Archive for March, 2013

Like a number of my patients, you’d like to avoid the disposable applicator that often comes with vaginal moisturizers—whether for environmental or cost reasons (or both!). I know many women prefer to use an applicator: no muss, no fuss. I can’t help but encourage women to reconsider the simplest approach: Wash your hands, apply moisturizer to your finger, and insert it in your vagina. This has a number of advantages—you’re experienced in washing your hands, your finger is warm and able to curve with your vagina, and you’ll know your body better. If you’ve used tampons without applicators or menstrual sponges or cups, you may be entirely comfortable with this method.

But I know our instinctive preferences are hard to retrain. Another alternative that’s worked for patients is to go to the drugstore and check out the syringes for one of appropriate size and cleanability. Note that these are typically designed for single use, so you’ll need to develop your own approach for washing and storing the syringe between uses.

Find a method that works for you! Vaginal moisturizer makes a difference with regular use.

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Remember oxytocin? It’s a hormone that facilitated the let-down of milk when you were nursing, and it’s released with nipple stimulation. Oxytocin also stimulates contractions for the uterus (which is why any of you who had labor induced might recognize oxytocin by another name: pitocin). Outside of childbearing, oxytocin works with other sex hormones to facilitate orgasm and increase the intensity of pelvic floor muscles. Oxytocin levels have also been noted to fluctuate  throughout menstrual cycles, correlating with lubrication.

This is a hormone that has lots of favorable effects on sex! There has been research in using it to enhance sexual function, but there’s not a product readily available yet. Stay tuned!

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Ladies, we have one more tool in the belt.

Last month, the US Food and Drug Administration (FDA) approved a new drug to treat the vaginal and vulvar pain associated with loss of estrogen in older women.

That pain is called dyspareunia, and it’s caused by the changes in the vagina and genitals that occur when we lose estrogen during menopause. As we’ve said (often), our vaginal tissues become thin, dry, and fragile as our estrogen levels decline, which can make sex very uncomfortable. Dyspareunia is common, and it doesn’t get better on its own.

Until now, treatment options have included using moisturizers (regularly) and lubricants (before sex) or replacing estrogen, either topically in the vagina or through hormone replacement therapy.

Now there’s a pill that you take once a day.

Osphena is called a “selective estrogen receptor modulator,” or SERM. Although it’s not a hormone, it works like one in that it affects some estrogen-sensitive tissues, like the vagina and the uterine lining (the endometrium). The vagina will thicken and become less fragile while other tissues, such as the breast, are affected very little.

In a 12-week trial of almost 2,000 women here in the US, the researchers saw a “statistically significant improvement” in the pain level of the women who took it compared with a control group.

Of course, there’s no free lunch when it comes to pharmaceuticals. Some common and less-serious side effects include hot flashes, vaginal discharge, muscle spasms, and sweating. But a few uncommon and more serious side effects include blood clots, stroke, and vaginal bleeding that can indicate cancer of the endometrium.

That’s why the drug comes with a black box warning from the FDA, and why the FDA advises taking it in the smallest amounts and for the shortest time possible.

It’s also uncertain whether the condition will reverse itself once the drug is stopped.

Despite the scary black box, I’m thinking that Osphena gives us another option. It might not be our first choice for long-term use. It still isn’t the magic bullet for all menopausal ailments.

But it might provide a little short-term boost, for example, to make a woman with severe dyspareunia more comfortable until the moisturizers or the topical estrogen kicks in. And until her renewed sex life helps rejuvenate the vagina because sex, in case you forgot, “is beneficial for maintaining vaginal health,” says Dr. David Portman, lead researcher in the Osphena trials for safety and effectiveness.

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“Concern” is a relative term. If you mean should you lose sleep, no. If you mean should you work with your health care provider for an explanation or monitoring, yes.

Pap tests (also called a Pap smear or cervical cytology screening) are used to look for changes in the cells of the cervix; abnormal cells can be identified early and treated appropriately. Pap tests provide information on both whether cells have changed and how much cells have changed, so  “abnormal” covers a range of possibilities.

The most common cause of abnormal Pap results is HPV (human papillomavirus) infection, and HPV also suggests a range: there are many types of HPV. Some lead to nothing at all, some are linked to genital warts, and some are linked to cancers of the cervix, vulva, and vagina. And, let me repeat, some lead to nothing at all.

When a Pap test returns an abnormal result, it’s typical either to monitor (repeat the Pap test in six months or a year) or to take an additional diagnostic step. A colposcopy is the most common; it sounds scary, but it’s really only a close visual exam of the cervix with a magnifying device. There are several tissue sampling procedures that take cells for additional lab examination.

About 70 percent of mildly abnormal results revert to the “normal” range at the next screening. That said, it’s important to follow your health care provider’s recommendation for a follow-up test. This is not the time to procrastinate on that office visit!

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I was sitting in a tiny hut in Mexico talking with a dignified older gentleman. Outside the ramshackle house, the sun shone on the empty desert. The ocean lapped the nearby shore. There was no traffic, no noise, no shops, no phones.

“The Americans, the Germans, and the Japanese are the hardest-working people in the world,” the man said.

First, I was startled that someone in this very remote place would be so astute. Then I wondered: Is this a good thing?

With all our mobile toys, we don’t ever have to stop working in America. We can be connected 24/7. Maybe we can squeeze in a few extra obligations after-hours. Or, we might be caring for parents and children, and sometimes spouses and grandchildren. Even if we’re retired, we’re programmed to run hard and fast.

But look what it’s doing to us. We’re stressed; we’re overweight; and we’re dog-tired.

Sex life? What sex life?

Ian Kerner, a well-known sex therapist, cites a recent study by the National Sleep Foundation in which one-quarter of American couples say they’re often too tired for sex.

Mary Jo Rapini, one of our medical advisors, recalls encouraging a couple to take time for a romantic getaway. “Oh no, who’ll plan that for us?” they asked. Well, “usually the couple enjoys planning these things together,” she said.

“We don’t have the energy,” they responded.

Think of sex as the canary in the coal mine. It’s one of the first things to go when life gets out of whack. But if you ignore that quiet little loss, pretty soon the bigger stuff suffers, like good health and relationships.

If sex is just another obligation, or you’re too tired to even think about it, you need a life/work balance adjustment.

If you don’t have some other physical or psychological problem, such as a thyroid condition, chronic fatigue syndrome, serious relationship issues, or hormonal imbalance, you shouldn’t be too tired for sex.

So, if stress, overwork, overcommitment, and the general pace of life, has killed your libido, consider this:

Allow time for sleep. Right now. Nothing else matters if you’re chronically sleep-deprived. Re-assess your involvements. Try to delegate tasks. Cut back on work. (Doctor’s orders.)

“A good night’s sleep every night—more so than exercise and a healthy diet—keeps our sexual engines humming,” says Barry McCarthy, PhD, a Washington, D.C., sex therapist.

Give yourself an hour to unwind before going to bed in the evening. Turn off the TV and all the other screens. “It’s terrible to have a television in your bedroom, which should just be for intimacy and sleep,” says sex therapist Sherri Winston.

Spend that time relaxing with a book. Share a cup of herbal tea. Cuddle with your honey. Take a bath.

Exercise.  Regular, moderate exercise is part of the work/life balance thing. Can you walk 30 minutes a day? Maybe with your partner? Can you find a gentle workout video? (My favorite now is hot yoga, but I have friends who spend 20 minutes a day with our old pal Jane Fonda.)

Exercise makes you feel better. It helps you lose weight.

And guess what? It helps you sleep better.

De-stress. Yeah, I know this sounds impossible. But you have a choice: You can continue to worship at the altar of overcommitment, at which you will offer up your health, your intimate relationships, and your quality of life.

Or you can bring your life into a healthy balance, and probably live longer—and have a lot more satisfying sex.

Need more persuading? Stress releases cortisol, a hormone that decreases testosterone, of which we women have precious little in the first place. Thus, stress directly hammers our sex drive even before the sleep-deprivation sets in.

Follow your rhythms. If you’re exhausted at night, why not have a little afternoon delight? Or maybe sex in the morning? Testosterone levels naturally rise a little then, so that might be the opportune moment to turn up the heat. Caress and cuddle at night and save the sizzle for the morning.

Just do it. You know how you may not be in the mood, but a little nibble on the ear, a little stroke on the thigh… and, well,… maybe…

Libido is like a puppy. Give it some loving, and it will follow you home. And sex begets more sex. You have to do it to want it.

When I recall the tranquility I felt in that simple hut in Mexico, I wonder if we somehow took a detour on the road to the good life. Maybe we can learn something about simplifying, cutting back, enjoying the little things, and loving each other from people who don’t have many possessions, but who probably sleep very well at night.

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Actually, do more than wish. Be active.

Sign this online WISH petition to add your voice to others advocating for greater attention to women’s sexual health needs. The WISH petition is sponsored by the International Society for the Study of Women’s Sexual Health (ISSWSH), which is a professional organization for those of us who work in the field of women’s sexual health.

The petition supports ISSWSH’s position that “female sexual disorders are valid conditions that warrant assessment, diagnosis and appropriate therapeutic intervention.”

But WISH is more than a petition. It’s an initiative dedicated to bringing “the medical community together with the public to recognize the importance of female sexual health, so that it is no longer considered a ‘lifestyle choice,’” according to MaryAnne McAdams, director of the WISH Initiative. The group even has a Facebook page.

As a professional in the field, I feel strongly about the need for more recognition, more acceptance, more treatment options, more research, and more pharmaceutical options for women who experience sexual dysfunction.

There are many of you. The numbers vary greatly (another area for research, perhaps?), but it is estimated that from 19 to 50 percent of “normal” women experience sexual dysfunction, according to a 2000 article in American Family Physician. Predictably, that number increases when the physician actually asks the patient about her sexual health, which many don’t. (An area for physician education, perhaps?)

As I’ve said before, I’d like companies to develop more pharmaceutical options for women, and I’d like the FDA to consider them seriously and carefully. I know that it’s easier to make a drug to treat erectile dysfunction. I’m well aware that women’s desire/arousal trajectory is complex and multi-dimensional, but the more tools we have in the bag, the more successfully we can treat women with sexual issues.

It’s easier, of course, to fall back on the old “it’s in her head” or “it’s a lifestyle choice” crutch. Thankfully, that attitude is becoming discredited and debunked, but those voices are still around.

“In the last few years, there has been a small, but very loud group who have been given the chance to speak during FDA Advisory Meetings claiming that female sexual dysfunction is a made-up condition and is not ‘real,’” says WISH’s MaryAnne. “The WISH petition may be used as a source of documentation to dispute that erroneous claim.”

As a physician who treats women’s sexual health, I’d like more attention paid to the issue by government agencies, pharmaceutical companies, and my colleagues. I’d like women’s sexual issues to be acknowledged, respected, and treated with intelligence, competence, and sensitivity. And since at some point in your life, you’ll probably experience some lack of libido, difficulty with arousal or achieving orgasm, or some pain during sex, I’m sure this is an important issue to you, too.

If it is, sign the WISH petition. We know size doesn’t always matter, but the number of voices on this topic does count!

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You describe cramps, not unlike menstrual cramps, after masturbation. Orgasm includes contraction of pelvic floor muscles, and it sounds like you’re experiencing some spasms of those muscles. Radical hysterectomies often require tissue removal or dissection surrounding the uterus and ovaries. It’s likely your spasms are caused within nerves and muscles that are still healing.

I suspect this will improve with continued healing, but using an anti-inflammatory medication like ibuprofen may help relieve the pain. If, three months or so after surgery, when most healing has taken place, the spasms and pain persist, a consultation with a pelvic floor physical therapist may be helpful. They can assess the muscles and nerves of the pelvic floor and often remedy persistent pain.

Continue that healing work! I’m hopeful the pain will resolve itself.

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