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Posts Tagged ‘localized hormones’

I’m an optimist by nature.

And that’s a good thing. I saw an article this week headlined “Women are not getting treated for menopausal symptoms.” It outlines the research behind the statement, research done in Australia but believed to be indicative of the reality elsewhere, including the U.S. and the U.K.

The researchers surveyed nearly 1,500 women who were 40 to 65 years old. Some of the results:

  • Up to half experience “vasomotor symptoms,” which include hot flashes and night sweats.
  • Seventeen percent said their vasomotor symptoms were moderate to severe.
  • Eighteen percent reported moderate to severe sexual symptoms.
  • Only 11 percent of respondents said they were using any hormone therapy.
  • Less than one percent were using non-hormone therapy.

This is, sadly, in line with other research I’ve seen over the past few years. Too many of us are taken by surprise by menopause symptoms. Too many of us expect the symptoms to pass in a month or two, when in actuality they may last for years. Too many of us suffer in silence (in one study, only 14 percent of men and women over age 40 had talked to their doctors about sexual health). And too many of our doctors lack either the information or the confidence to help us navigate these years.

And there are options available. The initial “alarming” findings from the Women’s Health Initiative regarding systemic hormone therapy have been largely disproved, put into a broader context of the trade-offs between quality of life and symptom management. The North American Menopause Society points out that breast cancer risk associated with systemic hormones doesn’t usually rise until “after 5 years with estrogen-progestogen therapy or after 7 years with estrogen alone”—which is likely long enough to weather the worst of menopause symptoms.

Localized hormones are an option for some symptoms; because they’re applied directly in the vagina, very little is circulated throughout the body. That limits or eliminates the risk of side effects, while still offering benefits in maintaining or restoring vaginal tissues.

New nonhormonal options for menopausal symptoms are also available, approved by the FDA. Osphena is a “selective estrogen receptor modulator” (SERM) that targets the vagina and uterine lining. Duavee is another medication in the SERM category that can be effective for hot flashes, with potential benefits for bone density. Brisdelle is an antidepressant that’s been prepared at a dosage that can help with hot flashes while minimizing its occasional side effects of weight gain and loss of libido.

Those are all prescription options, and there are plenty of steps women can take on their own, as well. That’s really our entire message, but if you’re looking for a place to start, these are the products women find most immediately helpful:

  • Lubricants make uncomfortable sex immediately more comfortable.
  • Moisturizers have longer-lasting effects, and can be used with lubricants to counter vaginal dryness.
  • Vibrators, as I tell women in my practice, are the reading glasses for diminished genital sensation.
  • And Kegel exercise tools help women keep their pelvic floors in shape, which is good not only for sexual response but for managing incontinence.

See how many things we can do? We don’t need to “grin and bear it,” as researcher Dr. Susan R. Davis, from the Monash University in Melbourne, fears we think. Step one is to believe—share some of my optimism!—that something can be done.

And then learn what you can, talk to your health care provider about your history, symptoms, preferences, and risks. Feel free to experiment until you find some options that make you smile.

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You say a prescription for estrogen seemed to increase your libido at first, but that effect has diminished. No, you haven’t become immune to estrogen. Unfortunately, libido is a bigger and more complicated issue than just one hormone. Many women don’t find any improvement in libido with estrogen; I tell patients it certainly won’t make it worse, and it may make it somewhat better. And it’s not uncommon for the initial effect perceived from a new treatment to wane over time.

You also ask whether where you apply the estrogen cream makes a difference to its effect on your libido. The medical answer is that because its effect depends on its entering the blood stream, it can be applied to skin anywhere it is likely to be absorbed. If you have pain with intercourse or dryness because of menopause, applying the cream to genital tissues may help, but that’s a different issue than libido.

Women’s libido is complicated (several hormones and numerous neurotransmitters in the brain are involved, as well as emotional and psychological factors), and the treatment options for low libido are currently limited. We offer a number of suggestions on our website, but I also encourage women to talk frankly with a menopause care specialist.

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Most topical or localized estrogen creams are prescribed to be used twice a week, which is the level at which they typically provide the most benefit with the fewest unintended consequences. If the usual application isn’t helping you regain comfort, a conversation with your health care provider could be in order.

Localized estrogen is most effective for vaginal atrophy; if you have other “systemic” symptoms of menopause, like hot flashes or night sweats, systemic estrogen may be worth considering. Systemic estrogen also improves vaginal health, but because it enters the system (as opposed to “localized” estrogen), there are more overall health considerations for its use.

If we had a conversation about how you measure “more effective,” I might suggest other, nonhormonal options that could be helpful to you. Moisturizers can improve tissue health, lubricants increase comfort and pleasure, warming products and vibrators enhance sensation, and massage oils encourage intimacy, for example. I encourage women to experiment with all of them!

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What you describe is going from arousal to “resolution,” without experiencing what you used to as orgasm in between.

The first thing I’d check if you came to my office is whether you’re on any medications that could interfere with orgasm. The biggest class of medications in this category are the SSRIs—antidepressants like Prozac and Zoloft. If you are, you can talk to your health care provider about alternatives that would have the effects you need without the same side effects.

Difficulty with arousal and orgasm are more common as our hormones change through menopause. The loss of estrogen diminishes blood supply to the genitals, which affects sexual response. There are a few ways to counter that loss:

  • More direct clitoral (external) stimulation can help—and not all of us are accustomed to needing that. A good vibrator is effective; we encourage women to consider vibrators with stronger-than-average vibration strength, and choose the products we offer at MiddlesexMD with that in mind.
  • Localized vaginal estrogen can also be helpful; you’ll need to talk to your health care provider to see whether a prescription is appropriate for you.
  • Keeping the pelvic floor muscles in shape is a critical piece of enjoyable sex, too. Strong muscles are part of strong orgasms–as well as preventing incontinence. We offer a new product, the Intensity pelvic tone vibrator, that uses electrical stimulation to contract the pelvic floor muscles in addition to its vibration patterns.

One more thing to consider: Women have at 50 about half the testosterone she had at 25, and testosterone plays a critical role in libido and ability to orgasm. There’s no FDA-approved product for women, unfortunately, but I prescribe testosterone off-label for patients with good results. Off-label use of Viagra or Cialis is also helpful to a few women. All of these off-label prescriptions require a conversation with your health care provider—and consideration of your overall health.

There’s every reason to be optimistic about regaining satisfying orgasm!

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In my practice, I typically ask to see a patient again three months after I’ve prescribed localized hormones. That’s so we can check in to see whether the therapy is addressing the symptoms as we intended. If it’s not, I typically look for other underlying causes or try other treatments; I’ve found these hormone products to be very effective and generally well tolerated.

Once we’ve found the right therapy, I typically see women annually to update their general health status and see whether treatments are still accomplishing their goals.

If your practitioner is suggesting something more, I’d suggest that you ask for clarification about the kinds of tests and reasons for them.

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When women in my practice have vaginal dryness or atrophy, I typically start by recommending a vaginal moisturizer. The key is to be faithful, using the moisturizer at least two times each week. Yes is the most popular vaginal moisturizer at MiddlesexMD; the fact that it’s available in pre-filled applicators is definitely a plus for women who don’t like the mess of other options!

If the dryness or atrophy is not effectively managed with a moisturizer (which can happen over time), then I add a vaginal (localized) estrogen product.

I should also mention that a new oral medication for vaginal dryness or pain was approved by the FDA this summer. Non-hormonal, it’s called Osphena and is available by prescription. Because it’s oral, there’s no mess! But you do need to make the consistent commitment, again, to regular use.

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What you describe is a natural result of the loss of natural estrogen through menopause. There are a number of localized estrogen options, including Estrace and Premarin creams, Vagifem tablets inserted in the vagina, and Estring, which is a ring also placed in the vagina.

The therapeutic dose of Estrace is 1 gram applied to the vagina and vulva two times a week; using less than that will be, as we doctors say, “subtherapeutic,” which means it won’t have sufficient effect! While the creams are effective when used as prescribed, many of my patients prefer and get more consistent doses from the ring or tablets.

You mention a family history of breast cancer. None of these options is “systemic,” which means that they can be used by women with breast cancer risk factors–even by some breast cancer patients. There’s a new option, too, that’s non-estrogen: Osphena is an oral daily medication that showed “statistically significant improvement” in vaginal and vulvar pain.

Moisturizers and lubricants can also help to increase comfort while a full treatment plan is taking effect.

It takes attention and consistency to regain comfort after being sexually inactive, but I’m sure you’ll find it’s worth the effort!

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