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Archive for June, 2014

You describe hot flashes and night sweats that began after a hysterectomy to reduce breast cancer risk. You’re right that the symptoms can be prompted by your sudden entry into menopause (through surgery) as well as by the prescriptions intended to deplete estrogen in your system. You are, as you know, not alone in facing this challenge!

I always start with lifestyle factors, which can lessen symptoms for anyone. You may be able to identify triggers (like caffeine, alcohol, spicy foods, or sugar) that you can avoid in your diet. Dressing in layers is a must for many of us. Now is the time to exercise regularly; women who do so may have fewer and/or less intense hot flashes.

Reducing stress—or learning new tactics to manage it—is helpful if you can do it (I know life doesn’t always cooperate). Paced respiration is a technique to ease the intensity of a hot flash when one occurs: Breathe deeply and slowly, inhaling through your nose and exhaling slowly through your nose or mouth. There’s also a biofeedback technique to slow the heart rate, which may lessen the hot flash intensity and duration (because an elevation of heart rate is part of the physiology of a hot flash).

Acupuncture has been very helpful to a number of my breast cancer patients in managing hot flashes.

Beyond that, we haven’t seen a lot of success with alternative medications and complementary therapies. Those that have been tried include isoflavones (found in soy but not recommended for breast cancer patients), black cohosh, chaste tree berry, ginseng, dong quay, red clover, yarrow and others. For those that have been investigated and undergone careful scrutiny, the results are disappointing; there is limited scientific evidence for most herbal options. That being said, placebo has at least a 25 to 40 percent response rate in nearly every study, so if you can determine that an herb is not harmful (check with your physician) I do not discourage women from trying herbal preparations. I wish we could make a recommendation knowing we are in fact offering beneficial outcomes, but that just hasn’t been so for these options.

There are some non-hormone prescription options that have favorable effects. Just in the past year the FDA approved Brisdelle specifically for the treatment of hot flashes. It cannot be used with Tamoxifen, but as a very, very low dose of paroxitene (generic for Paxil), Brisdelle is well tolerated with minimal side effects. The anti-hypertensive medication clonidine has been shown to reduce hot flashes for some women, as well as gabapentin (generic for Neurontin). Other antidepressants can reduce hot flashes as well: venlafaxine (generic for Effexor), paroxetine, and fluoxitene (generic for Prozac), and escitalopram (generic for Lexapro). All of these have a modest benefit to hot flashes. They each have the potential of side effects, so a discussion with your provider is helpful in determining an option best suited for you.

Good luck, and the good news is that time will work to your advantage for the hot flashes. This too shall pass—really!

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I’m a gynecologist. I talk about sex and body parts all day long, and I have for 25 years.

I guess I take a certain amount of openness for granted. I see intimacy as a cherished part of relationships, and sexuality as a natural part of overall health. So I’m a little surprised more people aren’t talking about both!

That the conversations aren’t happening was apparent last week, when I spent a few days in the exhibit hall at a major conference for nurse practitioners. Every time I turned around, another woman (mostly, but also some men) was saying, I’m so glad you’re here! I get questions all the time, and I don’t know where to go for information or where to send women for resources.

At our MiddlesexMD exhibit, we had a cross section of our products on display, and found plenty of curiosity about some of them. Kegel tools probably led in prompting conversations, with vaginal dilators following. One woman nurse practitioner brought her husband by to show him, up close and personal, the first vibrators he’d ever seen.

There were a few gasps and a little blushing, but once our conversations got underway, I’m hopeful that these health care providers began to see our “toys” in a different light. Because yes, there are symptoms anyone in perimenopause or menopause can recognize: vaginal dryness and less sensation. And yes, many of us see intimacy as a part of our relationships that we’d hate to lose. And most definitely yes, there are things we can do—products we can use—that help us to compensate for changes and maintain (and even regain) our sexual health.

So, to the woman who came to our exhibit saying, “Are those what I think they are,” the answer is yes. And no.

Beyond being “sex toys,” these products are also tools for increasing blood circulation, strengthening muscles, and nourishing tissues. By keeping sex not only possible but satisfying, they’re reducing stress, improving cardiac health, combating pain and depression, and burning calories. If we think about them in that light—practically as medical devices—perhaps we’ll be more open-minded about adding to our repertoire.

There was plenty that was encouraging, even energizing, about my conversations last week. There are thousands of nurse practitioners—and other health care professionals—who are willing and prepared to talk. Every woman can help by initiating the conversation when they have concerns about intimacy or their sexual health.

You don’t have to talk about sex every day, as I do. Just don’t be shy when it matters.

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The pelvic floor is made up of multiple muscles and supporting tendons. They act like a hammock or trampoline to support a number of vital organs: the bladder and urethra, uterus and vagina, and rectum and anus, to name a few. It’s a very unique area of the body, involving organs that play a role in varied and important functions: urination, defecation, sex, and childbirth.

Many things can disrupt the proper function of the pelvic floor; childbirth, natural aging, and menopause are common. Surgery can have an immediate effect. Sexual trauma may result in damage, and so can actions as simple as lifting or coughing. Symptoms of the pelvic floor not behaving properly might be urinary incontinence (involuntary loss of urine), painful sex, or constipation or difficulty moving bowels. Pelvic organ prolapse can cause or exacerbate some of those symptoms; that’s when one or more of the organs resting on the pelvic floor sag into one another.

A discussion with your provider about your symptoms, accompanied by a good pelvic exam, can help in determining whether pelvic physical therapy is likely to help your condition. To get the best outcome it is best to find someone who specializes in this area of the body. A great pelvic physical therapist can work magic!

A common reason for referring to physical therapy is urinary incontinence. As part of treatment, physical therapists use electrical muscle stimulation, employing devices that stimulate the muscles of the pelvic floor to teach them to properly contract and relax. One of these devices recently became available for home use. In addition to increasing continence, Intensity also treats orgasmic dysfunction (difficulty achieving orgasm). It works in two ways: providing electrical stimulation to the pelvic muscles (you increase the stimulation as the muscles get stronger) and offering a very intense vibration that improves the ability to orgasm. Orgasm is, after all, a series of very intense muscle contractions; as the muscles grow stronger, you improve orgasm. So far my patients have given Intensity two thumbs up! Other, lower-tech options to improve pelvic floor muscle function are vaginal weights and barbells.

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You ask about vaginal pH (the abbreviation stands for ‘potential hydrogen,’ a measurement of acidity). The scale for measuring pH is from 0 to 14, with a lower number meaning more acidic and a higher number meaning more basic. The normal pH of the vagina is 3.5 to 5.0. Being on the acidic end of the range means that the environment is unfriendly for unwelcome bacteria–and therefore more resistant to bacterial infections. There are a plethora of bacteria that belong in your vagina, the most predominant being lactobacilli. They produce lactic acid, resulting in an acidic pH and vaginal health.

A number of things can disrupt normal pH. Semen has a pH of 7 to 8, so after intercourse there will be a brief change in pH. Menstrual periods, with blood with a pH of 7.4, will also disrupt normal pH levels, and not so briefly; susceptibility to bacterial infections rises during menstruation. Douching can also disrupt healthy pH by flushing the healthy bacteria.

Perimenopause and menopause are major disruptors of pH, because the decline of estrogen causes the pH to rise (less acidic, more basic). This change is not brief at all; instead, it’s the new normal. Not all women are sensitive to changes in pH, but some are; we’re not sure why it varies from woman to woman. The most common infection related to the pH change is bacterial vaginosis (BV), caused by the bacteria gardnerella vaginalis, typically apparent because of discharge and odor. It’s inconvenient, but easily treated with an antibiotic.

To avoid that infection or its recurrence, maintain healthy vaginal tissues and a healthy pH, which keeps the lactobacilli around to do their job. Vaginal moisturizers help; avoid douching; and if you have recurring issues, use a condom during intercourse to minimize the effects of semen.

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While the cream you describe would be fine with the dilators themselves, we doctors recommend against using oils in the vagina. Oils tend to promote the growth of bacteria and break down or weaken tissues. Lubricants especially made for vaginal use are worth the investment.

If you’re using silicone dilators, use water-based lubricants with them. Silicone lubricants on silicone products (dilators or vibrators) will cause the surface to degrade over time.

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Given all of the unpredictability of perimenopause, you’re wondering which symptoms carry over into menopause and which are resolved: Will you feel your best all the time? Or your worst?

I so wish I could give you a solid answer. The reality is that multiple factors are at play, and your genetics, overall health, and lifestyle will affect how they combine.

What’s happening during perimenopause is that your hormone levels fluctuate wildly. Symptoms will vary, from person to person and from week to week. The key issue with the transition into menopause is the drop in estrogen. At the time of that change, in early menopause, many women experience the most symptoms: hot flashes, irritability, sleep issues, memory and concentration, dry skin, joint pain, and weight gain.

Most of those symptoms “resolve,” as we medical people say, which means they diminish or go away entirely. The two areas where the loss of estrogen has continued effect for post-menopausal women are bone health and genital tissue (especially what we recognize as vulvar and vaginal dryness).

So back to those other symptoms: If it’s irritability you’re wondering about, you’re likely to come “back to center” on mood, assuming that there aren’t other unresolved (or, heaven forbid, new) issues in your life. For memory and concentration, remember that staying mentally engaged and challenged is important for brain health for both men and women!

And, because I’m a physician, I need to reiterate: A healthy diet and regular exercise minimize symptoms at any point.

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