Archive for March, 2016

This is the second post in our occasional survey inspired by the results of a survey we co-sponsored withPrevaLeaf, makers of natural products for intimate wellness. You can read our first post here: You spoke. We’re listening.

Start with the easiest, most natural regimen first.Almost every day, I see patients who suffer, and I mean suffer, from vaginal dryness due to menopause or surgically induced menopause, such as hysterectomy. In medical parlance, the umbrella term for vaginal pain is dyspareunia, and the term for dry, brittle vaginal tissue is now “genitourinary syndrome of menopause,” just so you know (it’s been called vulvovaginal atrophy until recently).

If a patient comes to me, that usually means the condition is painful and probably damaging her sex life, and thus, her intimate relationship. It’s hard to relax and enjoy sex when it hurts, and sex is an important glue that binds a couple.

The first thing you need to know about vaginal dryness is that it is almost always treatable! You don’t have to suffer; sex doesn’t have to be painful. And you can take that to the bank.

The second thing you need to know is that you may need patience and persistence in seeking a treatment that works for you. You may need to persist until you find a practitioner who won’t tell you it’s all in your head and is willing to work with you to find a solution. (We call that person a sexually literate healthcare provider.)

As one survey respondent wrote: “I experienced severe vaginal dryness after going through chemotherapy for breast cancer at the age of 44. The first two doctors I visited could not tell me that I had vaginal dryness. Third time’s the charm! I saw a nurse practitioner who dealt with the issue. She was able to tell me what was going on and how to treat it.”

And you’ll still need to be persistent while you try out treatments until you find one that works for you. That can take some experimentation—three months is commonly how long it takes to thoroughly test-drive a treatment regimen. It’s inconvenient, but if you’re willing to persist, chances are you’ll experience pain-free sex again.

Generally, it makes sense to start with the easiest, most natural regimen first. Take care of your bottom by avoiding scents, harsh soaps, douches, non-breathable underwear. Then, use lubricants liberally during sex and use a moisturizer regularly. Natural and high-quality, of course.

If this vaginal-care regimen doesn’t do the trick, another option is topical estrogen. Many women are hesitant to use a hormonal product, but the recent report from the American College of Obstetricians and Gynecologists (ACOG) reaffirms that estrogen used topically in the vagina can offer significant relief without being absorbed systemically. So it’s safe for breast-cancer survivors.

Another option is the new drug Osphena, which acts like estrogen–without being an estrogen–to  vaginal tissue; it has no effect on other tissues, such as the breast. (This is called an estrogen agonist/antagonist.) So it’s also safe for those with breast cancer risks. It is a once-daily pill, however, and does have side effects that need to be taken into consideration.

Finally, an important way to keep vaginal tissue healthy is sex itself! Once you can tolerate a little sex, you’re on the way to enjoying a lot more.

Be of good faith, sisters. Many problems in life are tough to solve. Vaginal dryness isn’t one of them.

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Recently, MiddlesexMD conducted a short survey in partnership with Prevaleaf, a maker of natural feminine care products, to find out a few things about vaginal dryness, how you feel about it, and who you talk to about it.

Pretty interesting stuff, ladies. Especially your comments.

To be sure, it was a small-ish sample size of just over 100 women. Most (85 percent) of respondents were over 40, and were usually readers of the Prevaleaf or MiddlesexMD newsletter (you can sign up at the bottom ofthis page). So, this wasn’t exactly a rigorous and unbiased scientific study, but it was revealing nonetheless.

In fact, due to your many comments and the survey questions, we have a lot to talk about. In future posts, we’ll drill down into the concerns and questions you inspired. In this post, however, let’s take a broad view of the survey itself and some of the more telling tidbits it revealed.

First, virtually all women experience vaginal dryness to one degree or another. (If you don’t, you’ve caught life’s gold ring. Congratulations.) In this survey, 92.5 percent of respondents “sometimes” or “often” experience vaginal dryness either daily or during sex. This is no surprise. I treat women with this problem every day in my clinical practice.

We have a lot to talk about.Equally significant was the level of awareness—or lack thereof—about that eventual drying up of the well-lubed youthful vagina. For a lucky 10 percent in this survey, vaginal dryness was “better or less severe” than what the respondent expected, and for 3 percent it was right on point with expectations. But over half of you didn’t know what to expect, and for another third, it was worse than expected.

One respondent said “never heard of it until I had it!” Some mentioned feeling betrayed or angry at the way vaginal dryness sucks the joy right out of sex. (It’s very, very hard to enjoy painful sex.) We’ve discussed this a lot before, and we’ll continue to talk about our options, but for now, I want to reassure you in the strongest way possible: Vaginal dryness is extremely treatable!

Did you get that? It may take a little experimentation to find a treatment that works for you (or, sadly, perhaps also a practitioner who will listen to you), but it can be done!

A second major focus of our survey was about how often and to whom you talk about vaginal dryness. (It’s not like you’re going to bring up at a cocktail party. Right?) As it turns out, about two-thirds of you have at least mentioned vaginal dryness to your doctors, and sometimes you mention it often. Good for you! This is exactly what needs to happen.

We’ve discussed the embarrassment that often short-circuits this conversation, and the fact that more doctors ought to initiate it. However, if you’re one of the 36 percent who hasn’t talked to your doctor about painful vaginal dryness…be emboldened! Your doctor’s undoubtedly heard it before, and he or she darned well should be talking about it with you!

Most of you (78 percent) talk about painful dryness with your significant other, at least sometimes. Again, this conversation needs to happen so your partner doesn’t misinterpret your hesitance for rejection.

Most of you don’t talk about vaginal dryness with your friends. Understandable. I only wonder if we’re missing something here—if a little girlfriend talk about sexual difficulties might yield some helpful tips, tricks, and work-arounds. Or just reassurance that almost everyone else we know is in the same, bone-dry boat.

So, ladies, thank you for your candor. You gave us a lot of grist for the mill, which we’ll discuss in future posts.

Wait for it…


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Ever have a medical professional say to you, “This procedure is a piece of cake. You’ll be back on your feet in a couple days,” only to be popping Tylenol and cursing the day you were born fully a week later?

Ever step off the plane into a throng of strangers and realize you really should have researched this off-the-beaten-track destination a whole lot more before you booked the flight?

I don’t know about you, but before I venture into uncharted territory, whether It’s a medical procedure or a new travel destination, I like to talk to someone who’s “been there,” who knows what she’s talking about and is willing to tell it straight. The voice of experience is always reassuring.

So for Part 2 of our discussion on testosterone therapy, we bring you the voice of one of my patients who is on testosterone therapy and who was kind enough to share her experience with us.

Each woman's menopause story is unique.

As I mentioned in Part 1, in my clinical experience about 40 percent of women aren’t helped by testosterone therapy at all. A few others experience unpleasant side effects, and others still, like this patient, experience additional positive effects. While each woman’s experience is unique, many really do benefit from small dosages of the hormone.



Here’s a Q&A from one who did. Let’s call her Elaine.

MiddlesexMD: What were your expectations of menopause? Did you have a general idea of what to expect?

Elaine: The only idea I had of menopause was what is popularized by general media: hot flashes, temperamental moodiness, weight gain, fatigue, dry vagina, low sex drive. I didn’t want that to be my experience, and I decided I would do all I could not to have that be my story, but I really didn’t know what that would mean. Lucky for me, I have a smart, proactive health care provider that has always felt like she was on my team with my health story.

MiddlesexMD: What was your experience of menopause?

Elaine: My complaints were: intermittent feelings of anxiety, which I had never experienced before. Also I experienced somewhat diminished sex drive, but worse than that, when my hubby and I did have sex, it was SO MUCH WORK to achieve orgasm for me. Exhausting. I am so glad I am a runner and in good shape, because there is no way an out-of-shape me could even hope to work that hard without having a heart attack!

Then finally the orgasm was very flat and not very satisfying. Also I experienced some mild general fatigue; almost daily I would require a 10-minute nap, which never bothered me, but was relatively new to me.

MiddlesexMD: What was the problem–or set of problems–that you wanted to solve by seeking medical help?

Elaine: I described the symptoms listed above (anxiety, diminished sex drive, flat orgasm, some fatigue), without really expecting a solution. I expected Dr. Barb to say, “Yep, that’s menopause! Most women experience those things.” I thought she might recommend some herbal remedies, at most. I was obviously delighted with the solution she prescribed!

MiddlesexMD: What was the impact on your relationship of the symptoms that you had?

Elaine: My sex drive is improved, and the quality of orgasm is VERY much improved. Also, it doesn’t take forever for me to achieve orgasm. I almost never require a nap anymore, can’t think of the last time I took one, actually.

MiddlesexMD: Any other effects of testosterone therapy for you?

Elaine: The following are the unexpected effects: My anxiety symptoms, which were mild, are gone. I have noticed that mentally I feel more assured; I am able to more clearly see the forest for the trees; I am able to make confident decisions more quickly. I also have noticed that I am less likely to worry about whether people agree with me, or if they like what I have to say. I feel I can make intelligent decisions without being bogged down by wondering how my responses are received and if people agree or like me more or less for what I say.

I feel I am more able to present my true, authentic self/opinions. I am able to make decisions more quickly and with more confidence. I notice I don’t tolerate as much B.S. as I used to. (I am not rude, but I don’t go down that road with people anymore?) I feel somehow more clear and comfortable in my skin. I never expected this, but I love it.

I also have noticed that my muscle tone is improved, nothing freakish or dramatic, but I do notice it. I am running a tad bit faster, and I have more energy after a long run. I am no longer whipped for the day following a long run. I have noticed I have more overall energy, actually. I still sleep well at night, always did. I have experienced no other side-effects, such as extra hair growth or acne. I have noticed no negative side effects, actually.

MiddlesexMD: Does this experience suggest anything that you wish other women knew or were told?

Elaine: It sure makes me happy that I have such a great health care provider who is on the cutting edge with drug therapies, knew about this option, and took the time to explain it to me. I have mentioned it to several friends, and they have never had such a discussion with their health care providers. I wish women knew that all the stories about menopause (icky side effects, moodiness, weight gain, etc.) are not necessarily the experience of every female.

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I love options. Moose Tracks or Mackinaw Island Fudge? Mocha or machiatto? Phillips screwdriver or allen wrench?

Mostly, I like having options for my patients. At this awkward middle-age time of life, issues are complex and solutions are rarely straightforward. So I like to have a toolbox of treatment options to choose from. If one method doesn’t work, maybe another will.

To be clear, I always start with the most natural, straightforward treatment possible, postponing pills, prescriptions, and hormones. To this end, a healthy lifestyle is the first and most important contributor to a good sex life. Along with lavish use of moisturizers, lubricants, toys, and imagination.

But when these things fall short, it’s nice to have options.

Healthy lifestyle first and most important contributor to good sex lifeThat’s what testosterone therapy offers—another tool. Another treatment regimen that might fan a faltering libido and fading intimacy in an otherwise healthy relationship. Like any treatment, this isn’t a silver bullet or a magic pill. In fact, it’s controversial. There just isn’t a lot of research on long-term use or even on how testosterone functions in women. (Spoiler alert: a lot different than in men.) It isn’t FDA-approved, although it’s been prescribed “off-label” for decades in the US and is prescribed legally in Europe and elsewhere.

In women, testosterone is produced at much lower levels than in men, mostly in the ovaries and adrenal glands. As we age, and especially if our ovaries have been removed, testosterone levels drop sharply. This isn’t the only reason for diminishing sexual desire but it may be part of the picture. (In medicalese, a distressing loss of libido is called hyposexual desire disorder—HSDD.)

Since declining testosterone levels, menopause, and HSDD tend to happen in tandem, maybe a causal link exists among them, so the thinking goes. Obviously, it’s more complicated than that, but for some women, a little testosterone boost just seems to work. As a recent bulletin from Harvard Medical School states: “…in some but not all studies, testosterone therapy has been shown to be an effective treatment for HSDD in carefully selected postmenopausal women.” In my clinical experience, testosterone therapy improves libido, desire, and/or the ability to orgasm in about 60 percent of the women who take it.

So, what are those “carefully selected” qualities that make a patient a good candidate for testosterone therapy?

First, testosterone won’t cure difficulties in a relationship that may be contributing to intimacy problems. Other libido-killers include depression, fatigue, anxiety, certain medications, and the usual menopausal suspects: loss of estrogen, night sweats.

In the absence of physical or psychological factors, women who are distressed by their lack of libido (the classic definition of HSDD) might find relief with a little extra testosterone in their system. I monitor blood levels during treatment with the goal of restoring testosterone to the level you probably had when you were 25 years old.

Some women (about 20-30 percent of my patients) experience some added benefits, such as improved mood and more energy, while another 10 to 15 percent have less positive side effects, like unwanted hair growth or acne. And for about 40 percent of my patients, testosterone therapy isn’t helpful at all.

Testosterone can be safely applied topically; I usually prescribe a gel, the same FDA-approved topical gel that is used by men, but at one-tenth the dose, which I find offers a safe and consistent delivery of the medication.

For some women, testosterone is a game-changer and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy is a solid treatment option. A woman who’s tried it will tell her story in our next blog post.

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Localized estrogen (delivered directly to vaginal tissue most commonly via a ring, tablet, or cream) are very low dose and are not absorbed systemically. The prescription information supplied with these products has been the same as for systemic estrogen, which is taken orally. In November 2015, the FDA held a hearing on a change to the package insert for localized estrogen products to reflect actual research and clinical trials. While we still await FDA’s decision on this request, we in the medical and research communities have not seen increased risk in localized estrogen use.

Some women who are concerned about estrogen use are breast cancer survivors. The American Congress of Obstetricians and Gynecologists (ACOG) recently published a statement on the safe use of localized estrogen for breast cancer patients. Safety for breast cancer survivors is a further reassurance to those of us who have not had that diagnosis.

All of this is to say, if the localized estrogen is the best solution for comfort, I think you can rest assured that it’s safe to use for the next 30 years!

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Before we begin, I just want to reiterate our long-held position here at MiddlesexMD: Natural is always better. By that I mean, if you can ease vaginal pain and enjoy sex comfortably using non-hormonal products like moisturizers and lubricants, that is always the first and best option.

That is also the position taken in a new report issued two weeks ago by the American College of Obstetricians and Gynecologists (ACOG). But when the non-hormonal route just doesn’t cut it, when the pain of vaginal dryness and atrophy is unpleasant enough to interfere with life and good things like sex, then the ACOG committee says that topical estrogen treatment is a good option even for breast cancer survivors. (Check outthis link on our website for tons more information.)

Let’s dig into this.

For a long time, doctors focused on simply helping women with breast cancer to survive. Now, the good news is that women who have had breast cancer are indeed surviving for years longer. So the focus has shifted to quality of life—like making sure that sex is comfortable, for example.

This can be tricky, because we all know that estrogen is a bad thing for breast cancer survivors. In fact, a type of breast cancer, called “estrogen-receptor positive,” which unhappily is more common in postmenopausal women, has special receptors that are sensitive to estrogen. With this type of cancer, estrogen acts like fuel, making the cells grow more quickly. That’s why ongoing treatment for women who have had this type of cancer includes Tamoxifen or “aromatase inhibitors” that block estrogen activity.

Problem is, of course, estrogen is a good thing for our vagina, among other parts, and a lack of estrogen wreaks havoc on that sensitive system. Thus, drugs that block estrogen activity also cause urinary tract infections and painful vaginal dryness and atrophy. These side-effects can be so severe that 20 percent of women simply stop taking the drugs.

We know that oral estrogen replacement therapy—taking estrogen pills—increases systemic estrogen levels, but what about localized estrogen that’s used externally to treat vaginal dryness and atrophy? Does that increase estrogen levels in the body? Does it increase the risk of relapse?

While there hasn’t been a lot of research on the subject, ACOG released its committee report early in February stating: “Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.”

The ACOG guidelines recommend using the lowest effective dose for as little time as possible. And while the hormone comes in three forms: cream, ring, and a vaginal tablet, the lowest rates of absorption and the most accurate dosages occur with the ring and tablet.

For women whose symptoms are severe and who aren’t sufficiently relieved just by vaginal moisturizers and lubricants, it’s nice to know that there are other options. If you’re a breast cancer survivor who is suffering from vaginal dryness and painful sex, it’s time for a sit-down with your doctor to discuss treatment options. It’s time to start living well again.

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In the last post, we talked about the placebo effect and the surprising ways that it may create the very brain changes that drugs like painkillers or antidepressants are meant to mimic. In this post, I’d like to focus on a way to more consciously harness that brain-power.

We’ve talked before about mindfulness meditation and how it can improve the experience of sex by enhancing your ability to pay attention to the present moment and reduce mental distractions. Studies have shown that when you practice mindfulness over a period of time, it actually creates observable, measurable change in the brain.

By the same token, observable, measurable change to a different part of the brain also accompanies prolonged periods of stress and depression.

Here’s how the process works:

The amygdala is a specific part of your brain is programmed to respond to stress. It’s a nut-shaped structure deep in the primal area of your brain, which is intended to quickly mobilize your body’s resources to respond to an emergency. You breathe faster to pump more oxygen into your blood; your heart beats faster; adrenaline floods your system; vision narrows and attention focuses.

All good stuff for an emergency.

Unfortunately, the amygdala is activated, and your body responds in the exact same way to stress, whether it’s trouble at work or difficulty at home or ongoing financial problems—you know, modern life. Chronic stress keeps your body on “high alert,” in emergency mode. Neither the body nor the mind is equipped to handle chronic stress.

Beyond the physical toxicity of chronic stress, it trains the brain in specific ways in a kind of biofeedback loop. By continually reinforcing certain neural pathways, the amygdala actually grows measurably larger. The neural pathways that you reinforce tend to become the default, habitual way that you respond to life’s challenges. And you lose the ability to more easily respond with higher-brain functions, like cultivating a sense of well-being or contentment. It’s just not the default.

Conversely, meditation, prayer, positive thinking, activate the prefrontal cortex and hippocampus areas in the brain. Over time, for people who do those things regularly, those neural pathways become stronger and those parts of the brain become larger. “You shape [your brain] by your thoughts and behaviors,” says Jo Marchant, author of Cure: a Journey Into the Science of Mind Over Body, in an interview on NPR.

“Studies show that if a group of people meditates, the amygdala then becomes smaller and the hippocampus and prefrontal cortex become larger,” says Marchant, “and that’s probably not anything specific to meditation, but it’s just that reducing stress and changing patterns of thinking over a period of time then is reflected in the structure of the brain.”

The critical point is that we have the capacity to actually shape our brain, but that it happens with regular practice, like an athlete training for a race. Developing either the stress-related amygdala or the higher-thinking prefrontal cortex takes time and conscious effort.

The implication for your sex life, not to mention your overall quality of life, is significant, to say the least. Not only does the practice of mindfulness work to lessen stress, but a 2014 study found that “mindfulness-based group therapy significantly improved sexual desire and other indices of sexual response, and should be considered in the treatment of women’s sexual dysfunction.”

Mindfulness works especially well for sex because it involves simply experiencing each moment with complete presence and lack of judgment or anticipation. (Not so easy to achieve; that’s why it take practice.) Mindfulness guru, Jon Kabat-Zinn, calls it “presence of heart,” and what better place for a heartful presence than the bedroom? Especially, considering the tsunami of distractions that you probably bring to that sanctum—yesterday’s tepid performance review, the extra pounds around your waist, the sharp comment from your grown daughter, and whether you’ll orgasm this time. And on and on… you know, monkey mind.

With the truly significant benefits of developing a habit of mindfulness, why continue to trudge down that neural pathway of stress and unhappiness? (Because it’s so darned familiar, that’s why.)

Now that you know there’s a better way, why not start a new brain-training regimen? We’re so convinced of the merits that we offer Thich Nhat Hanh’s wonderful book, The Miracle of Mindfulness, and Kabat-Zinn’s CD set, Mindfulness for Beginners, in our shop.

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