Archive for May, 2014

Many of the women I see in my office would like a black and white answer: Where, exactly, are they on the path to menopause? What, exactly, can they expect? Unfortunately, I can’t really give them a solid answer, and here’s why.

Perimenopause—that period (no pun intended!) between regular menstruation and menopause—isn’t a steady progression. It’s more like two steps forward, one step back. Sometimes, one step forward, two steps back. You may have some signs along the way, like moodiness, insomnia, irregular periods, hot flashes, lack of interest in sex, or vaginal dryness.

Sometimes FSH tests are used to help fill in the picture, providing one more data point. I don’t often recommend these tests, though, because although the tests are accurate at that moment on that day, they can be wildly misleading—unless you’re not yet in perimenopause (in which case the test can point to other issues) or you’re in menopause—which you already know because you’re not menstruating.

Here’s what’s happening with FSH (follicle stimulating hormone): The pituitary gland sends out FSH to tell the ovaries to make estrogen, which helps eggs grow (stimulating follicles!) and thickens the uterine lining. The pituitary gland acts like a thermostat: if it senses estrogen production is low, it “kicks on” and releases more FSH.

But as I said, the path to menopause is not a straight one; most women have erratic periods before menopause. So even if you are 52 and have every other symptom of perimenopause, if you take the test during the one time in six months you happened to ovulate, your FSH levels would suggest you’re not menopausal. Lifestyle-related factors like stress and smoking also affect FSH levels, making them even less helpful.

Check out the graphic to see the kind of unpredictability that’s typical. The first graph shows regular
Typical Hormone Fluctuationshormonal fluctuation when you’re having regular cycles. The second graph shows how wildly all four hormones may vary over six months. The last graph shows that a consistently high level of FSH accompanies menopause. But, again, if you’re not having periods, you don’t need a hormone test—either from a doctor or an at-home saliva test—to tell you you’re menopausal. (If, by the way, you’ve had a hysterectomy, endometrial ablation, or another procedure that’s eliminated periods but you still have ovaries, you have the same unpredictability in hormone levels. Charting your symptoms for a few months may be the most helpful approach.)

I understand that the ambiguity of perimenopause bothers some women. As a physician with a pretty good understanding of all the pieces at play, maybe I find it too easy to recommend that women tune in to their bodies and take it a month at a time. I’d love to hear from women who’ve found ways to be “in the moment” with The Change!

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As you suspected, the “vaginal cuff” is the healed incision at the top of the vagina after the surgical removal of the cervix and other pelvic organs.

The vagina is just as functional as it was before surgery, but the depth is unpredictable. The tissue is somewhat elastic and stretchy–comparable to the inside of your cheek when you poke your tongue against it. If there seems to be less depth than you (and your partner) need, using dilators can gently and gradually stretch the tissue to a new capacity.

An intravaginal vibrator (like the Liv2) may be helpful to you as you determine what your needs and your new reality are.

Sincere congratulations on achieving remission from the cancer for which you were treated, and best wishes as you rediscover your sexual self!

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The dryness, discomfort, and frequent infections you describe are consistent with vulvovaginal atrophy (now sometimes called “genitourinary syndrome of menopause”) and, possibly, vulvodynia. The mainstay of treatment for these conditions is to “estrogenize”–add estrogen to–the vagina.

It was once thought that all estrogen posed some vascular risk, so I understand the hesitation about continued use for you after a blood clot. More recently, though, localized (placed directly in the vagina rather than taken orally) estrogen has been shown not to raise the risk of thrombosis. Estrogen products still carry the “black box warning,” regardless of the method of administration. About a month ago, though, additional data were presented to the FDA asking them to remove that “class labeling,” since the means of administering makes such a difference. We’ll see what happens, but you can ask your health care provider to reconsider.

In addition to continuing the use of a vaginal moisturizer, you might also use a silicone lubricant (Pink is a favorite at MiddlesexMD). That type of lubricant reduces friction and gives more glide or slipperiness. And you could ask your health care provider to prescribe a topical xylocaine, an anesthetic that you can apply to the area to make you more comfortable during and after intercourse.

Have another discussion with your health care provider, and try all your options! Comfortable sex is possible for you.

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The MiddlesexMD team and I spend some time at medical conferences, so I know that vaginal dilators aren’t a mystery just to a lot of women: They’re also a mystery to some medical professionals! Dilators are one of the biggest sources of curiosity when we show our products at those conferences (the other, in case you’re curious, is Kegel tools).

Less estrogen means less elasticity in our tissues. Tissues that were actually pleated—imagine how a pleated skirt can expand and swirl!—become flatter and therefore less stretchy—think pencil skirt. Moisture helps, but so does some regular and gentle stretching, which reminds those tissues of what it is we’d like them to do—both in width and depth.

That’s where vaginal dilators can help. Dilators are typically offered in a set with graduated diameters, starting at about a half-inch and increasing to an inch and a half or so. If you’re looking to recover what we doctors call “patency,” or openness, you’ll start with the smallest dilator that’s comfortable and work your way up. If you’re maintaining patency, you may be using less of the size range.

We have instructions for using vaginal dilators on our website. As with moisturizers, regularity is important—and you know that’s true for many areas of self-care, from exercise to hand lotion.

At MiddlesexMD we offer a variety of dilators, so you can choose the set that works best for you. All of them meet our criteria for safety (safe materials and quality manufacture) and effectiveness (size increments and firmness for insertion). I’m happy recommending any of them, which actually gives me pause in calling out what’s good about each—feels almost like naming a favorite child! The Anjali set, which comes in a pouch, is our lowest-price option, so if cost is a barrier for you, grab that one and go! This set of five, made by a medical-products company, I like for its size range (there’s a set of seven, too) and feel; because they’re solid, they have some heft. And our newest option, Soul Source dilators, are made of silicone, which has some benefits: You can warm them for more comfortable use, plus they just feel more “touchable.” Their colors are cheerful and friendly, too, which doesn’t hurt!

These descriptions suggest some criteria for you to use in making a choice. If you’re working with your doctor or physical therapist to treat a specific condition, she or he may have additional advice about which might work best for you, as well as how you adapt their use for your situation. Don’t be shy about asking!

I had a woman in my practice just the other day who told a typical—but, for her, life-affirming—story: She’s been single and, when she found a new guy to be serious about, she also found herself unable to have intercourse. Now, after three months of dilator use, she’s having sex comfortably. Such a simple tool, you’ll think when you’ve seen or tried them. But, trust me, so effective.

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Perhaps you’ve seen reviews of a new book, called Sex After…: Women Share How Intimacy Changes as Life Changes. It’s definitely in my reading pile. The author, Iris Krasnow, interviewed 150 women from 20 to 90 about their sex lives.

The surprise—to Iris and some reviewers—was that the women in the later chapters were claiming some of the best sex of their lives. Among the comments:

We are so comfortable with each other that we will try anything to keep things hot.

When you’re younger, it’s all about the orgasm, then it’s over. I love this suspended feeling, the absolute intimacy we have been able to achieve.

Given my conversations with patients in my practice, I’m not surprised. There’s a whole lot of life after 50, and a whole lot of pleasure.

Two things typically get in our way: First, just as our kids never wanted to know we had sex (mine are adults and still don’t want to know!), we’re culturally just a little uneasy with grandparents having sex. Silly, but there it is.

And second, we could do a better job of sharing information about how to keep sex comfortable for just as long as we want it—and expanding our thinking about what “sex” means as intimacy beyond vaginal intercourse.

Most of the women I see are interested in being sexually active—I am, after all, a gynecologist. Every now and then, though, a woman will tell me, “We’re done with all that. And it’s okay.”

I think it’s awfully hard to tease out how we really feel about that “okay”: If it’s not cultural messages that we’re too old for sex, it’s a cultural message that we need to keep at it to stay young. For many of us, the discomfort we may now experience with sex is enough to sway us toward that “too old” message.

But beyond the effect on relationships I’ve talked about before, what I hear from the women in this book echoes my own experience: Sex is part of feeling alive, powerful, energized, secure, blissed, refreshed. I’ll decide for myself when I’m ready to give that up.

And you can, too.

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