Archive for August, 2016

There may be a Santa Claus after all, Virginia.

Of all the menopausal afflictions, vaginal dryness (or genitourinary syndrome of menopause—GSM—in medicalese) is the most pervasive. Virtually all of us will experience GSM to one degree or another, either due to menopause, hysterectomy, breast cancer, or some other hormone-disrupting event. Some of us will suffer from GSM to such an extent that sex or even a gynecological exam is impossible.

Yes, lubes and creams help. Estrogen replacement helps a lot, but not all women can or want to use hormones (especially if they’re breast cancer survivors, although localized estrogen has been confirmed safe). And there’sOsphena, a new nonhormonal drug that has proven effective. Still, nothing beats that firm, moist tissue we took for granted at 30.

Enter the MonaLisa Touch. With a name like that, you might hazard a guess that it was developed in Italy, and you’d be right. (I’ll never view that enigmatic smile in the same way again.) The procedure has been available in Europe and South America for a while and was recently approved for use in the US by the Food and Drug Administration.

The MonaLisa Touch is the same type of laser abrasion used to rejuvenate facial skin but repurposed for vaginal tissue. (This should not be equated with cosmetic surgery, however.) It’s a laser treatment that creates small lesions and removes a surface layer of dry vaginal cells. This causes the vagina to make collagen and stimulates the mucus membranes. A new, moist, healthy layer of tissue then develops.

Voilá!  A 30-year-old vagina.

Wait a minute, I can hear you say: What about side effects? What about risks? Is this procedure appropriate for everyone?
Dr. Barb DePreeWell, that’s the thing. The procedure appears to be safe and appropriate for women suffering from GSM, painful sex, mild urinary incontinence, and/or frequent urinary tract infections. Pain and side effects are slight—maybe one or two days of redness or soreness. It’s an outpatient procedure done with no or very little anesthetic.  Results have been promising with 85 to 90 percent of women experiencing relief, sometimes almost immediately and sometimes significantly. “This is as close to the best result a medical treatment can achieve,” says Dr. Cynthia Krause, ob/gyn and assistant professor at the Icahn School of Medicine in New York City.

The procedure is straightforward, involving three laser treatments performed at six-week intervals. While many women experience relief quickly, the full effect may take up to six weeks after the final treatment. Laser treatment of vulvar and external vaginal tissue may also help with urinary incontinence and UTIs. Following that, an annual “touchup” may be required.

So, what’s the catch?

Well, for one thing, the procedure is new. While short-term studies are very positive, long-term data on side-effects or efficacy simply isn’t available. For another, it’s the cash. Since the procedure is new, most insurance companies won’t cover it, although that may change as the treatment becomes more mainstream. Cost varies depending on the region, but ranges from around $1500 to almost $2000 for the three required treatments.

Still, many women are thrilled with the chance to enjoy pain-free sex with their honey again, not to mention the freedom from a painful, burning, itching bottom. Like any treatment, however, there are no guarantees. Not every woman experiences the same result.

Still, for many women who suffer from the sexual difficulties and pain of GSM, the MonaLisa Touch is definitely worth looking into.



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You eat right. You exercise. You meditate. You read interesting books.

But if you’re neglecting your sexuality, you’re not as healthy as you could be. Plus you’re missing out on plenty of fun–and perhaps even a little taste of heaven.

Yes, sex can be good for you–even if it’s alone. Here’s why:

Sex is great exercise.It helps you relax. With sex, important hormones and neurotransmitters rise and fall, especially dopamine and oxytocin. There’s research showing sexual intercourse can lower blood pressure for women. And having an orgasm could even improve your sleep, thanks to the hormone prolactin.

It sparks your libido. Sex is a use-it-or-lose-it proposition. Having sex increases vaginal lubrication, blood flow and the elasticity of your vagina, all of which adds up to craving more of the same. On the other hand, women who don’t have sex can lose their vaginal patency.

It perks up your immune system. Yup. A study from Wilkes University in Pennsylvania said college students who had sex once or twice a week had higher antibodies than their peers. Okay, maybe you’re past your college years, but it’s worth a try, right?

It could improve bladder control. Kegel exercises give your pelvic floor muscles a workout, but so do orgasms. I recommend both.

It’s great exercise. Not only will you burn calories (calculate how many), but sex also raises your heart rate, and it keeps your estrogen and testosterone levels balanced, all of which helps to ward off heart attacks and osteoporosis.

So here’s the question: What if you haven’t had sex for weeks, month or even years? Is it too late to reap the benefits?

No. It’s not too late, even at our age.

Recently I wrote about a patient I’ll call “Sue,” who was in a new relationship after nearly 20 years of celibacy.

No. It's not too late.“My body had definitely changed since 1997,” wrote Sue. “I would encourage anyone facing any type of sexual challenge… don’t give in to the shame that would try and make you hide from your issue. Sexual intimacy is so precious and valuable to a marriage that it’s worth the discomfort (physical and emotional) it takes to press through.”

If, like Sue, you’re ready to “wake up” sexually, start by finding a supportive, experienced menopause specialist who can help you get on the right path. You’ll find that hormones (systemic or localized), moisturizers, vaginal dilators, and personal vibrators are all helpful on this journey.

To make it easier to get your hands on helpful products to revive your sexuality, we’ve sought out high-quality, effective products for our shop. It’s a confidential, reliable way for you to experiment (and have fun) while improving your overall health.

What could be better?

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I’ve been writing about the use-it-or-lose-it phenomenon and the fact that sexually inactive women are in danger of losing their ability to enjoy a physical relationship after menopause if they take a long break from sex, whether it’s with a partner or from self-stimulation.

Now, I’d like to introduce you to Sue (not her real name), a patient of mine who had a hysterectomy in her 20s, was widowed in her early 40s, and had the good fortune to fall in love again at age 59.

A petite, attractive woman, Sue had no idea how much her genitals suffered from lack of attention for nearly 20 years. During her first office visit, I could barely insert a Q-tip® in her vagina, yet I wanted her to know there was hope for her future if she was willing to do the work needed to “wake up” again sexually.

Intercourse isn't the only way to create intimacy with your partner.Sue wrote: It was a very difficult thing to tell my future husband, but he responded with such understanding and compassion. Instead of feeling embarrassment and shame, I was comforted and strengthened by his assuring me that no matter the outcome, it didn’t change his feelings for me or his intentions for our relationship. If anything, the whole process has only served to deepen and strengthen it. Being believers, we trusted that just as God had miraculously brought us together, He would see us through to a satisfying and pleasurable sex life.

I prescribed Osphena and vaginal dilators for Sue, then saw her several times as she prepared to consummate her marriage. Her condition didn’t change overnight, so although she and her new husband were physically affectionate as newlyweds, they were unable to actually have intercourse until several months after their wedding.

Sue’s husband Bill (also not his real name) wrote: What did happen during our first 7 months of marriage was truly a miracle… we connected emotionally, physically, spiritually…. I would not trade that time of growth and intimacy for anything. We will have this deep and priceless quality of sexual intimacy the rest of our married lives. It has been the foundation of our love, our joy, our story.

I especially appreciate Bill’s emphasis on intimacy. And it’s a good reminder that intercourse isn’t the only wayto create intimacy with your partner.

Thankfully, Sue and Bill had the right mix of patience, persistence and prayer to create the passionate relationship they both desired.

Bill added: We now have a fully pleasurable and intimate marriage bed and it’s terrific. Sue is an amazing, wonderful, fabulous lover. But more importantly, she is truly my dearest friend and confidant. I love her with all my heart.

Be persistent. Have patience. Pray or meditate.Here’s my advice: If physical symptoms are keeping you from being your sexual self, find a menopause specialist who can help you again enjoy the pleasure and other benefits of sex. Know that it will take time. Be persistent. Have patience. Pray or meditate, remembering that spirituality can help keep you balanced. And keep your sense of humor because, yes, there will be awkward moments.

Will it be worth your time and effort? You bet. In my next blog post I’ll talk about the health benefits of being sexually active.


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There are many reasons that women may go months, or even years, without engaging in any kind of sexual activity. She may be without a partner. Or she may be in a relationship where the sizzle has fizzled–her husband or partner is more like a roommate than a lover.

You may be in a relationship where the sizzle has fizzledAs a side note, I think there’s an epidemic of peri-menopausal and menopausal women who have given up on sex as their bodies change and their priorities shift. Sadly, losing intimacy in a marriage can lead to or exacerbate the distance between two people. I suspect that a number of late-in-life divorces happen because of that loss.

As a friend recently said, “In many relationships, sex is the glue that binds a relationship together.”

I often remind my patients about the use-it-or-lose-it fact of life: If you’re sexually inactive, your body can have some unpleasant surprises for you when you try to be sexual again. Doctors call that losing vaginal patency. (Patent means “open” in the medical world.)

This can happen especially quickly after surgical menopause as your hormone levels decrease, making the tissues of your vagina thinner and more fragile, with less circulation to those tissues. And if your vagina isn’t having any stimulation, those changes will happen more rapidly.

Don’t give up!

Most women can get their “groove” back with the right regimen of vaginal treatments along with patience and persistence.

Last year, I saw a patient (I’ll call her Sue) who had a hysterectomy in her late 20s, then was widowed at a young age and not in any sexual relationships for nearly 20 years. At age 59, a spark was kindled and she fell in love again. I asked Sue if she’d be willing to have us share her story, and am very grateful that she not only agreed, but provided correspondence from her husband as well as herself.

Most women can get their groove backWhen Sue first came to see me, the situation in her nether region was pretty grim. I could barely insert a Q-tip® into her vagina. Her vaginal moisture was non-existent and while she thought she had entirely lost her sex drive, the new romance had revived it. Yet she knew that if her relationship moved to marriage, she would want to revive her interest in–and ability to have–sex.

Each situation is different. For Sue, I began by prescribing Osphena, and I encouraging her to use vaginal dilators to stretch her vaginal walls, making them spacious enough to do their job.

If you’re in a situation where you haven’t been “using it” for a long time, I’d encourage you to seek out a gynecologist who has the expertise to help you bring your sexuality back to life for a relationship with a partner or for the health benefits of self-stimulation.

You can read more about Sue’s story in my next blog post, but I’ll give you a sneak preview: It took several months of “work,” with more than a few ups and downs, but Sue and her new husband are now enjoying a pleasurable and intimate marriage bed.

The lesson is this: With the right help, combined with persistence and patience, you can make a come-back and enjoy the benefits of a healthy sex life again.



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Previously, we examined several herbal remedies that are commonly taken to relieve hormonal symptoms. Plants have been used since time immemorial for treating health conditions, and I have the utmost respect for plant-based medicine.

Except for three caveats: 1) botanical (plant-based) treatments can have side effects and drug interactions just like any other medicine; 2) their use, dosages, and efficacy in treating specific illnesses haven’t been rigorously studied; and 3) the manufacture of these products isn’t held to federal standards for safety or consistency.

So my general approach to botanical therapies has been to proceed with caution. Always tell your doctor what natural remedies you’re taking, buy products from reputable manufacturers, and pay attention to how they’re affecting you.

Except for soybean products. I withdraw most of my qualifiers for soy.

While soy has gotten a bad rap in some quarters, especially since most of the US-grown beans are from GMO seedstock, soy still comes close to being a superfood in my (and others’) playbook.

Another tick in the plus column is that soy has been subjected to numerous rigorous scientific studies. (Not to mention that it’s been consumed for millennia in Asian countries.)

My approach to botanical therapiesRecently, new studies have shed light on how soy might work to relieve menopausal symptoms, such as hot flashes and even vaginal dryness. Its effects aren’t always straightforward, as in “eat more soy, have fewer hot flashes” (although sometimes, it is just that straightforward), but it does clarify how soy is broken down in our systems and under what circumstances it seems to be effective.

When we consume soy products, such as tofu, soy milk, tempeh, edimame, it’s metabolized in our gut into two main isoflavones: daidzein and genistein. These compounds have phytoestrogenic properties, meaning that they mimic estrogen in some ways. (However, seem to carry less risk than estrogen,  related to estrogen, and in fact, some research suggests they may have some protective qualities.)

Some women (about 30-40 percent of North American and Europeans; significantly higher percentages of Asians) carry a gut bacteria that can metabolize daidzein into a substance called S-equol. And this, according to at least one recent study, is the bit that is strongly linked to relieving hot flashes and other good stuff.

Among the women who produce equol, those who ate the most soy and had the highest levels of daidzein, reported far fewer vasomotor symptoms (VMS–or hot flashes in common parlance) than equol producers who ate less soy. “Among equol producers, higher equol availability attributable to higher soy consumption contributes to decreased VMS,” the researchers concluded.

Among women who didn’t naturally produce equol, there was no link between higher levels of daidzein and fewer hot flashes. Either you could produce equol and reap the benefit of soy or you couldn’t. Until recently, the only way to find out, says North America Menopause Society executive director, Margery Gass, was to conduct your own personal experiment: Eat soy foods for 4 to 6 weeks, and if it didn’t help, you probably couldn’t metabolize equol.

You either had the right gut flora or you didn’t.

Recently, however, a Japanese pharmaceutical company, Otsuka (Pharmavite in the US) has developed an S-equol dietary supplement made from fermented soybean germ, so whether you are among equol-producing women or not, you have access to the same VMS-busting possibilities.

Studies are fragmentary and scattered, but the consensus seems to indicate that S-equol, either produced naturally or taken as a supplement, is a viable and safe way to reduce the frequency and severity of hot flashes. It also may have positive effects on skin health, including regeneration and thickening of vaginal tissues without the risks associated with hormonal supplements.

Theoretically, you can take 10-40 mg. of S-equol supplement per day for relief of hot flashes. Since it’s metabolized quickly, you should take it in several 10 mg. doses at different times. S-equol has no negative interactions with drugs or supplements, and its side effects are minimal, although research is contradictory, so women with a history of breast cancer are advised to avoid it.

So there you have it. No guarantees, but with very little risk or expense you can conduct your own naturopathic experiment in taming menopausal symptoms. Let us know how it goes.


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