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Choices abound. Some are inconsequential—the whim of the moment. Others matter, like your choice of health care provider. I’d like to make the case that, although you may be well past childbearing years, you haven’t outgrown being a woman. Ergo, you still have very unique and specific needs that are best served by a specialist with training and experience in all things feminine.

Most gynecologists see an abrupt migration of their older patients to internal medicine or family practice providers. “…between ages 45 and 55, you start to see a very sharp decline in the number of encounters between women and their ob/gyn–and a mirror-image rise in visits to internal medicine,” says Dr. Michael Zinaman, director of reproductive endocrinology at Loyola University Medical Center in this article.

Not for one moment am I suggesting that this is a bad thing. General practitioners take a broad and thorough approach to patient care. In a typical exam on an older woman, an internist would screen for diabetes, colon and other common cancers, osteoporosis, high blood pressure and cholesterol, anemia and other blood disorders—basically, the whole enchilada. Since heart disease is the #1 killer for women, it’s a good idea to have this type of broad screening every year.

Internists also counsel with patients about lifestyle issues, such as smoking or weight control, diet or exercise (which I also do regularly). And they might refer and coordinate a patient’s care with various specialists.

So, why might a woman who no longer needs reproductive care and who may or may not even have her reproductive organs continue to see a gynecologist? Well, for all the stuff we talk about on this website, for starters.

Older women have specific needs and vulnerabilities for which gynecologists have deep and specific training and experience. The incidence of breast and ovarian cancers increase with age, for example. And although internists may do pelvic exams (and note that “may”; even when, after age 65, we no longer need a pap smear, we still need regular pelvic exams) and order mammograms, gynecologist have years of practice in detection and treatment.

Then, there are all those everyday annoyances of menopause and an aging reproductive system—pelvic organ prolapse, incontinence, hormonal disruption, and all those vexing sexual changes we address here on MiddlesexMD. When it comes to treating these quotidian challenges to health and well-being, gynecologists are simply the specialist. We’re more likely to know about new treatments and medications; we’re more likely to catch anomalies; we’re very attuned to kinds of changes that can signal something serious.

But the bottom line? This isn’t one of those either/or decisions. You can choose between a chocolate sundae and a frozen yogurt, but the choice isn’t between a gynecologist and a general practitioner.

You need both. And both healthcare providers need to be working together for you. “A collaborative approach would be very good,” said Dr. C. Anderson Hedberg, head of general internal medicine at Rush-Presbyterian-St. Luke’s Medical Center.

In one study comparing the type of screenings women tended to receive from primary care doctors as opposed to gynecologists, researchers found that gynecologists were more likely to screen for cervical and breast cancers, and osteoporosis, while primary care doctors were more likely to test for colon cancer, high cholesterol, and diabetes.

I’m thinking you wouldn’t want to miss out on any of this fun stuff, and you sure want to know early on about issues or warning signs. But in the end, you make the judgment calls about your health. You decide what doctor to see and how often and whether or not to follow medical advice. That’s as it should be.

Having the right medical team on your side simply gives you the ability to make the best, most informed choices.

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Yeah, I know. The last thing you need right now is another list of ways to avoid stress during the holidays. The mere thought of another list is stressful all by itself.

Pay attention to what you're doing this moment.I don’t cotton to holiday de-stress lists, either. That’s why I combed through dozens of tips from experts and ordinary folks to winnow out what I think are the best, most truly helpful holiday reminders. I’m betting that something on this list will truly make your life easier and your spirit more joyous. Most of the suggestions even have some science behind them, which always makes me happy.

For the mind and emotions
  1. Cultivate gratitude. If you develop an attitude of gratitude (as they say), you’ll find yourself in a happier place. This is more substantial than simply counting your blessings (although that works, too). You can be generous; you can be large of spirit. This is necessary soul-work and deserves attention at any time of year, but this season of hyper-consumption is a good time for a reality check. Do a shift in a soup kitchen or a food pantry. Be a Salvation Army bell-ringer. Deliver Christmas baskets to the less fortunate. Giving money is important, too, but it doesn’t pack the life-affirming power of face-to-face contact.
  2. Be non-judgmental. Before Uncle Bob begins his NRA rant or Aunt Millie makes not-so-sotto-voce comments about your grandchildren, prepare your mind. These are the people with whom you share the planet and your DNA. You aren’t going to change them, so you might as well adjust yourself. Practice a benign attitude of acceptance. A glass of wine also helps.
  3. Visualize. What one word describes what you hope for this holiday season? Peace? Serenity? Acceptance? Love? Write it on a card (or several) and tape it to the bathroom mirror. This is your holiday guide and mantra.
  4. Be mindful. We wrote about this in a previous post, but its impact on stress-reduction can’t be overstated. Pay attention to what you’re doing this moment. When you get to a holiday task you enjoy, decorating cookies or the tree, maybe, tackle it with focused attention and just enjoy the heck out of it.
  5. Smell citrus. The lemon-y scent of citrus smells clean, but it also increases norepinephrine—a mood stabilizer and stress-reducing hormone. Rub some lemon or orange essential oil under your nose or carry a hankie dabbed with the scent for a dose of feel-better. Use it as aroma therapy during the holidays.
For the body.
  1. Exercise. Holidays are a black hole for shrugging off daily routines. Who has time to exercise? That’s exactly why it’s so important. Exercise is critical during stressful times because it gooses our system with feel-good endorphins and increases energy levels. Getting outdoors for a walk or jog amplifies the effect.
  2. Go natural. Research shows that patients with a view of the outdoors heal faster. It also reduces stress. So, open the curtains; flood your house with natural light; and bring the outdoors in with pine boughs, holly berries, and essential oils. Go outside and gather your own for a double exposure.
  3. Eat moderately. You can certainly enjoy every morsel of holiday fare—just don’t get carried away. You know how you’ll feel after a night or several of overindulgence—and the morning of January 2 will be very, very bleak indeed. Once again, practice mindfulness. Pay attention to the colors, tastes, and delicious holiday smells. You’ll be less likely to blindly put things in your mouth, and you’ll enjoy what you do put there a lot more.
  4. Sleep. It’s hard to turn off the mental hamster wheel that you’ve been running on all day. But good sleep is essential to good functioning, and bad sleep is a total killjoy, as we all know. There’s a well-developed science of sleep hygiene. Here are a couple of safe natural sleep aids: Chamomile has been used to aid sleep aid for hundreds of years. What is more soothing that a hot mug of chamomile tea before bed? Melatonin is a hormone that helps regulate your sleep/wake cycles. Some people find that 5 mg. of melatonin before bed helps them feel sleepy and fall asleep faster. It’s safe, inexpensive, and easily found in pharmacies.
  5. Touch. What is it about loving touch? Research shows that touch releases dopamine and oxytocin—both soothing, mood-altering hormones. You don’t have to go all the way to home base (but if you do, sex is a great stress-reliever as well); just a gentle hug, shoulder massage; quick kiss helps put the moment in perspective. Don’t neglect the power of touch this season.
For your sanity
  1. Clean house. No, not you. Get your house deep-cleaned early in December. You’ll love knowing that the dust bunnies no longer live under the beds and that you’re ready for drop-in guests and family overnights at any moment.
  2. Simplify. Ditch fussy traditions. Lower your expectations. Spend less. The point is to enjoy the time with family and friends and to savor the sensual beauty of the holiday. The contemporary focus on fancy gifts and decorations and a whirlwind of parties is distracting and exhausting. Just say “no” to the distractions from the true spirit of the holidays.
  3. Watch a Christmas classic. For an enjoyable break, gather whatever family is available and settle in with hot chocolate and popcorn to watch your favorite Christmas movie, whether it’s Charlie Brown or Miracle on 34th Street. You can’t go wrong with an easy and heartwarming evening like this.

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Can anyone guess what we have in common with female orcas (killer whales}?


That’s it. We share menopause with only two species on the planet, and both are whales: the orca (killer whale) and the pilot whale (which is technically a dolphin). All other mammals, including gorillas, chimpanzee, elephants, dogs, cats, and camels continue to bear young, albeit with decreasing frequency, until they die. No other mammal experiences literally decades of post-reproductive life.

Except us and the whales.

Of course, the big question biologists ask is, Why? From a Darwinian perspective, bearing young assures the continuation of the species. Decades of life without fertility makes no evolutionary sense. (According to biologists; we, on the other hand, might feel otherwise.)

Now, after decades of closely observing a specific pod of killer whales in the Pacific Northwest, biologists have greater understanding of the role female elders play in the whale community. The almost eerie parallels to our human experience have piqued the interest of scientists and writers, who think perhaps the way of the orca may shed light on human menopause.

For years, scientists thought human menopause was simply due to medical advances that enabled women to outlive their normal genetic lifespan. Without the intervention of modern medical technology, so the thinking goes, we too would bear children until we died, like our close mammalian cousins. Evolution, remember, favors traits that support the passing on of a species’ genes.

Enter the orca.

Female orcas stop calving in their 30s and 40s, but they continue to live for many decades beyond that—well into their 80s. “Granny,” the oldest of the Northwest orcas, is thought to be over 100 years old. After decades of observation, including hundreds of hours of underwater video, scientists began to understand that these old gals weren’t just freeloading on their sons and daughters. They were critical to their survival.

Orcas mostly hunt salmon, stocks of which vary, sometimes greatly, from year to year. It is the older female orcas that tend to lead the pods, and this is especially noticeable when the salmon stock is low. During lean years, the older females more frequently lead the clan. At those times, the accumulation of knowledge and experience by the older females give the orca a critical edge.

“That kind of knowledge is accumulated over time—accumulated in individuals,” said Darren Croft, professor of animal behavior at the University of Exeter in this article.

Studies of death rates were also revealing. The whale clans are matrilineal, with sons and daughters staying with the mother for life. Mature sons are so dependent, in fact, they are called “mummy’s boys.” They leave the clan periodically to mate, but they return to follow their mothers. When an older female dies, her sons and daughters are more likely to die as well. In fact, a son is eight times more likely to die within the year after losing his mother.

While these characteristics don’t exactly parallel human experience (we don’t tend to enjoy having our aging sons follow us around), they do point to the critical role of older females to the survival of the clan, whether whale or human.

Recent studies of hunter-gatherer societies reinforce this hypothesis. Given the long and costly job of raising human children to adulthood, grandmothers play a critical role in the well-being of the family, often taking on the role of forager-in-chief and caregiver for a daughter’s children.

It’s called the “grandmother effect.” Evolutionary biologists hypothesize that these contributions of an older woman offsets the decades of infertility. The grandmother assures that her genes are passed along by making sure that her grandchildren survive.

By no means do the grandma orcas take a back seat to the kids. They remain spry, vital, and active into their advanced years, maintaining their role as guide and coach. But the old gals have also been seen cavorting sexually with young males, presumably to teach them a thing or two about the birds and bees—and the cetaceans.

“Besides being the repository of knowledge about where to go in case of lack of food, they also lead very rich lives,” says Deborah Giles, director of the Center for Whale Research.

And so do we. This evolutionary state of affairs wherein we enjoy decades of vigorous, post-reproductive life while contributing to the well-being of our kin and the world in general is a pretty happy state of affairs, I’d say.

If the whales are any indication, far from being redundant, useless, or invisible, we continue to fill important and meaningful roles after menopause, which we have garnered through years of experience.

“We complain, women of my age, of becoming invisible, and it’s true—you realize how very much you’re defined by sexuality. But I have a sense—galvanized by stories about the killer whales—that now is the time when you become the person you really want to be,” writes journalist Christa D’Souza, author of The Hot Topic, a book about menopause.

“The idea of women passing on information; the idea of wisdom with age—there’s a beauty in that that is about something other than being able to reproduce.”


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The United State of Women “Healthy Women. Healthy Families.” summit in Washington D.C. didn’t focus specifically on perimenopausal and menopausal women, yet my conversation with attendee Marta Hill Gray naturally circled around to the topic of women, aging, and sexuality.

Marta, a women’s health advocate, worked behind the scenes to promote “pink viagra,” and she continues to be an insightful observer of women’s issues.

What have you observed about society’s view of women beyond the childbearing years?

As women age, society says we are supposed to suck it up and get on with it, but that doesn’t mean we are healthy and actually taking care of ourselves. For so many women, when you get to menopause no one has taken time to tell us what to expect.

After attending the event, what advice do you have for my readers?

Talk to daughters, sisters, nieces, and friends about the changes that are coming.Younger women need to know the time will come to a time when their bodies are going to change. As older women, we need to talk to daughters, sisters, nieces, and friends about the changes that are coming. Let them know that once you have your babies, it’s not over. We should really mentor them in being diligent about their bodies, so they ask better questions and they’re smarter than we were.

Your mom may tell you about having their period but not about menopause… It is a big deal. And women need to know there are doctors like you, menopause providers, who can make it manageable, who can give you treatment options and care and guidance so you move through it gracefully.

Not all doctors are comfortable with women in menopause.

That’s true. And if you don’t have health care providers you can talk to you, you need to fire them and find one you can talk to. Yes, you can fire your doctor, it’s all right! Just because they wear a white lab coat doesn’t mean they know how to help. You should be able to comfortably discuss any topic including bowel movements, urine, sexuality … all of that is important.

There seems to be more openness to talking about sexuality and sexual health today than when I began my practice.

I agree. The fact is that we’re living longer, we look better, and we are more involved than previous generations of women our age.

We're living longer and are more involved than previous generations.It is such a life-affirming thing to be a sexual creature, yet so many women have painful intercourse, and then they shut down, which can hurt relationships. I think that women going through menopause should definitely be able to depend on their health care provider to give them information and tools to overcome the challenges. It is different for everybody and, just as it is when you’re younger, it is very personal. A lot of women don’t know they have options and choices.

Women’s health and women’s sexual health isn’t behind the curtain anymore. It is being forced out on the table partially by the fact that our world is smaller and we know so much about girls as slaves, genital cutting, sexually transmitted diseases… everything is discussed and it will continue to be so discussed because these are facts. It’s an open discussion now, and the word vagina can be said. Women make up 50 percent of the population, and we are full citizens.

Younger women are leading the charge and they will not be denied. They have no fear. I think it’s fantastic, and it’s going to get better and better.

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You can't talk about women's empowerment without talking about health.My good friend and women’s health advocate Marta Hill Gray recently attended the first summit of The United State of Women, a gender equality movement with high-profile support from Michelle Obama, Warren Buffet, Oprah, Meryl Streep, Amy Poehler and other well-known celebrities. (To learn more, watch this two-minute film.) Naturally I was interested (and very curious) to hear all about this event, which was convened by the White House in Washington D.C. Here are highlights of my recent conversation with Marta:

I understand the topic of this summit was ‘Healthy Women, Healthy Families.’

Yes, you can’t talk about women’s empowerment in any fashion without talking about their health—it’s one and the same, and it hasn’t been given enough attention and respect. It was exciting to see 5,000 women who took time to fly from around the world for this event.

It was a tsunami of attention around women’s issues.

What was your main take-away?

There was a lot of sizzle with big-name celebrities… but more importantly, it really put a spotlight on younger women who are dedicating their lives to women’s issues

Millennials are really stepping up and very much engaged in ways we may not have been at that age. The younger women are leading the charge and they will not be denied. They have no fear. I just think it’s fantastic, and I think it’s going to get better and better.

What kinds of speakers did you encounter?

I saw some wonderful health care professionals who are working with under served communities, helping women get the support and education they need, and helping them understand their rights are in terms of pregnancy, treatment options and even what insurance will (and will not) cover.

For example, The Women’s Law Center spends all of their time answering the phone and explaining to women what their rights are, like the right of all women to have breast reconstruction surgery after a mastectomy.

Those are the kinds of things that many of us take for granted, but not all women get the same information or the same treatment.

What surprised you?

I am seeing a real shift in the language and the public perception about women’s health. This isn’t just a women’s problem—it’s a problem for men, for boys, for sons. This impacts families and it impacts lives.

Why this special focus on women’s health?

Women's bodies need to be understood separatelyHere’s an epiphany: Women’s bodies are not like men’s bodies. They need to be respected and understood separately. Yet, women don’t know about their bodies, there is often shame about it and there many cultural nuances. The question is, ‘How can we support women who need this kind of care?’

But the good news is that things are changing. This summit was full of vibrant conversations instead of the shame of years ago.

I was encouraged by the young women. To them, it’s so important that there’s no thought of repercussions. It gave me great hope to see women who are so sharp and directed and capable.

My conversation with Marta went beyond the summit to the topic of women, aging, and sexuality. Watch for my next blog to learn more.

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Last month MiddlesexMD advisor and psychotherapist Mary Jo Rapini shared some advice about how to restore your sense of sexual self after divorce. That conversation led to another, about some of the unexpected challenges we face when we re-enter the world of dating after an absence of… well, it could be decades! 

My first advice for people getting back into dating after a divorce is to tread slowly. It’s a whole new world out there, and if you’ve been married for some time, the dating scene is sure to overwhelm and frighten you. You’ll know you’re ready to begin when you no longer feel like you need a partner, but would like to enjoy another’s company. When you’re lonely and riddled with pain, you don’t make a good partner; that’s not the time to look for someone. Sacrificing your own physical and emotional health to get a “fix” of feeling desired again is never a good idea. But be assured that time is only a temporary patch.

When you’re ready to start dating, tell friends and colleagues you respect that you’re looking or open to meeting new people. People you respect have respect-worthy friends; they’re usually your best option for getting a date with someone you’ll like. If you don’t have many friends, you might start by searching out groups you could join to meet other single people. Cooking classes or groups, poetry readings, church groups, plays, and sporting events all provide opportunities to connect with others who appreciate the same things you do. Being with others helps build your confidence and provides feedback about how you present and appeal to others. Being married may have enabled you to not focus on your looks, your mannerisms, and your lifestyle. Dating forces you to evaluate all of those qualities that you may have taken for granted or not explored.

Lots of people have been trying out online dating. It’s great for letting you “date” on your own time, ask a lot of questions, and get to know someone in the comfort of your own home. It’s scary because it can provide a “cover” for someone to lie, take advantage of you by saying what you want to hear, and to serial date without you knowing. You need to be cautious and smart. Online dating does give you a chance to experience dating, though, before you take a risk and actually dress up and meet up. I encourage women to focus on the experience rather than any specific outcome. I date online only vicariously—as a relationship psychotherapist—but here are the things I see helping my patients avoid problems:

  • Stay anonymous with your user name, personal information, and phone number—until you and only you decide you’re comfortable giving out that information. Once it’s out there, you can be harassed and pressured. If you don’t know a person enough to trust him, don’t.
  • Make decisions cautiously. Don’t move too fast; one conversation is not enough to commit to meeting someone in person. The same behaviors that work well for physical dating are valuable with online dating.
  • Look at several different photos. Who is the person with? Is anyone cut out of the photo? Has it been photo-shopped or otherwise altered? Why? Ask questions. I would like to say it doesn’t matter what we look like, but that would be a lie. Most people cannot trust someone until they see a photo.
  • Talk on the phone at least once—hopefully more—before you meet someone. A voice tells you a lot more about a person. Online dating is a little bit like putting a puzzle together. The pieces of a person’s life should make sense when you see them together.
  • Take your time before meeting—one of the great assets of online dating. When you decide to meet, do it at a public place. Tell your best friend or several people where you’re going and your date’s name and phone number. Trust your gut when you see the person. You can always back out at the last minute. If the person tries to pressure you or argues with you in any way about meeting you, that’s a red flag. Don’t go.
  • Always take yourself to the meeting place. Never let them pick you up and don’t have someone drop you off unless they can come at any time to pick you up. This is not the time to be vulnerable. If you are meeting someone from another city, state, or country, make your own travel plans. Don’t tell the person where you are staying or your travel details. Set a meeting time and place and meet there.
  • If, at any time, you feel you are unsafe with this person, call the police. They will give you counsel in regards to what you should do. One of my patients decided to meet someone she met online in Colorado. She became frightened when, after dinner, she went to his place and he wanted to have sex. He was into asphyxiation and almost killed her. She told me she had a bad feeling in her gut when she met the guy, but she didn’t honor it.

Dating after a divorce is all part of the journey you find yourself on after signing the papers. It isn’t easy, but it’s an opportunity to grow and explore. Stay open, and allow yourself to really experience what happens. Dating when you’re older has its advantages. You are wiser and understand the fragility of relationships. You no longer need a person to fulfill you; you are looking for one to share your life with. Take your time, and enjoy the experience.

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