Archive for June, 2018

It would be very, very unusual for an old episiotomy scar to become problematic. You say you experience dryness, irritation, and a “tearing feeling,” which sounds to me entirely consistent with vulvodynia (also called vestibulodynia or provoked vulvodynia). Other ways the pain has been described are “sandpaper,” “cutting,” or “ripping.” The most common experience with vulvodynia is pain with intercourse, and usually not with other activities (although sometimes women have sensitivity when wiping after urination). There may or may not be vaginal dryness.

If the pain you’re experiencing is related to atrophy, which is very common and usually evident by vaginal dryness, the Premarin vaginal cream you describe using should be quite effective for that. A topical steroid, which you’ve also been prescribed, would be helpful if there’s an identified vulvar skin condition or dermatosis, but I’m not sure any of your descriptions indicate that the steroid is beneficial. You also asked about the Mona Lisa Touch, which has been shown effective for atrophy, but not vulvodynia, at least thus far.

For patients with vulvodynia, I use a compounded prescription of low-dose estrogen plus testosterone applied to the opening of the vagina (the introitus) two times a day for 12 weeks, tapering to once a day or less. Another option might be Intrarosa, a relatively new treatment for vulvovaginal atrophy, which I’ve begun using with some vulvodynia patients. Intrarosa is a vaginal insert, used nightly; it’s metabolized to testosterone (and estrogen) in the vagina, so I think this is going to help vulvodynia.

Note that vulvodynia can be difficult to diagnose, because the vulva and vagina may look normal. Describing your symptoms accurately will be extremely helpful!


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A few years ago, I shared that the FDA had approved flibanserin, the first available treatment for those experiencing HSDD (hypoactive sexual desire disorder), low sexual desire that can’t be attributed to external circumstances like medical conditions or relationship difficulties. I said then that it made me optimistic that additional treatments would be developed.

I’m happy to say that my optimism wasn’t unfounded. The FDA is reviewing another treatment for HSSD called bremalanotide, which is self-administered through a disposable auto-injector. While it’s not a “pink Viagra,” it is designed to be used right before a sexual encounter, rather than on a daily basis, like the tablet flibanserin. HSDD results from an imbalance in chemicals, and bremalanotide works by changing the balance between “inhibitory and excitatory neural pathways in the brain,” according to its maker, AMAG Pharmaceuticals.

It could be approved early in 2019, and that would be good news for the estimated six million pre-menopausal women who have HSDD—about one in ten (and for post-menopausal women, too, but the study didn’t include them; like Addyi, this new drug is likely to be explicitly approved for the population included in the study). Most of those women likely don’t realize that what they are experiencing has a name, and that it’s now treatable. Instead, they may believe they have to accept low libido as part of “middle age.”

It’s true that it’s normal for desire and sex drive to fluctuate. Each of us decides what’s right for us and our partners. But if what you thought was a passing dip in desire lasts for longer than six months or so, then talk to a healthcare professional. It could be HSDD—and soon there may be one more way of treating it!

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You say you’re considering pelletized subcutaneous testosterone as a response to flagging libido. I have seen good results with testosterone therapy, which you can read about in this blog post.

Testosterone, however, is one time that I never recommend pellets. It’s very difficult to manage levels and dosing in the pellet form, and I’ve seen plenty of awful outcomes of way-too-high doses, including masculinization that in some cases is irreversible (clitoral enlargement is one possible irreversible consequence, for instance).

While testosterone treatments are not FDA-approved for women in the U.S., we have plenty of data on transdermal, bioidentical testosterone use in women, and I think there is evidence those can be used safely if kept in female therapeutic ranges. I just don’t see pellets as allowing management in that safe therapeutic range. I use male pharmaceutical products at a fraction of the dose used for men.

Estrogen is fine in pellet form, but even there I rarely use pellets. We have such great bioidentical pharmaceutical products that are so much easier and flexible to use, with known, consistent dosing, which pellets just can’t provide. It’s hard to get too much estrogen delivered to women, in general. Although I have seen super-high levels with pellets, we don’t have information that this is harmful, and the only adverse side effect is usually breast soreness, which is reversible.

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Couple outdoors in springBuilding and maintaining intimacy takes time and dedication. It takes being attentive over the long haul. But many of the things that contribute to intimacy over time can also revitalize your relationship in the moment. Here are five things you can do right now—but that we hope you’ll do regularly—to make your relationship better.

  1. “Speak” your partner’s love language. According to Gary Chapman, author of The 5 Love Languages, there are five ways to express love: words of affirmation, acts of service, receiving gifts, quality time, and physical touch. It’s important to use your partner’s love language. While you may feel most loved when your partner spends time with you binge-watching your favorite show, he or she may feel most loved when you fix the problem with the router on the home network. Figure out your partner’s language, and then express your love by doing something in that love language.
  2. Say something positive. Years ago, two researchers did a longitudinal study of couples solving conflict. They found they could predict with 90-percent accuracy which couples would break up “based on the balance between positive and negative interactions during conflict…. For every negative interaction during conflict, a stable and happy marriage has five (or more) positive interactions”—inside jokes, teasing, or touching, for example. These so-called masters of marriage use positivity not only in moments of conflict but on daily basis to stabilize their marriage, and you can, too.
  3. Lighten up. Sing off key, dance La Macarena badly in the kitchen, or simply tell a joke or share an amusing anecdote from your shared history. (Be sure to choose one that’s entertaining to you both, and not one that’s humorous at your partner’s expense.) This time of life involves some emotional and physical hardship, so is it any wonder that we sometimes take it all too seriously? While we intuitively know that playfulness and shared laughter brings us closer to our beloved, research verifies that it really does. And not everyone has to think you’re funny—the only thing that matters is that your partner does.
  4. Check your cell phone at the door. Smartphones have become central to our lives, but their ability to distract us exacts a toll that we often overlook. In tests that measured cognition, people who completed task with phones on their desks (even when the phones were turned off) performed worse than people whose phones were in another room. The greatest gift you can give someone is your undivided attention. Leaving your phone in another room with the notifications off demonstrates to your partner that he or she has your undivided attention—and makes it easier to deliver on that promise.
  5. Celebrate a recent success, even something small. According to Tara Parker-Pope in her book, For Better, there’s a correlation between celebrating and increased trust, intimacy, and satisfaction in the relationship. So, whether your partner got a promotion, finished an online course, or had the courage to have a difficult conversation with a family member, get out a cheese platter and a pitcher of lemonade, and sit on the porch for a spell and savor the accomplishment together.

And here’s one extra thing you can do right now: Share this list with your partner—because you shouldn’t be the only one working at laying the groundwork for intimacy in your relationship.

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What you describe is an unpleasant (you said “putrid”) odor, almost like ammonia. The odor is worse after intercourse. You wonder if it could be related to an ablation you had over a year ago. Tests for yeast infections and trichinosis have been negative.

Your symptoms don’t sound consistent with an effect of the ablation. A much more rare possibility might be an intrauterine infection following the surgery that is chronic and causing these symptoms, but I rule it out because it would most likely lead to other physical symptoms. An endometrial biopsy would be needed to assess that possibility.

What it sounds like is bacterial vaginosis (BV), which is an overgrowth of bacteria in the vagina resulting in a discharge and odor. It is treated with antibiotics (oral or vaginal). Some women are prone to recurrences; if you are one of them, you may be helped by a product like Balance Moisturizing Personal Wash. You could also consider using ProB, a daily oral probiotic for vaginal health, available over the counter. It contains lactobacilli which are important in maintaining a healthy bacterial balance.

Here’s an overview of vaginal health, which you could consider when you’ve recovered for other ways to keep your pH in balance: Vaginal Health Begins with Bugs.

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The Intensity, which we call a “pelvic tone vibrator,” would certainly not be harmful in any way. There is some clinical evidence that increasing pelvic floor muscle strength and tone may improve prolapse a bit, and it is very possible it may reduce the progression or the prolapse to some extent.

The Intensity adjusts for a perfect fit and then uses electrodes to stimulate muscle contractions to increase tone. It has an additional vibration function, because that, too, increases circulation in surrounding tissues and orgasm is, in itself, great pelvic floor muscle development. (Read more here about how to use the Intensity.) The makers of the Intensity recommend that you be able to insert the Intensity shaft at least four inches for effective use.

Good luck!

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Getting Out-Together!

Summer has finally arrived, along with the opportunity (and energy) for different kinds of date nights. My date night strategy in the summer is driven by the climate where I live: Summer is a short season, but the days themselves are blissfully long, with daylight that extends until 10 p.m. That makes it easier to plan date nights that are active. It’s a great time to change things up with your partner to keep things interesting. Here are a few ideas to get you started.

Couple walking beachPush a favorite activity in a new direction. If you already enjoy taking a leisurely evening bike ride together, that’s great! Your body thanks you and your relationship is likely stronger because of it. You already know that biking is something that works for both of you. Now just add a twist, perhaps by trying tandem biking, or by planning a daylong (or even overnight) bike trip. If you like to walk, consider doing more strenuous hikes. You might be surprised by how much tackling something that’s familiar yet challenging invigorates your relationship.

Get competitive! You and your partner might not think of yourselves as competitive. But competition has some things to offer a relationship. First, it gives you a common goal. Second, preparing for the competition—whether that’s a 5K or a chili cook-off—automatically carves out “couple time.” Finally, struggling together—the frustration, hardship, mutual support, and laughter that are all part of it—can strengthen the bond between you.

Walk—or foster—a dog. Sometimes seeing your partner in a new light can make you swoon all over again, almost as hard as you did when you first fell in love. The Humane Society has lots of opportunities for volunteers, including playing with and walking dogs. What better way to enjoy each other’s company than spending quality time with small fluffy animals? (Just make sure you know where you both stand on actual adoption.)

Be a tourist in your own town. This is something you can do even if—perhaps especially if!—your town is not a true vacation destination. Put together a short list of the best places in your area, and then spend a date night visiting them. Maybe it’s a museum, or a small park that has rare flowers, or a kitschy attraction just off the nearest expressway. You may have to get creative and keep a sense of humor, but that’s part of the fun. Miniature golf, a river that’s great for tubing, or a pick-your-own farm—all are fair game. You may develop a whole new appreciation for where you live, but at minimum you’ll have fun trying together to achieve that appreciation.

Intercourses CookbookPack a picnic that feeds your relationship. What would a summer date night list be without this old chestnut? Incomplete! What can make this traditional summer date night special is what you choose to talk about while sitting on a blanket nibbling on cheese and grapes. Choose something romantic, like how you met. Or something important, like what keeps you awake at night or what impractical thing you still dream of doing. Or work together to create a list of where you’ve celebrated every anniversary since you first got together. All of these topics feed your relationship. They open you to insight about each other and reminding you why you were attracted to each other.

If you forget everything here, I hope you’ll remember the underlying premise: Get out together! Get moving together! Both are sure to bring you together emotionally, and that is where intimacy begins.

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