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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.

You asked. Dr. Barb answered.I’m not sure which “tightening product” you’ve seen. The only way to tighten the vagina is to tighten the surrounding muscles. Kegel exercises (we give instructions on our website) target the muscles of the pelvic floor. And many women find that exercise tools (like vaginal weights or a barbell) helps them be sure they’re flexing the right muscles. I also recommend the Intensity Pelvic Tone Vibrator, which uses a combination of electrical pulses and vibration to build pelvic tone.

You asked. Dr. Barb answered.The sexual arousal creams and gels are effective, and beneficial to most women who use them. Like our category of “warming lubricants and oils,” they typically use an ingredient like menthol, mint, or pepper to stimulate circulation, which increases responsiveness during intimacy. Read the instructions for the product you intend to use, to be sure you understand whether it’s for internal or only external use; lubricants are generally safe for internal tissues.

Arousal and warming products have the potential to cause some irritation for those women with significant atrophy, or thinning of the vulvovaginal tissues. I recommend applying a small amount to the genitals in advance of sex to make sure it’s comfortable and pleasurable.

You asked. Dr. Barb answered.Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.

MonaLisa Touch is a laser treatment for vaginal atrophy, also known as genitourinary syndrome of menopause. I explained the treatment option in a blog post a few months ago.

You asked. Dr. Barb answered.The treatment is quite effective for most patients, but it is costly. As a new procedure, it’s not covered by most insurance companies; without insurance coverage the expense (cost varies by region, but figure $1,500 to $2,000 for the three required treatments) is a limitation for many. The procedure needs to be updated regularly, probably about once a year for most women.

We also lack long-term data on its efficacy and side effects. We are very hopeful the clinical trials will soon be available to assure its effectiveness and safety.

“Midlife: when the Universe grabs your shoulders and tells you “I’m not f-ing around, use the gifts you were given.” —Brene Brown

I don’t know about you, but I love seeing old people in love. The way they hold hands toddling down the street. The way they go about their daily tasks having made peace with the past. I think it’s a miracle when love lasts this long and ages this gracefully.

Relationships encounter lots of challenges in the course of a lifetime, but from my own observations, which are supported by the data, the midlife transition, that somewhat fraught passage, is nothing to sneeze at. Menopause aside, the awareness of time passing often arrives unexpectedly and with surprising intensity, leading both men and women to make decisions that belie common sense, compared to which the red Corvette might be among the most benign. For example, the highest divorce rates from 1990 to 2010 occurred among couples over 50, according to this study. Concurrently, co-habitation rates among over-50s tripled from 2000 to 2013.

Whatever the cause—longer lifespan, greater economic freedom for women especially, cultural change—the fact is that something shifts when folks approach that midlife marker, and it’s often the woman who agitates for change.

This isn’t necessarily a bad thing. Periodic reevaluation and readjustment is healthy. So is honestly confronting ingrained habits and responses that ultimately stifle intimacy and deflect communication. Like a vintage car, most lengthy relationships require a major or minor tune-up now and then.

Still, midlife often opens a Pandora’s box of restlessness and dissatisfaction—the perennial is this all there is? What happened to the passion? Am I missing out? Do I really have to endure the quirks and habits of this individual for the rest of my life? What is really important? What dreams have I buried?

Those existential questions herald an important crossroad—the frontier between youth and maturity. With regard to your most intimate relationship, you can:

  1. Invest in what you have. Work on ways to reinvigorate and reignite the flame. This won’t be the passion of your youth, but something burnished by time and familiarity. A golden glow rather than red-hot embers. If your relationship is solid and things have just cooled off with time and neglect, it’s worth investing for the future.
  2. Reinvent it. Sometimes a creative change eases the chronic irritations that can erode a longterm relationship. Some couples successfully stay together but give themselves extra space with separate households, for example, or planned time apart, or splitting the daily finances and decision-making that cause problems. Rejiggering the quotidian foundation might ease the annoyances enough to allow a couple to value and appreciate the familiarity and intimacy that has developed over many years.
  3. Scrap it. This is a very tough judgment call, but some relationships have never worked well; some matches are misses; and sacrificing the years you have left may not be worth it for one or both of you. Dismantling a lifetime is a heartbreaker (or—maybe a release), but you may end up in a better place when the dust settles.

Major life transitions should never be done in haste. They deserve a considerable degree of mature reflection. We all know people who make fast and sometimes rash decisions in the throes of passion or as a desperate attempt to seize a day that appears to be slipping away. Amid the landmines of midlife, the baby is sometimes thrown out with the bathwater.

Here’s a little reality check.

However irresistible the urge, don’t blow up your life. Wait. Reflect. Seek counsel. The demand to create something more authentic, to realize cherished dreams is real and should be honored. But the best path forward probably isn’t over the shattered pieces of your present life.

You still have time. You can still seek your bliss, optimize potential, maybe with more freedom and effectiveness now that the kids are grown and you’re more self-confident. Start a business. Learn Chinese. Travel. The world is your oyster—just in a different shell than when you were younger.

Romantic passion is a landmine. Passion is powerful, blinding, and temporary. You can’t make good decisions in its throes. And even the most incredibly passionate relationship will inevitably fade with the demands of daily life. White-hot passion doesn’t last; it’s not meant to. And when reality checks in, the dirty socks on the floor look the same. Trust me on this one.

Talk to someone if you need to. A therapist. A friend. You can’t see things clearly (even if you think you can). Trust the counsel of someone wise and objective.

Don’t freeze out your partner. However restless and unsettled you may feel, your partner is probably not the enemy. You want to elicit support, not resistance. Anyone would feel threatened when cracks appear in the foundation of a secure life. Anyone would feel uncomprehending and maybe hurt. If, however, you are able to communicate what you’re feeling, even if it’s confused and incoherent, at least there’s a bridge rather than a canyon.

“This too shall pass,” writes blogger Deb Blum in this article. “It will pass more gracefully and completely if everyone is gentle and loving and gives the space necessary to get through this time.”

And that study about over-50 divorce rate also found that the longer a marriage lasts, the less likely it is to end in divorce. So those old folks holding hands in the park? The real deal.

You can’t really tighten your vagina. What you can do is tighten your pelvic floor muscles, which surround the vagina. We offer a variety of products designed to help you improve pelvic floor tone, as well as instructions on how to do Kegel exercises.

There are some laser treatments that have been offered to tighten the vagina. They’re relatively new treatment options, and the outcomes seem quite variable.

Strengthen your floor!I hope this helps! (And I’ll note that strengthening your pelvic floor is also good for preventing incontinence, so there’s lots of reason to develop the Kegel habit!)

 

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