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Archive for October, 2017

I’m just gonna say it: the best time to get information about sex after a hysterectomy is before the hysterectomy ever happens.

When a patient come to me with sexual issues after having had a hysterectomy, and she is unclear about what kind of hysterectomy she actually received—what organs were removed or whether she had a laparoscopic or a vaginal procedure, for example—this indicates to me that she may not have sought or received the information she needed in order to make an informed decision.

Whether to have a hysterectomy is a loaded topic these days, so let’s just dive in and get the facts out of the way, shall we?

Hysterectomy is the second most common surgical procedure performed on women after caesarian section.  Almost 12 percent of women between 40 and 44 have had one. That number rises to 30 percent by the time you’re 60. About 600,000 procedures are performed every year in the US—the highest rate in the world, although other developed countries also do a lot of hysterectomies.

Most hysterectomies are performed for such benign but bothersome conditions as fibroid growths, endometriosis, heavy bleeding, and vaginal prolapse. Only about 10 percent are done for truly life-threatening conditions such as cancer or a uterine rupture during childbirth.

It’s almost like having a hysterectomy has become a normalized part of growing older as a woman. You get your hair colored, and you have a hysterectomy. That’s just how it goes.

Recently, however, women’s health organizations and other health professionals—as well as women themselves—have been questioning that inevitability and pushing for less radical treatments for benign conditions. These include less invasive treatments, such as having a progestin IUD placed or endometrial ablation for heavy bleeding or uterine artery embolectomy treatments for fibroids. Still, hysterectomy remains the most common go-to for a host of “female troubles.”

Like any surgical procedure, a hysterectomy involves weighing risks and benefits. These are dependent on factors such as age, childbirth history, the size and shape of the uterus, among other considerations.

For example, it might be better for a younger woman with a benign and treatable condition to first try the alternatives to the permanent removal of her uterus because her reproductive organs are still fertile and hormone-producing. Even a woman in perimenopause is still producing hormones with all their good protective benefits to vaginal tissue, heart, and bone.

A post-menopausal woman with an unpleasant uterine prolapse, on the other hand, might be a very good candidate for hysterectomy. This patient’s hormone production has virtually ended and other treatment options aren’t permanent or also involve a surgical procedure.

Sometimes, however, when a woman’s quality of life is so compromised, when she’s in enough pain or bleeding so erratically or profusely, she may be willing to do anything to make it stop. A hysterectomy will make it stop and will often improve both sex and quality of life. But a frank patient/doctor discussion is still critical—so she understands her options and, insofar as possible, what the outcome will be.

So—there are options for treatments of benign conditions such as fibroids or endometriosis. Hysterectomy is invasive and permanent, so it makes sense to explore other options first. But if a hysterectomy seems to be the best approach, you then need to know about the different types of hysterectomy and their outcomes.

This is important, ladies, because how quickly you recover and the effect on your sex life has everything to do with the type of surgery you have and what organs are removed.

We’ll discuss this in a post next week.

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You mention joint pain, weight gain, and food cravings in addition to hot flashes as symptoms of menopause. Menopause has such a variety of symptoms, depending on each individual. Lifestyle matters more; exercise is more important; adequate sleep and good nutrition—all of these have a greater impact to quality of life now than they did previously.

I wish I could tell you there is good data suggesting vitamins have a favorable impact on menopausal symptoms, but the trials looking at the specific supplements you mention and others suggest no benefit greater than placebo. But, hey, placebo has about a 30-percent response rate in any trial, so there is certainly no harm in using them. They provide some general vitamins that will not be harmful, and may help if you aren’t getting them in your diet.

The symptoms you mention could all potentially benefit from hormone therapy (HT). The loss of estrogen is huge for most women, and the loss of progesterone to some extent as well. For many women the only way to address symptoms adequately is to consider HT. More and more data suggests that HT is beneficial for women specifically with weight gain; that was a lead article in one of my journals just this week.

It’s a complicated journey that is nuanced, and each woman needs to assess her own symptoms and goals and determine the best approach to managing through menopause. It’s difficult to address all of the treatment options in a single Q&A. You might find the North American Menopause Society (NAMS) website helpful: menopause.org. They cover many issues related to menopause.

Good luck!

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Maybe you were that girl. The last one to get her period. Maybe it’s déjà vu all over again as you wait… and wait… to cross the reproductive finish line. Menopause. It’s certainly been a thing for your girlfriends, but you only know about it secondhand.

Do not fret. Recent studies confirm a few educated guesses about women who begin menopause late, and most of it is good news for you.

Most women reach menopause between 45 and 55; the average age is 51. Menopause officially occurs one year after your last period. Late onset is considered anytime after age 55, at which point, a woman has been producing estrogen for at least 40 years, depending on when she began menstruating.

Factors that affect when a person begins her reproductive years and reaches menopause have a little to do with heredity and occasionally may be related to do with environmental factors. Those who smoke or live at high altitudes, for example, tend to begin menopause early. Most often, it occurs… well, when it occurs.

As any menopausal woman knows, estrogen is an important hormone that regulates lots of systems in your body, from your brain to your skin to your reproductive organs and keeps them running smoothly. That’s why the absence of estrogen in menopause sends you into such a tailspin and requires several years to adjust to.

We know that estrogen has protective effects on our bones and our heart. Two large-scale, recent studies confirm that women who reach menopause late, and thus are exposed to estrogen for longer, also tend to have fewer cardiovascular problems, such as strokes or heart attacks.

For example, one very recent study looked at longitudinal data for over 3,000 women, specifically examining the reproductive years—the total number of years from first menstruation to menopause—in women age 60 or over. They determined that “every one-year increase in reproductive duration… was associated with a 3% reduction in a woman’s risk of angina or stroke.”

Women with more reproductive years are also at lower risk for osteoporosis and have fewer fractures. Since estrogen keeps skin smooth and supple, late menopause tends to keep your skin smooth and your vagina lubricated.

If you are still menstruating at 55, please continue your diligence with regular gynecological exams and screenings, while you enjoy your supple skin and healthy heart. I’ve seen more vulvar cancers in the last three months than in the previous 15 years, and these were among women who hadn’t had a pelvic exam in years.

Overall, you’ll probably live longer, according to two large-scale studies. A 2005 study followed 12,134 Dutch women for 17 years and found that, when all the risk and protective factors were considered, “the net effect was an increased life span.”

Another study examined the effect of late menopause on the chances of living to age 90. These researchers selected a diverse group of post-menopausal women from the Women’s Health Initiative, the massive study of 16,251 women that ran from 1993-1998, and followed them until 2014. Of the 55 percent of women who reached age 90, odds of survival for those with over 40 reproductive years were 13 percent higher.

Neither lifestyle, weight, reproductive factors, contraception use, nor hormone therapy nor significantly altered these survival rates. The determining factor was the number of reproductive years.

“Later age at menopause is associated with better health, longer life and less cardiovascular disease,” said Ellen B. Gold, a professor emeritus in public health at the University of California, Davis, School of Medicine in this article.

So buckle up, late bloomers, it might be a smoother, longer ride than you thought.

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What with slow but steady treatments for menopausal issues trickling into the marketplace (OsphenaDuavee and Brisdelle, for example), my toolkit is getting bulky. That’s good news.

Now another pharmaceutical option is on the market. The FDA approved Intrarosa last year for treating “moderate to severe pain during sexual intercourse (dyspareunia)” caused by thinning and drying of vaginal tissue during menopause. It’s been distributed in the US by AMAG Pharmaceuticals since July 2017.

Intrarosa is an interesting drug. It’s a synthetic version of a steroid naturally produced in our adrenal glands, called prasterone or dehydroepiandrosterone (DHEA). Prasterone is considered a “precursor hormone” because it is inactive until it comes in contact with vaginal (or other) cells, where it stimulates the production of both estrogen and testosterone. By interacting with vaginal cells to produce estrogen, elasticity and pH levels in vaginal tissue are improved, ideally making sex less painful.

If the term DHEA rings a bell, that’s because it’s commonly used as a nutritional supplement made from wild yam and soy. Sometimes called the “youth hormone,” DHEA is said to improve aging skin, aid in weight loss, and improve mood, among other health claims. While DHEA has been studied for many years, data on dosage or long-term safety haven’t been established.

Intrarosa is a suppository inserted into the vagina once daily at bedtime where it dissolves overnight. The effectiveness of Intrarosa was tested in two, 12-week trials of 406 women between the ages of 40 and 80 who had troubling symptoms of dyspareunia. They were randomly assigned to receive either Intrarosa or a placebo. Two additional 12-week trials and one year-long trial attempted to establish the safety and side effects of Intrarosa, according to the FDA press release.

Clinical trials support the effectiveness of Intrarosa, and FDA approval has been a high bar: “Intrarosa, when compared to placebo, was shown to reduce the severity of pain experienced during sexual intercourse,” said Audrey Gassman, MD, FDA spokesperson. One source said that Intrarosa seemed about as effective as a very low-dose topical estrogen.

Side effects appear to be relatively mild: six percent of women experienced vaginal discharge, which could be related to suppository itself, and a very few experienced abnormal Pap tests, the significance of which is unknown. Intrarosa doesn’t come with a black-box warning, and there is no warning against using it with breast cancer patients, which we’re happy about (it hasn’t yet been specifically trialed with that population). However, blood levels of circulating estrogen after taking Intrarosa were “below the threshold” of a post-menopausal woman.

Currently, AMAG Pharmaceuticals is offering an introductory program to “commercially qualified customers” of a zero-dollar copay for the first prescription and no higher than a $25-dollar copay for refills during the initial launch. After that, it’s anyone’s guess. Because vaginal cells tend to regenerate quickly, you should know within a few days to a couple of weeks whether Intrarosa will work for you.

Painful sex caused as a condition of menopause is incredibly common. Aggregating the data from many surveys indicates that about 32 million women have some symptoms of vulvovaginal atrophy. Of those, between 45 and 80 percent—quite a range, obviously—report having painful intercourse. Half of those women say they aren’t seeking treatment for it. You do the math. I’m just saying that in my experience, painful sex follows menopause like spring follows winter.

So, having another treatment option makes me happy. Is Intrarosa the magic bullet we’ve all been hoping for? Time will tell! I’ve been prescribing this fairly frequently already. If you suffer from dyspareunia, a conversation with your doctor about the potential risks and benefits of Intrarosa would be worthwhile. I’m interested to explore its effects with vulvodynia and the testosterone component. It’s a solid option with relatively low risk that may help many women.

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