May 13, 2019

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Q: If I even get an orgasm, it’s weak. Any ideas?

There are many reasons women have a decline in the ability to orgasm. Most often it is aging and all that goes with it: the loss of hormones, changes in vasculature (blood vessels) to the area. This is a common and frustrating condition for women.

You asked. Dr. Barb answered.

It sounds like you have addressed some of the hormone issues with Estrace vaginal cream. This loss can be related to other medications; there’s a long list of medications that interfere in sexual function. The primary offenders are mood meds, pain meds, and cardiovascular meds (again, this list is very long).

I have found systemic testosterone therapy to be effective for about 50 to 60 percent of my patients. This is considered off-label (not approved for women for this condition) use of testosterone, and not all providers are comfortable or familiar with using testosterone. Another option is Viagra, again, off-label; there are women who respond favorably to using this medication at low doses. Wellbutrin is an antidepressant that for some women (again, variable from woman to woman) will improve sexual response

Vibrators: Stimulation for more satisfactionHave you used a vibrator? A vibrator provides more direct clitoral stimulation, which is generally necessary for women to achieve orgasm. For many women this—and patience—is a very helpful tool.

May 09, 2019

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Q: Is it too late for me to try hormone therapy?

You say you’re seven years into menopause. You’re no longer having hot flashes or night sweats, but you’re aware of heart palpitations, occasional insomnia, anxiety, irritability, weight gain, and mental fogginess. You’re wondering if it’s too late for you to try hormone therapy and whether it could help with the symptoms that are of concern for you.

First of all, congratulations on upping your exercise regimen! That can make a difference in a number of aspects of health--as well as your feelings of strength and vitality. Exercise tops the list as lifestyle changes that are beneficial for menopausal symptoms, so I applaud your efforts and encourage you to continue.

You asked. Dr. Barb answered.The symptoms you share are absolutely on the list of many women who transition through menopause, or are, in other words, “hormonally related.” There isn’t, generally speaking, a “too late” in the timing to consider hormone therapy (HT). The exception is for women who are more than ten years beyond menopause and have known cardiovascular disease. For this group of women, initiating hormone therapy too long after menopause may introduce some increased cardiovascular risk.

The response to HT for palpitations, insomnia, mood disruptions (and by the way, anxiety and irritability are the top two I hear), weight gain, and mental fog is somewhat variable. We would expect some degree of benefit, but whether all of these symptoms respond favorably is hard to say.

Yours is the precise situation where I advise women (assuming no contraindications) to consider a course of HT to see how you feel. It usually takes two to three months to get a sense of benefit; there may be a dose adjustment in that time.

For many women it is well worth the trial to see how you respond and how much better (or not) you feel. Good luck!

May 06, 2019

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Q: What’s with this burning sensation?

You describe a burning sensation when you urinate, which occurs for several days after intercourse. You’re using a lubricant and have had the MonaLisa therapy treatments.

You asked. Dr. Barb answered.These symptoms you describe sound consistent with possible atrophic vaginitis, vulvodynia, or a UTI caused by intercourse. Many women are not finding complete resolution of their atrophy with the MonaLisa Touch therapy. It may be helpful to add a prescription therapy; there are many safe and effective options.

Vulvodynia is a condition of inflammation at the introitus (the entrance) of the vagina, causing burning pain with and after intercourse. For some women the action of intercourse actually causes a UTI, a bladder infection that may be causing those symptoms.

You’ll need a discussion and a careful exam and assessment with your health care provider. Once the cause is determined, you can pursue the appropriate solution.

April 25, 2019

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Q: Can I feel again?

You say that genital sensation is diminished, and you’re hoping for a surgical “fix.” You also experience some dryness, and wonder whether that “fix” could also affect lubrication. You’re also weighing the potential benefits of hormones.  

There aren’t surgical options to restore genital sensation. The “vaginal rejuvenation” approaches have no clinical data yet to support their benefit. I was on a phone call just recently with about 15 providers from across the country, discussing the topic of “vagina rejuvenation.” There are now some very difficult complications that have come from some of these treatments. I would caution you on this; we just don’t have enough good information to say it is a safe and effective option. While I absolutely empathize with your desire for a quick and lasting “fix,” unfortunately that just isn’t likely given available options.

Loss of sensation is a natural part of aging. Countering the loss is an individual exploration.

Hormone therapy absolutely improves loss of sensation. The genitals have more estrogen receptors than any other area of the body, which means that the impact of estrogen is greater in the genitals than in any other area of the body! Especially in menopause (or other times of low estrogen), hormones (including testosterone) are a big ingredient of sexual function.

Exercise is a critical component of overall wellness (see this blog post on the topic). Exercise improves energy and self-esteem, releases helpful hormones, and does more that translates into improved sexual health and function.

Loss of sensation is a natural part of aging, as well as of chronic diseases like heart disease or diabetes; it can be a side effect of medications. The changes that lead to the loss of sensation happen over years. That means for each individual, countering that loss is a bit more complex than a single simple answer that works for everyone. For many women, vibrators work wonderfully to heighten sensation. Trying a warming or arousal lubricant might be helpful now that your genital tissues are healthy.

I hope this is helpful.

April 18, 2019

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Q: Will these menopause symptoms never stop?

You say you’ve been menopausal for 20 years, and on HRT for part of that time. You still have night sweats and hot flashes, nearly every day and night. You’re missing your sex drive. Your doctors have told you these symptoms may or may not stop.

I’m afraid I have to agree with your doctor: Over time, most women will have fewer and fewer bothersome symptoms of menopause, but for others the symptoms will be for life. We don’t have any way to predict for whom the symptoms will resolve or when that might happen.

While lifestyle—diet and exercise—matters, it isn’t the complete solution. Congratulations on losing weight and building an exercise habit! I suspect your symptoms would be worse if you hadn’t lost the weight or were not exercising.

While estrogen is the most effective treatment for hot flashes, some women will benefit from other treatment options such as certain antidepressants, gabapentin, clonidine, and the herbal product Relizen. You could speak with your provider about considering a non-estrogen option.

Good luck!

April 16, 2019

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Q: Which moisturizer would be safe for me as a cancer survivor?

All of the vaginal lubricants and moisturizers we carry are safe for women who have had uterine or breast cancer. None of them contains soy.

Soy is converted to an estrogen-like substance in about 25 percent of women who ingest it, that is, about 25 percent of us have an enzyme in our GI tract that converts soy to an estrogen-like substance. It is only oral/ingested soy that may be a concern to you; the vagina doesn’t function in the same way.

April 11, 2019

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Q: Can you suggest a product for hot flashes?

You say you’d been using Relizen, but tried another over-the-counter product that didn’t work as well. When you went back to Relizen, it wasn’t as effective. Relizen is actually my first recommendation for non-hormonal hot flash management; patients in my practice have had great success. I have had nearly no success with Amberen, the other product you tried. I’m not sure why Relizen wouldn’t work now when it previously had. Have you been on it for 12 weeks or longer? Sometimes it can take that long to have benefit.

You asked. Dr. Barb answered.There are dozens and dozens of herbal products that claim hot flash relief; virtually none of them have clinical data to support claims of benefit. I am not opposed to women using herbal products, they just can’t be depended upon to work very well. The most widely used non-hormonal treatment of hot flashes is Effexor (venlafaxine), a prescription antidepressant that for about half of women reduces hot flashes—but is has its own side-effect profile that needs to be considered. Talk to your health care provider about that as an option. Prozac, Lexapro and Paxil also may provide some benefit. I have had patients who have had quite good success with acupuncture as well.

Of course the most effective treatment of hot flashes is estrogen. And there is exciting research for non-estrogen options in treating hot flashes. They influence temperature regulation in the brain, but those are likely a few years before coming to market.
April 08, 2019

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HRT: The (Current) Upshot

In 2013, I wrote about the conclusions a roundtable of international experts had reached about hormone replacement therapy. The gathering was put together by the Society for Women’s Health Research (SWHR), an extremely reputable organization. After the roundtable, the SWHR advocated putting “HT back on the table so that women can discuss with their providers the option of symptom relief and possible long-term health benefits.”

I agreed and still do. The information I’ve seen since then only reinforces my belief that, while it’s not right for everyone, it may be right for some, and for that reason it’s a conversation worth having with your healthcare provider, who can help you evaluate the risks for you.

Your doctor will look at your current health—your weight (women who are 20 pounds or more overweight when perimenopausal are twice as likely to develop breast cancer after menopause), lifestyle (e.g., exercise and diet), and any menopausal symptoms, such as hot flashes and disrupted sleep.

Your doctor will also want to discuss your family medical history, including, for example, whether any immediate family members have had Alzheimer’s disease, strokes or heart attacks, osteoporosis, or breast cancer. Those are not necessarily indicators that you shouldn’t take HRT, as we’ve discussed in recent posts:

Alzheimer’s:  As the authors of Estrogen Matters have pointed out. “...[no current treatment] significantly delays or prevents Alzheimer’s disease except estrogen, which can decrease the risk of Alzheimer’s disease by up to 50 percent.”

Heart health: The research shows that when you begin HRT when you are under the age of 60 or within 10 years of entering menopause (when you haven’t had a period for 12 consecutive months), it significantly reduces coronary artery disease and overall mortality—possibly adding as many as three or four years to your lifespan, according to some experts.

Don't dismiss HRT without getting the most current information. Decide what's best for you.

Bone health: No therapy has proven to be better at preventing osteoporosis and fractures in the spine and hips than estrogen replacement therapy. In order for it to be entirely effective, however, women have to begin taking it in menopause and continue for the rest of their lives. We need to think of osteoporosis as a chronic condition, like hypertension or diabetes.

Breast cancer: When the Women’s Health Initiative found no increased risk of breast cancer when it updated its study in 2006. Furthermore, meta-analyses, which compare data from multiple studies, show that women who began HRT three to five years after their diagnoses and remained on it for an average of three years had a 10 percent decrease in chance of recurrence.

All courses of treatment have risks and benefits. My suggestion: Don’t dismiss HRT because you’ve heard it’s bad. Get the most current information. Have a conversation with your doctor, who can help you decide what’s best for you!

April 04, 2019

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Q: Can I resume HRT after breast cancer?

You asked. Dr. Barb answered.You say you had a lumpectomy in two quadrants and radiation therapy for treatment of breast cancer five years ago. Congratulations on being cancer-free at this point! You’re wondering if you can resume the estrogen and progesterone therapy you were taking before your breast cancer. You remember it as improving your “sex life, bone density, energy, mental outlook, and mental clarity."

This is a difficult decision, with no easy answer. It might depend on the details of your cancer, e.g., the estrogen/progesterone receptor status, whether lymph nodes were involved. For more widespread disease, with a greater risk of recurrence, it is less likely seen as an option. I certainly have breast cancer patients in my practice now on HT. They felt like the potential risk was worth the significant benefit they gained in symptom management with the HT. But this is where it is very individual.

Could you have a conversation about taking HT for at least 3-6 months to see if this really does significantly improve how you feel and function (you won’t have the answer to bone health improvement in that time)? If it doesn’t really improve your quality of life, then you know, and maybe you discontinue it. Oncologists, in my experience, generally are opposed to HT for breast cancer survivors.

Have you read Estrogen Matters? If you haven’t, you might want to. You would benefit from learning about the broader picture of hormones and risk.

Good luck in your decision-making!

April 01, 2019

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Q: What can I do to manage mood swings and anxiety in perimenopause?

You say you still have monthly periods, and also have “horrible mood swings and anxiety.” You’re feeling sympathy for your husband! There are three options that come to mind to address your anxiety and mood:

The first option might be using an oral contraceptive, the safety of which depends on your health risks and requires a discussion with your health care provider. Oral contraceptives suppress your ovarian function so you no longer “cycle,” reducing the hormone fluctuations and improving mood.

Another option is using estradiol, which is used continuously all cycle long. We feel most of the disruptive symptoms are due to a fall in estrogen, so if we can support estrogen levels throughout the cycle, it can significantly improve mood.

The third option is using a “mood medication” to treat the underlying anxiety and mood swings. Usually this is with a medication from the class of meds called SSRIs (Selective Serotonin Reuptake Inhibitors) which includes Prozac, Lexapro, Celexa, Zoloft and many others.

Whichever of those options you might pursue, it’s most important to address lifestyle. Exercise is at the top of the list to benefit mood, recommending 45 to 60 minutes 5 days a week. Make sure you are getting 7 or more hours of sleep/night. Reduce consumption of sugar and processed carbs, eating whole foods as much as possible. Manage stress and practice yoga—it really can help!

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