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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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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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If you visit the Dame Products website, the first thing you notice is that it is young, hip, straightforward, and unapologetic. The second thing you notice is that the company’s co-founders, Alexandra Fine and Janet Lieberman, are very smart. Janet, in fact, has a degree in engineering from MIT, and Alex has a master’s in Social Work, specializing in marriage counseling and sex therapy, from Columbia.

Their company is on a mission: “to design well-engineered sex toys, to heighten intimacy, and to openly empower the sexual experiences of womankind.”  And they aren’t kidding.

From their first meeting in June 2014 until they crowdfunded Eva, their first vibrator, on Indiegogo, raising $575,000 in six weeks, Dame Products has been on a tear.

What you notice about that first product, Eva, is that it is small-ish, unobtrusive, and kind of weird-looking—somewhat bug-like. And that it doesn’t come in pink. (There is, in fact, very little pink anywhere on the website.) Eva does come with wings, which are designed to be tucked inside your labia, making it a hands-free device during sex. In fact, the pressure of a partner’s body during sex ratchets up the sensation, according to one reviewer. (We hope to offer the Eva soon.)

Eva was followed by Fin, which we’ve just added to our shop, a two-finger device that comes with a detachable “tether.” You can either slip your fingers through the tether (for those of us lacking in the manual dexterity department) or use it without.

Both are high-quality (medical-grade silicon), carefully designed products made by women for women—an idea whose time is long overdue. Dame aims to uncouple sex toys from the provocative and erotic—the “male gaze”—and toward an everyday tool that actually works for women. “We want them to be like something from Ikea, not the lingerie shop,” says Fine. Tellingly, its products aren’t shaped like dildos, which don’t actually stimulate the clitoris. These ladies understand that female orgasm can be finicky and that the action has to be in the right spot.

Another element that distinguishes these vibes from many others is their low-tech simplicity. You can’t program a playlist with it or choose among a selection of designer vibrations. There’s a button on top and a choice of three speeds. Easy peazy. “Because that’s what women were telling us they want,” says Fine.

Although the brand has a young, millennial sensibility, chances are that the over-50 customer will appreciate it for the same reasons as her younger cohort: it’s petite and attractive; it’s practical; it works; and Eva, especially, is designed with couple sex in mind. Not to mention being the first fully-female-designed brand on the market, which we all appreciate.

Expect to hear more from Dame. A dedicated department—Dame Lab—is soliciting ideas and comments from women—and men—for future products. Do the vibes need more power for older users? Do you have suggestions that might make it better? Talk to the dames. “We welcome feedback,” says Fine. “The community really drives our ideas.”

Personally, I appreciate a company that’s unapologetic and passionate about designing quality sex toys. It’s time these products move from the realm of the semi-kinky to something that we all can talk about and use without embarrassment. These dames are doing a good job making that happen.

They call it the “female gaze.”

 

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I’ve got good news and bad news for you. The good news is that you’re just like 75 to 80 percent of women! The majority of women are not able to experience orgasm only with vaginal penetration or stimulation. Most of us need direct clitoral stimulation to orgasm, whether that stimulation is oral, digital, or with a vibrator.

You asked. Dr. Barb answered.A recent journal article on this topic described one factor of influence was the distance between the clitoris and the vaginal opening (read more in this blog post). A few millimeters can make a difference to how orgasm is experienced–and that’s an unmodifiable factor! Since each of us is individually made, the bad news is that if you haven’t experienced vaginal orgasm by now, you’re likely not going to.

There’s one option for you to try: Some vibrators, like the Gigi2 and the Celesse, are shaped specifically to put pressure on the “G spot.” If you’re one of the people for whom orgasm can happen through G-spot stimulation, one of those vibrators can help!

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Oh, I feel for you. You say you have pain (and no doubt other symptoms—like fatigue and depression) from lupus, fibromyalgia, and Sjogren’s syndrome. You see your lack of interest in sex becoming a larger problem in your marriage as the difference between your sex drive and your husband’s increases.

The first order of business is to find a health care provider with whom you can discuss this aspect of your health. The pain you mention may be generalized pain from the autoimmune conditions you have, or it may be pain with intercourse. Painful intercourse is nearly always a treatable condition, so addressing that if you experience it is critical.

You asked. Dr. Barb answered.The harder issue is the “desire discrepancy” you describe in your marriage. While the situation is not uncommon, your additional health issues add a degree of difficulty. Assuming any issues with painful sex have been addressed, there are some medications that can be helpful for low libido: Addyitestosterone, and Wellbutrin, to name a few. Your health care provider can help you understand if any of these can be an option for you depending on your health history and other medications you’re taking.

For more about low libido, you can read this blog post on the emotional component and this one that includes an overview of the condition and common causes. It could be helpful to read these to have some terminology in mind when you meet with your health care provider.

The situation you describe might best be addressed with a (sex) therapist—perhaps not a dedicated sex therapist but one who has expertise in health-related relationship concerns. (Here are two blog posts on sex therapy: one I hoped would demystify it and one that explains how it works.) Your health care provider is likely to be able to direct you to someone with experience to assist you and your husband as you navigate this significant challenge.

Best of luck in reaching some common ground!

 

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You say that your wife suffers from lichen sclerosus, a condition that creates skin tissue that is thinner than usual (and is a higher risk for postmenopausal women). Warming oils and lubricants, unfortunately, create discomfort rather than arousal for her. I’m not aware of an option in that category that would work for her, since the ingredients that make them effective–usually something minty or peppery–will almost certainly cause an adverse reaction.

Plain lubricants won’t cause that reaction; those we include in our product collection should be well-tolerated by lichen sclerosus patients.

There are a couple of other options you and your wife could explore for arousal. The use of testosterone has been beneficial for 50 to 60 percent of the women in my practice who’ve tried it. Testosterone is by prescription and off-label for women, which means a discussion with her health care provider is required.

Other prescription options include localized estrogenOsphena, or Intrarosa (a recently available FDA-approved choice). Any of these would increase blood supply by “estrogenizing” the genitals, which can improve arousal and orgasm as well.

Congratulations on undertaking this exploration together! Good communication and mutual support are so important to shared intimacy.

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In previous posts, we discussed why menopausal weight gain is such a game-changer, and we explored how to limit the damage through dietary changes. Now, we’ll talk about the second critical key for maintaining—or regaining—a healthy weight after menopause.

You know what I’m gonna say.

Exercise. Not only does a regular exercise regimen help you burn more calories, which is what weight loss is all about, but it can also give you a higher quality of life and actually stave off illness.

Longitudinal studies have found that people who are more fit at midlife have lower levels of chronic illnesses, such as heart failure, diabetes, Alzheimer’s disease, colon and lung cancers, as they age. Although other factors, such as heredity, play a role, in general, higher fitness levels were strongly linked with lower rates of major chronic illnesses. “Compression of morbidity” is when debilitating illness doesn’t happen until close to the end of life—and people with healthy, active lifestyles tend to have compression of morbidity.

How’s that for paybacks?

I can tell you from personal experience that a regular, moderately challenging exercise regimen relieves stress, helps you sleep better, reduces the “aches and pains” associated with aging, and helps you to keep up with normal activities of daily life. It regulates your bowels and your moods. And simply feeling stronger and more capable physically helps you to feel more capable and in control of your life generally.

However, I will also say that maintaining a serious (and by serious, I mean regular and moderately challenging) exercise regimen is not easy. It takes time and self-discipline. It makes you sweat. It makes you breathless and it might make you sore.

Not only that, you have to approach exercise differently in your golden years than you did before. You won’t be able to just take off running without a serious warm up; you’ll have to watch your form more carefully; you’ll want to opt for low-impact exercise. Your postmenopausal exercise regimen should contain four elements:

  • Cardio. This is the aerobic stuff that gets your heart rate up, like walking fast enough that you can talk, but not sing (about 3.5 mph, which I find I can do with practice and conditioning), biking, swimming, dancing. Unless you know your joints can take it, stick with low-impact aerobics. The Centers for Disease Control and Prevention (CDC) recommends two-and-a-half hours of moderately strenuous aerobic exercise per week.

Lately, high intensity interval training (HIIT) is recommended to increase the effectiveness of an aerobic workout. In this regimen you alternate bursts of higher activity, such as jogging, with a less active period, such as walking. This gives you an “afterburner” effect in which your muscles continue to burn oxygen after the period of high activity. This AARP article has a good explanation of the benefits of HIIT.

  • Strength (resistance) training. This helps you maintain muscle strength. (Remember that you lose at least 20 percent of muscle mass as you age.) You can use weights or resistance bands, body weight or exercise machines. The CDC recommends weight training 2 days per week.
  • Flexibility. Stretching and toning exercises maintain your range-of-motion and keep your tendons healthy and your joints juicy. Don’t bounce or jerk while stretching. Hold positions for at least 30 seconds and don’t stretch to the point of pain. It’s a good practice to stretch after your regular workout. Here’s a simple stretching routine from the Mayo Clinic. Yoga is fabulous for maintaining flexibility and relieving stress. (Listen to our podcast on this topic here.) It also counts as strength training, so consider joining a class once or twice a week.
  • Balance. Balance is another capacity that diminishes with age, but it’s important to maintain because injury from falls is common and serious. Tai chi is a great discipline to improve balance, but so are simple exercises, such as standing on one foot, unassisted, for 10 seconds or standing first on tiptoe and then heels—simple exercises you can do every day.

Arguably, the hardest part about exercise is getting started. If you have any health conditions that might limit your activity, such as high blood pressure or arthritis, you need to talk with your doctor about what exercises you should and shouldn’t do.

Ideally, you should find a gym with classes or a trainer to get you started—to make sure you’re using correct form, and to show you how to use the machines. Yoga or Tai chi classes with experienced teachers are fantastic and motivational for establishing an exercise regimen.

Get on your mat every day.If this isn’t practical or possible for you, you might turn to the internet for videos and programs. You want substance, knowledgeable leaders, and safety, not razzle-dazzle. Try Fitness Blender (free workout videos and programs for all levels of fitness), Daily Burn, ($15/month; variety of workouts, including yoga, tailored to age and fitness level) or Yoga Today ($15/month with a discount for yearly membership; many workouts tailored to fitness level).

The next hardest part of an exercise regimen is continuing. You will miss days; you will have days in which you don’t work as hard as you should. After a few missed sessions, starting again is hard. That’s just how it goes. You start over; you don’t quit.

Part of the battle is finding a program that works for you—one that is varied, challenging (you are progressively lifting heavier, going longer and faster), but that isn’t killing you. Soreness is good; pain is bad. Move carefully without overextending or snapping joints. Always warm up and cool down.

This is your new normal: a clean diet, a daily exercise regimen that alternates weight training and aerobic exercise and incorporates stretching and balance segments.

I promise you that every ounce of effort invested in a healthy diet and regular exercise will return to you many-fold in a much higher quality of life now and in lower risk of chronic illness down the road. Let me know how it goes and send me any questions you may have. This stuff is too important to overlook.

 

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