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Archive for December, 2017

We had a power outage for a few days mid-month. If you want to discover the stuff you’re made of, experience a small tear in the fabric of life, like losing power in winter. I discovered that I am made of tissue paper.

It was a temporary and brief interruption. An inconvenience. But as the hours dragged on, I became increasingly impatient. Appointments didn’t happen; work piled up; my phone couldn’t charge; I was entirely offline. I couldn’t afford to lose this time! I called the power company. I checked for updates obsessively. I ignored the fact that teams of (mostly) young men were working around the clock in bitter weather to get us all back online.

Then, after power was restored, and I had rescheduled appointments and comfortably reordered my life, I came across a blog post from my colleague, Mary Jo Rapini (who was a recent guest on my podcast, too).

She lives in Houston and, while her house was unaffected, she regularly interacts with those who lost everything to Hurricane Harvey. For these survivors, life can’t be so easily resumed—it isn’t a matter of flicking on a switch. They are living in temporary housing or with friends and relatives. Significant parts of their lives—homes, pets, photographs, precious possessions—are gone forever. Many, if not most, of those affected will deal with PTSD for a long time.

That story is repeated for thousands of people throughout the world—in California and the Middle East and Africa. I can’t really imagine being in those circumstances, and I suspect that tissue paper doesn’t hold up so well.

Mary Jo’s message cast my small discomfort in a new light. I was complaining about a paper cut, while others not so far away are recovering from an amputation. It was a helpful reality check.

“Love is a verb,” says Mary Jo. Love manifests itself in actions large and small. Hidden and heroic. It reveals itself in the work that only you can do in this world, whether that’s taking care of grandchildren or founding an orphanage.

Love and gratitude is what this season is all about. I’m taking that more seriously these days. For starters, I’m grateful for that power outage.

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Here’s an idea to spice up a holiday evening: Gather your coffee klatch girlfriends, or your BFFs, or even your sisters and/or daughters, make popcorn and margaritas, and watch “Love, Sweat, and Tears,” the new documentary about menopause.

Even better, snuggle up and watch it with your partner, because the red thread running through all the information about hot flashes and mood swings is that our sex lives don’t have to be disrupted or put on the shelf forever because of menopause. We can still be sexual beings; we can still be attractive; we darned well can still have sex.

Sound familiar?

The movie was a labor of love for Dr. Pam Gaudry, an ob/gyn who specializes in treating older women. After years of consulting with patients in the throes of menopause, Dr. Pam came to realize that of all the difficulties accompanying menopause, the most disturbing to many of her patients was the disruption of their sex lives. Losing this deep and intimate connection with loved partners was the most distressing part of menopause. And she knew that losing sexual intimacy is completely unnecessary.

Dr. Pam wants to educate women about menopause, about how to stay vital, healthy, and sexually fulfilled. She wants to blow up the social stigma surrounding menopause (that we’re dried-up old crones). “Women should look forward to this transition,” she says. “I want them to know what to do to protect their vaginas so they can have exciting, comfortable, and worry free sexual intercourse for the rest of their lives.”

In the film, Dr. Pam travels across America interviewing actors, comedians, clergy, medical professionals, as well as ordinary men and women about love and menopause. Joan Rivers is the headliner, in what turned out to be her last interview before her death in 2014. “I’m on a mission,” says Dr. Pam in her interview with Rivers, “to save menopausal vaginas in America.”

“Well, sign me up,” says Rivers.

In the course of the film, Dr. Pam interviews several colleagues that MiddlesexMD readers have met—Mary Jo Rapini and Dr. Michael Krychman. I make a cameo appearance, too.

Basically, Dr. Pam covers the same ground that we do here at MiddlesexMD because we have the same mission and message. She does it holistically, with humor and a lot of sage advice. “I want women to know why they must protect their vaginas,” she says. “I want estrogen in their vaginas when they’re going into the ground. And no woman should die without using a vibrator.”

You can rent the movie on YouTubeNetflix, or Amazon. (Run time about an hour and twenty minutes)

Do not hesitate to gather selected friends and family and watch this movie together. For you and your honey, it’s required viewing. A pop quiz will follow.

 

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You ask whether there’s effect on your pH level from swimming several times a week in a chlorinated pool and whether inserting a tampon would provide some protection. The vagina is, in its natural state, not an open space but collapsed, that is, the walls are lying next to each other. Imagine a balloon before it is blown up. We refer to the vagina as a “potential space,” because space is made there only when needed—for a tampon, childbirth, or sex.

The vaginal pH isn’t disrupted with a relatively brief swim or tub bath. Inserting a tampon actually would be more likely to act as a wick, introducing more chlorinated water because of its absorbency.

Chlorinated water certainly can affect the vulva and surrounding skin; I do hear that from a number of patients. In that case, be sure to rinse thoroughly after swimming, and then apply a product like Lubrigyn Lotion (available in wipes, which you can put in your bag to take to the pool) to soothe by moisturizing.

 

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Among other things, sex is a nice aerobic workout. You breathe hard; your heart rate goes up, as does your metabolic rate. You burn calories. (Yay!)

Therein lies the rub for us older folks.

Isn’t the stress on the cardiovascular system dangerous for anyone with a heart condition? Especially if he or she doesn’t know about it? Or, even when the doctor gives you the green light to have sex, the specter of a sudden attack always looms in the background.

“I think it’s important to healthy relationships to have this anxiety lifted,” said Dr. Michael Ackerman, professor of medicine at Mayo Clinic. “[People] always ask about exercise and how active they can become,” he said in this article. “They almost never ask directly about sex,” but, once it’s mentioned, he said, ”the floodgates open.”

Now, a large and robust study provides the most detailed picture we’ve even had of the actual numbers of people who suffered a fatal heart attack during sex. Researchers examined lifetime medical records from 4,557 people in Portland, Oregon, who died of a sudden cardiac arrest from 2002 to 2015.

Of the 4557, the number of people who died of a heart attack during sex or within an hour after?

34.

That’s it. Thirty-four people ranging in age from 37 to 83. Of that number, 32 were men. Thus, the risk of having a heart attack during sex in men is 1 percent, while for women, it’s .1 percent. While doctors always knew the risk of heart attack was slim, now that the risk is quantified, even researchers were taken aback. “I’m a little surprised at the really tiny number,” said Dr. Sumeet Chugh, senior author of the study and a professor of medicine at Cedars-Sinai Heart Institute in Los Angeles.

It goes without saying to follow your own doctor’s instructions for activity if you have a heart condition. But if you’re given the “all clear” for sexual activity, I hope these numbers put your mind at ease. No need to abstain from one of life’s sweetest pleasures.

“[This is] a wonderful answer for those who love sex,” said Dr. Ackerman. And, I might add, for those who recognize the link between sexual health and overall good health.

 

 

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For nigh onto 30 years, the North American Menopause Society has encouraged research into and disseminated information about all things menopause. It’s the hub of the wheel for healthcare professionals and individuals alike seeking the latest scientific information and objective advice about “the change.”

One presentation at this year’s annual meeting in October struck me as particularly apropos for MiddlesexMD readers—part refresher course; part new information. So I’d like to pass it along.

In a wide-ranging talk, Dr. Nick Panay, a gynecologist from Great Britain, explored current understanding of that most common and persistent problem of menopause: painful sex due to vaginal dryness. He reminded us that lots of women will suffer from it (about half of women at some point in life), and that many won’t mention it to their doctors. He encouraged healthcare workers to ask: “If you don’t ask, women often won’t volunteer the information.”

So far, so good, but ground that’s been covered.

Everyone likes sex better with good lubrication, he said, and women often expect their bodies to lubricate adequately, just like they did “before,” so when they inevitably don’t, it’s a real buzzkill for sex.

This state of affairs can be tackled in many ways—topical estrogenOsphenaIntrarosa, and the good old stand-by, moisturizers and lubricants. According to Dr. Panay, moisturizers and lubes can provide relief from vaginal dryness, but they don’t address the underlying cause, which is loss of estrogen. Only estrogen can do that.

Turns out, however, that a couple additional considerations might affect how your body reacts to a specific moisturizer and/or lubricant, depending on its ingredients. In this report, Dr. Panay mentions three physical characteristics of the vagina that might be altered by components in what we put there.

  • pH balance. A healthy vagina is slightly acidic with a pH value between 3.8 and 4.5. Ideally, whatever lubricant or moisturizer you use should be close to those values to retain the vagina’s protective bacterial balance.
  • Osmolality. This is a fancy concept that refers to the amount of particles dissolved in a liquid. High osmolality has a lot of “stuff;” low osmolality doesn’t. The way this works in the vagina is that, ideally, equilibrium is reached between vaginal cells and the moisturizer or lube, depending on its osmolality. When the osmolality is off-kilter, it either draws water from vaginal cells or over-moisturizes them, either of which could cause changes in the vagina. In a test of several products on slugs, for example (yes, like you see pictured below), which as we know are all about moisture and mucus, products that were hyper-osmolalic (high levels of particles) irritated the slugs a lot.
  • Additives. Ingredients like glycols, parabens, and preservatives, which are found in some products can also irritate the vaginal lining, kill good bacteria, and increase susceptibility to infection.

Ideally, says Dr. Panay, the lube/moisturizer you use should be as close to vaginal mucosa as possible—a product that is “optimally balanced in terms of both osmolality and pH and is physiologically most similar to natural vaginal secretions.”

slug like those used for testingTrouble is that the ingredients in a moisturizer or lubricant aren’t always listed on the label and identifying those with correct osmolality and pH levels is fairly impossible for the average user, especially since a product with a good pH level might have bad osmolality numbers. Dr. Panay shared the results for several dozen products available worldwide, and we were happy to see that YES VM, a moisturizer, and YES WB, a lubricant, both scored very well in the testing (we shouldn’t be too surprised, since they’re both very popular in our shop).

So what’s the practical application for all of this new data? For us at MiddlesexMD, we’ve got some new criteria for vetting and recommending products from our shop (sadly, Dr. Panay’s tests couldn’t include every product currently available). We hope that makers of moisturizers and lubricants will take these new findings into account in their formulations, and we can now ask for data on osmolality in addition to pH levels when we evaluate products.

For you, keep in mind that lubes and moisturizers are the first line of attack in making sex comfortable (or possible) and in keeping vaginal tissue flexible and moisturized. According to Dr. Panay, this is true even if you use topical estrogen or another drug, such as Osphena or Intrarosa. Choose your products carefully, looking for high-quality products that are free of glycol, parabens, and other additives.

Pay attention to any increase in vaginal irritation or infections. Your lubricant or moisturizer could be contributing. Don’t give up on lubes or moisturizers, though: Try another product or formulation that’s a better match for your pH and is providing the right amount of moisture to your tissues.

 

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There are many reasons women may have pain with sex, so I can’t be certain of the specific cause for your wife. A pelvic examination by her health care provider is needed to determine the cause and therefore the proper treatment.

That being said, the most common cause of painful intercourse in perimenopause (the phase before menopause) or post-menopause (beyond the year after the last menstrual period that marks menopause) is due to the reduction or loss of estrogen and the atrophy or dryness that result.

You asked. Dr. Barb answered.Using a vaginal moisturizer regularly, two to three times a week, is a great place to start; if the atrophy is not advanced, restoring moisture to the tissues may help. Using a silicone lubricant with sex may help, too. I recommend Pink, which is very slippery and, because it has Vitamin E and aloe, it’s soothing, too. If there’s been some vaginal narrowing in the process of atrophy, vaginal dilators can be helpful, too, by gently stretching the vaginal tissues.

I hope this is helpful, and encourage you and your wife to pursue a medical evaluation to enhance her chances of regaining comfort! There may be a physical issue that needs addressing, and there are also prescription-only products available to address her symptoms. For a practitioner focusing on menopause care, I recommend the North American Menopause Society’s practitioner finder.

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