Archive for October, 2013

Estrogen–and vaginal moisturizers–generally lower the pH level, making it a more healthy environment. The vagina is typically slightly acidic, like tomatoes or wine. The loss of estrogen with menopause can throw off our pH levels, reducing circulation and lubrication. Being able to generate enough moisture is part of what allows our vaginas to reregulate pH level after intercourse, when semen, which is more alkaline, is temporarily disruptive.

(To ask your own question of Dr. Barb, use the pink “Ask Dr. Barb” button top and center on our website.)

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Recently, I was browsing through an online discussion board about the pros and cons of hormone replacement therapy. I ran across this comment from a participant: “I’m going to try bioidentical hormones like Suzanne Somers. I’ve heard they’re safer.”

Whoa! I thought. Let’s do some objective homework first, and weigh the risks before you jump in.

Celebrity endorsements notwithstanding, bioidentical hormone replacement therapy (bHRT) is neither the miracle cure nor fountain of youth touted by Ms. Somers. Nor is it some kind of snake oil concocted by salacious quacks or unscrupulous doctors and pharmacists.

The truth is, of course, much more nuanced.

As a physician, I’d always opt for more treatment choices when it comes to helping women with the unpleasantries of menopause. I want more drugs in the arsenal, more ways to treat hot flashes, sleeplessness, and loss of libido. However, the entire topic of bioidentical hormones is so laden with emotion and misinformation that it takes a very fine point to tease fact from hyperbole.

We laid the groundwork on bioidenticals before, but the issue continues to befuddle and mislead, so let’s circle back and fill in some gaps.

Any hormone therapy, whether bioidentical or synthetic, is only intended to ease menopausal symptoms. Hormones were never meant to keep your memory sharp or your hair shiny or your skin taut. Hormones are not a fountain of youth. The latest medical guidelines state that hormones should be taken at the lowest possible dose for the shortest period of time needed to ease symptoms. This is because hormones, whether bioidentical or synthetic, are drugs and they interact with other systems in the body, sometimes in ways that are not well understood.

Point #1. Menopause isn’t a disease; it’s a natural transition. Hormone therapy is intended neither to keep your hormones “in harmony” nor to keep menopause at bay indefinitely. Hormone therapy is intended to ease the symptoms of the menopausal transition when they are interfering with your life.

Next, bioidenticals aren’t necessarily “natural” and therefore “safer.” The marketing message that hooks women is that bioidentical hormones are derived from “natural” sources and are therefore safer than hormones from other sources.

Bioidenticals are estrogens that are indeed made from plant sources, but they are processed (synthesized, if you will) to create a hormone that can be absorbed by humans. “All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product,” writes Dr. Oz in this article.

With bioidenticals, however, you end up with a molecule that is exactly like (identical to) human hormones, whereas non-bioidentical hormones are similar but not identical.

Any hormone, whether those your body produces or those you ingest, affects your body. Also, the delivery method, whether a patch, pill, or vaginal cream, also affects the way your body absorbs and responds to the hormone.

Point #2: Don’t equate “bio” with something “natural” and therefore risk free. Taking any hormone involves some risk. (Decisions about hormone therapy need to be based on careful consideration for each individual—understanding both the potential risks and benefits for that woman.) Bioidentical hormones are so-called because the molecule is identical to the human hormone and because they are derived from plant sources, even though they must be synthesized to be useful.

“So ‘natural’ doesn’t necessarily equal ‘safe’—and may simply be a euphemism for ‘unregulated,’” according to this article in the Harvard Women’s Health Watch.

You can, we should note, get bioidentical hormones that are FDA approved and regulated. Many familiar brands of hormonal rings, creams, patches, pills, and gels are both commercially manufactured by pharmaceutical companies and bioidentical. These include Estrace, Femring, Vivelle, Vagifem, and Prometrium, and more.

You know what you’re getting with these products. You know that the active ingredient is in the form and dosage that the label says it is. That kind of uniformity and “safety” is the assurance provided by FDA testing and approval.

Point #3: Many major brands of commercially manufactured hormones are both bioidentical and FDA approved.

Next, let’s understand what “custom-compounding” means. Many bioidenticals are touted as natural, safe, and custom-made just for you to bring your hormones back in balance. Custom-compounded drugs are made in small, customized batches by pharmacies that specialize in custom-compounding. They can be prescribed by a clinician.

Custom-compounding is very helpful when a patient needs a special dosage of a medication, or a different delivery method, or is allergic to a filler in a commercial drug. Maybe, for example, you need a lower dose of progesterone than is commercially available, or you need it in a vaginal cream, and the big pharmas only make it for administering orally.

However, neither the process nor the product is FDA-regulated or approved, and in fact, studies have shown that they are much less consistent than commercial products. In a few highly publicized cases, contaminated medications distributed by custom-compounders have been responsible for serious illness, infection, and death. An example is the outbreak of fungal meningitis in the fall of 2012.

The problem with custom-compounded hormones arises with claims of customized products that are safe, natural, and that will restore hormonal balance, among other things.

In actuality, it’s not possible to accurately pinpoint hormonal levels in an individual because they are constantly changing. The hypothalamus, pituitary and ovaries (the HPO axis, as we call it) work in a very integrated and precise way to direct hormone production. Our replacements aren’t able to replicate that concert of events, but we can do a good job of replacing the hormones more consistently, which many women prefer to the ‘ups and downs’ we’re familiar with. The only way to determine an effective dose is through symptom control—the lowest dose that relieves a woman’s symptoms. “Salivary and blood testing of hormone levels used by custom compounders is meaningless for midlife women as their hormone levels vary throughout the day, and from day to day” is the North American Menopause Society position.

“This doesn’t mean that you shouldn’t consider compounded hormones. Just realize that, in a real sense, you’re going to be an experiment of one,” says the Harvard Medical Watch article.

Also realize that custom-compounded drugs usually aren’t covered by insurance, and the regimen of testing and compounding gets expensive very quickly.

Point #4. Custom-compounding of drugs is a time-honored practice of making drugs in small batches or according to specific needs (while the processes and products aren’t subject to federal regulation or oversight). Claims that these products are healthier, safer, or somehow contain properties lacking in commercial products should be viewed with suspicion.

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When women in my practice have vaginal dryness or atrophy, I typically start by recommending a vaginal moisturizer. The key is to be faithful, using the moisturizer at least two times each week. Yes is the most popular vaginal moisturizer at MiddlesexMD; the fact that it’s available in pre-filled applicators is definitely a plus for women who don’t like the mess of other options!

If the dryness or atrophy is not effectively managed with a moisturizer (which can happen over time), then I add a vaginal (localized) estrogen product.

I should also mention that a new oral medication for vaginal dryness or pain was approved by the FDA this summer. Non-hormonal, it’s called Osphena and is available by prescription. Because it’s oral, there’s no mess! But you do need to make the consistent commitment, again, to regular use.

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You refer to hot flashes, weight gain, mood swings, and loss of libido as symptoms of menopause, and all of those happen for some women. Menopause doesn’t equate absolutely to those symptoms for everyone, though; each woman’s menopausal transition will be unique to her. Not every woman has every symptom, and even those women who share a symptom may experience it differently. About two-thirds of women have hot flashes, for example, but for some it means loosening a top button and for others it means running for the ice cubes!

What I’ve seen in my practice is that the healthier you are overall, the easier the transition is likely to be for you. That means being as close as you can manage to your ideal weight, eating well and nutritiously, exercising regularly, and getting enough sleep. My motto for women at our age: “You’re now high maintenance, so you need to behave that way!”

The good news is that the healthy habits that help you through menopause also enrich the rest of your life, so you can be as active as you choose to be for longer. And being well-informed about what’s to come will help you be calm and adaptable, which will also help keep symptoms managed.

If you’d like some company along the way, subscribe to this blog or our twice-a-month newsletter or like us on Facebook. And talk to your women friends! We can learn a lot from each other about how we’re compensating for the changes we’ll all go through.

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This is the kind of question that makes me grateful to have Mary Jo Rapini, who specializes in relationship counseling, as an advisor to MiddlesexMD. When I shared some of your story with her, she said:

It sounds as though your wife may have felt detached from you for a number of years. Recent events have caused her to realize that her concern for you was actually still love, which is a first step: She still loves you, and you still love her.

I often see that couples who lack intimacy actually lack communication. I’d recommend that you focus on communicating better, resolving conflict, and taking every opportunity to be intimate without a focus on physical intimacy or intercourse. It sounds as though your wife has feelings she’s uncomfortable talking to you about, which suggests that counseling for her alone would be wise. A therapist can help her understand what she is feeling so the two of you can work together to restore a healthy sex life.

Therapy is also best when you are both healthy physically—including your sexual health. Some women react to perimenopause with depression or anxiety, which it’s helpful to address first.

We hope that’s helpful, and that you and your wife are able to have a full life together. We’re all in favor of healthy, lasting relationships!

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Ringing the Love Button

Maybe you gathered from last week’s post that the clitoris is command central of the female orgasm. Perched atop the labia minora, its sole purpose and function is sexual pleasure. It has more nerve endings than the penis, and—although affected by conditions that reduce blood supply—it can retain sensitivity as you age.

Most of the clitoris is out of sight, extending deep within and around your vagina and labia. “The most recent anatomical research suggests that the clitoris is perhaps better described as the ‘clitoral complex,’ where the vagina, urethra, and clitoris all function as a unit rather than as individual parts,” says Dr. Debby Herbenick, in this article for Men’s Health.

Unlike the penis, the clitoris can orgasm repeatedly without a refactory (rest) period. Clitoral orgasms also last from between 10 to 30 seconds and involve from 3 to 15 contractions, which can reach from the abdomen to the vagina.

So, rather than creating artificial divisions and hierarchies between whether an orgasm is vaginal or clitoral, why not view the whole area as one big erogenous zone? Clitoral orgasms involve the vagina and vice versa, so neither is “better” or more desirable. Every orgasm is right on the money. Use what works, rather than focusing on the vagina, which as you know, can get a little cranky right about now.

And if you can coach your partner on some clitoral finesse, lovemaking could take on a whole new dimension.

Let’s return to the fact that the clitoris, as we mentioned before, is “homologous” to a penis—it has the same biological features. Thus, it has to be treated gently. Too much or too rough and it’ll either hurt or go numb. So start slow and gentle.

To begin, use lube on your fingers. (Your partner’s tongue is great.) Start a vibrator on low. The glans (head) is usually too sensitive to touch directly, so stroke the hood over the top of the glans, stroke around the labia minora and the vaginal vestibule. Stroke inner thighs, breasts, nipples. Use round and round and over the top motion on the clitoris.

For the partner: Tongue action on and around the clitoris is very erotic. Done well, it can make her “come” all by itself. Don’t jump into action. Get things warmed up with your best foreplay action.

Then, with lubed fingers begin a gentle, playful massage downtown—gently stroke her inner labia, across, over and around her clitoris. As your partner becomes aroused, slide between her legs and begin using your tongue, licking firmly up the tiny shaft of the clitoris, using separate strokes at first. Vary the action with quick darting motions on the exposed glans or by flicking her clitoris with your tongue. Begin using a firmer, continual stroke without breaking contact until she begins to orgasm.

You can then quickly move to penis-in-vagina action until you orgasm, or you can cup her “mound” with the palm of your hand, applying gentle pressure to her clitoris, which feels very comforting.

You don’t have to go crazy with the tongue action (how exhausting that would be!). Set the scene well with foreplay; keep the action gentle and varied, increasing both the frequency and firmness as she becomes aroused. Some handwork on her breast and nipples helps. And remember, practice makes perfect!

Good positions to increase clitoral contact during sex include the faithful missionary but with the partner pressing down to engage the clit. Either partner can reach the clitoris if she’s on top or in the rear entry position. “There’s no need to be overly fancy during sex—the very best positions are the ones that focus on the clitoris,” says author and sexologist Dr. Logan Levkoff.

Finally, the clitoris needs good blood flow to be its best orgasmic self—and orgasms boost the immune system, support a healthy sleep cycle, and help keep your hormones balanced. You can keep clitoral blood flow through:

  • Exercise. “Twenty minutes of moderate exercise increases a woman’s genital engorgement by 168 percent—and the effect persists for hours,” writes Weed. Go for a walk with your partner, she suggests.
  • Sex and masturbation. It’s the whole “use it or lose it” dichotomy. You have to keep the tissues plumped and primed or they atrophy, especially as you age.
  • Clitoral pump. That’s the whole purpose of this handy device—bringing blood and, ergo, sensation and function, to the clitoris. In no way should a pump replace the first two parts.

Clitoral stimulation techniques of your own? Please share.

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I assume that your hormone therapy is oral or transdermal and systemic. There isn’t evidence that says hormone therapy contributes to weight gain. In fact, some of the research suggests that it can be helpful in maintaining a healthy weight.

Based on my experience, I believe hormone therapy is weight neutral—although if it makes you feel better and sleep better, it can be very helpful to an overall healthy lifestyle, which includes exercise and a good diet.

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