But the idea of women masturbating was also extremely threatening.

“I have read debates between doctors over whether women should be allowed to ride bicycles or whether the pleasure they might induce from the seat made it an unacceptable moral hazard,” writes Erik Loomis in “The Strange, Fascinating History of the Vibrator.”

Lest you think that we’ve evolved beyond these repressive and delusional ideas and that female sexuality is more acceptable today, think of the recent diatribe against a college student who spoke in favor of requiring health insurers to provide contraception. Or the statements alluding to “legitimate rape,” or the suggestion that a woman can’t get pregnant because her body “will shut the whole thing down.”

Have we really come all that far, Baby?

In any case, the discredited vibrator slunk back into view in the 1960s, first as a kinky sex toy and then as a symbol of women’s sexual liberation by feminists.

In a major national study of sexual behavior conducted in 2009, of over 2,000 women surveyed, 52.5 said they had used a vibrator.

If nothing else, the peculiar story of the vibrator should help us recognize how strongly we are influenced by cultural messages. A vibrator is not a medical device nor is it some unsavory symbol of sexual deficiency. For those of us who need extra stimulation to keep our sexual parts lubricated and functional, it’s just one important tool.

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