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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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You say you’re four years past menopause, and in addition to hot flashes and other symptoms, you have dryness and have had vaginal atrophy—a decrease in the size of your vaginal opening. This is a classic symptom of genitourinary syndrome of menopause (GSM, earlier called vulvovaginal atrophy). Without estrogen, the vaginal tissues become thin and fragile, and the vagina can shorten and narrow.

Vaginal moisturizers, which you say you’re using, are of some benefit. They’re better at prevention, though, started during perimenopause or early in menopause; once atrophy is advanced, they’re less helpful and may be irritating, as you’ve experienced.

You asked. Dr. Barb answered.The most likely effective treatment is localized estrogens (cream, ring, or tablet) or something like Osphena (oral and non-estrogen) or Intrarosa. You say you like to avoid chemicals, and I understand that; estrogen is a natural chemical, and the local application is to replace what your body used to produce naturally in the way that has the fewest side effects. Osphena and Intrarosa work like a hormone, even though they aren’t one. These are all prescription therapies, and a necessary component of your plan to counter the effects of vulvovaginal atrophy, which is chronic and progressive.

Once the tissues are healthier, you may need to use vaginal dilators to regain increased “capacity” (patency, in medical terms) of the vagina.

Whenever there is pain involved, that problem needs to be addressed first; once you’ve achieved physical comfort, you may find a sex therapist helpful if issues remain, as your gynecologist suggested. In the meantime, no one should blame you for not wanting to have painful sex!

A number of the things you say are very familiar to me: you’ve had plenty of natural lubrication and you’ve never had issues with intercourse. The unfortunate reality is that menopause changes the game, more dramatically for some of us than others. What was true for the younger you is no longer the case (ask me about menopausal weight gain!). But! I know how important intimacy is to relationships, and if you’re willing to make the effort, it’s almost always possible to regain function and comfort again.

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You asked. Dr. Barb answered.You say you’re looking for clitoral stimulation, and options you’ve tried are either too intense or have too small a surface–or both. My personal favorite and a top seller for MiddlesexMD is the Siri2, which is rechargeable. It has patterns as low as a soft flutter but a range wide enough for most midlife women. (I’ll admit I got mine before Lelo added the option to sync to the beat of nearby music.) A less expensive option is the Kiri, which is battery operated but still plenty powerful. It has 16 different speeds and six patterns.

Both of these options are shaped specifically for clitoral stimulation, with broad curved surfaces that I suspect you and your partner will find more satisfying than the shape you described.

Enjoy

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Recently, we’ve been discussing the reasons to have (or not to have) a hysterectomy and the various surgical options—all very important information to have before you decide to have the procedure.

Now let’s talk about what happens after the surgery. Specifically, what might happen to your sex life.

Usually, your doctor will tell you to wait about four to six weeks before having sex, depending on the type of procedure you had. You might want to clarify with your doctor exactly what he or she means by “sex.” Usually, that means vaginal penetration. So ask if oral sex is okay. How about using a vibrator or a hand?

When you’re ready for intercourse, you’ll want to start gently—lots of lube and gentle penetration. If the cervix was removed, it may take time for the top of the vagina (the “vaginal cuff”) to heal. Penetration may feel differently for a while. (Here’s a good metaphor for the process.)

Sometimes, emotional healing has to happen as well. After all, hysterectomy is the surgical end to childbearing. For some, depending on the reason for the hysterectomy, this is a relief; for others, it’s a significant and sometimes difficult transition. If you are overwhelmed by emotion or even depression, give yourself some time and space to heal. You may also need to seek out a listening ear or professional counselor to regain balance.

If your ovaries were removed, and you haven’t yet gone through menopause, or even if you’re in perimenopause, be prepared for the possibility of significant emotional and physical change. With the removal of your ovaries, hormone production suddenly stops, and you’re now in surgically induced menopause. This requires some preparation ahead of time and some patience and therapy after the procedure.

The good news is that, for most women, sex tends to be unchanged and is sometimes better. The parts necessary for orgasm are still intact, and the issues that may have caused the trouble in the first place (pain or bleeding) are gone. “Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don’t have their original problem to interfere with sex,” writes Dr. Paul Indman in this article.

This opinion is supported by several studies confirming that, for most women, sex is the same or better after a hysterectomy. In a small study of 104 women, researchers determined that the best predictor of the quality of sex after a hysterectomy was the quality of sex before the procedure.

Despite the research, some women say that sex just isn’t the same. They report weaker orgasms and less sensation, loss of libido, and difficulty with arousal. Therapies can help—hormone replacement, localized estrogen, lubes and moisturizers—but they can’t replace nature.

Furthermore, although the vast majority of women recover well, a hysterectomy is still a surgical procedure with all the attendant risks and uncertainties. Unexpected outcomes happen—nerves may be damaged; prolapse or fistula may occur. The long-term effect of removing significant abdominal organs is still poorly understood.

With that in mind, some tips for approaching this, or any, surgery might be:

  • Try the most conservative treatments first. Fibroids, heavy bleeding, endometriosis can be treated with less invasive methods. Start there. A hysterectomy isn’t the first line of defense.
  • Opt for the most conservative surgery. If a hysterectomy is the best choice, make sure you understand your options. The least invasive surgical options (vaginal or laparoscopic) simply have better outcomes. If there’s no good reason to remove your ovaries, ask about keeping them.
  • Do your homework and line up your resources. Make sure you and your partner understand what’s happening and be prepared for a time of adjustment afterward.

Several years ago, an acquaintance had a total hysterectomy that included the removal of her ovaries. She was post-menopausal at the time, but sex was still very important to her and her husband. She was worried about the effect her hysterectomy would have on their sex life and discussed it with her doctor.

Recently she told me that there had indeed been a period of transition after her hysterectomy, but that over time, she had regained her former sensation, including the deep, pleasurable orgasms she had been accustomed to.

“I don’t know how it happened,” she told me. “I just worked from the memory of what sex had been before my surgery and focused on regaining that. And I did.”

Everyone’s experience is unique. It’s impossible to predict with utter certainty how an individual will respond to any surgical procedure. With a good medical team, good information, and a supportive partner, you’ve tilted the odds strongly in your favor.

 

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As I mentioned in the last post on this topic, even after you’ve decided to have a hysterectomy, a few critical questions remain. Time for a sit-down with your surgeon to hash them out.

First: How will he or she perform the procedure. There are three basic surgical options. The type of procedure your doctor chooses will affect the speed of your recovery, how long you’ll be in the hospital, and how much pain you’ll experience.

  • Abdominal hysterectomy involves removing the uterus through an incision in the abdomen, usually along the bikini line. This route involves more risk, more pain, and a longer recovery period. Depending on your unique situation, this may be the best (or only) approach, but studies consistently show that, in most cases, the following two options are preferable.
  • Laparoscopic hysterectomy involves using tiny cameras and surgical tools—sometimes operated by a robot—inserted through small abdominal incisions, either to do the hysterectomy entirely or to assist in a vaginal procedure. This is less invasive with good outcomes.
  • Vaginal hysterectomy is just what it sounds like—the uterus is withdrawn through the vagina without requiring an incision. Generally, this procedure was found to involve fewest complications, to take less time to perform, and to offer the best outcome. Some factors, such as the size of the uterus or the shape of the pelvis, might prohibit a vaginal hysterectomy, but overall, this is the best choice.

You should discuss what procedure your surgeon recommends and why. The quality and speed of your recovery rests in his or her hands.

The second topic to thoroughly discuss with your doctor is what, exactly, he or she is taking out. Here are the three umbrella categories of hysterectomy.

Hysterectomy

Hysterectomy is the removal of your uterus and the cervix, which is the organ at the top of the vagina. A lot of discussion and very few facts surrounds the pros and cons of leaving the cervix intact. Unless there’s a problem with the cervix itself, there’s no biological need to take it out—or to leave it in. The preponderance of evidence suggests that the cervix has little to do with sex, and removing it doesn’t seem to change sensation or to affect orgasm.

Removing the cervix, however, can change the vagina: It can become shorter, although rarely enough to compromise sex; some nerves might also be affected, which could make the top of your vagina more sensitive, and not in a good way. But the vagina, as we know, is a very stretchy and forgiving organ, so with the use of dilators (and gentle, consistent sex) the situation can be remedied.

Often, the cervix is removed prophylactically, to avoid a small but real cancer risk. Without a cervix, there’s no longer a risk, ergo, no more pap tests. That’s one point in its favor.

Supracervical Hysterectomy

In the supracervical hysterectomy procedure, only the uterus is removed, leaving the cervix, fallopian tubes, and ovaries intact. In this case, you probably won’t experience much difference in your sexual activity unless you were accustomed to deep-muscle uterine contractions with orgasm. No uterus; no more muscular contractions. You might notice other changes, however, that we’ll discuss in the next post in this series.

Hysterectomy with Bi- (or Uni-) Lateral Salpingo-Oopherectomy

Hysterectomy with bi- (or uni-) lateral salpingo-oopherectomy. Yes, it’s unpronounceable. This is the removal of one or both ovaries and the fallopian tubes along with the uterus. Unless you’re well into menopause, this procedure can put a woman in a hormonal tailspin.

The ovaries are the seat of much of testosterone production (it’s also produced by adrenals) and estrogen production—all the good stuff that keeps the sexual apparatus and our moods humming nicely along. Removing them while they’re still functioning puts a woman into immediate and sometimes intense menopause. It’s called “surgically induced menopause.” For that reason, ovaries are left intact, if possible, especially in younger women.

The decision can be complicated, however. The ovaries themselves can be diseased. Also, some women carry a genetic trait called the BRCA mutation. They are at a much higher risk for breast and ovarian cancer. While breast cancers are often identified at early stages, no screening or early-stage detection exists for ovarian cancer. It’s usually discovered later, when it’s very hard to treat. For women without that genetic trait, the risk of ovarian cancer is low, but not zero.

When menopause is surgically induced, your sex life (among other things) is likely to be seriously impacted just as it is in menopause. You should prepare for low libido, a possible decrease in arousal, dry vagina—all the issues we cover so repeatedly here.

I’d strongly advise you to line up resources ahead of time. Make an appointment with a gynecologist who specializes in menopausal issues. You might be a good candidate for estrogen and/or testosterone therapy. Stock up on lubes and moisturizers. Fire up the vibrator. The hormonal transition could be rocky, but with support and medical oversight, you’ll get through it. Sex (and life) will be good again. Promise.

A lot of issues and options are involved with the decision to have a hysterectomy (beginning with the question of having one at all). Believe me, you want to understand the process, your options, and the possible outcomes. When it comes to this part of your body and your being, you want to know what’s going to happen and to minimize the surprise factor.

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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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