I referred a few weeks ago to the controversy surrounding recommendations for the frequency of mammograms. A conversation over the weekend reminds me that there’s a similar fog surrounding the change in guidelines for Pap guidelines, introduced about two years ago and now working its way through health insurance policies.
We used to all take for granted that our annual Pap screen was the centerpiece of our annual physical exam. In fact, many women calling my office for appointments referred to the appointment that way: “my annual Pap test.” And the prevalence of annual Pap screenings did have an effect, lowering the cervical cancer rate in the U.S. by more than 50 percent over the past 30 years, according to the American Congress of Obstetricians and Gynecologists (ACOG).
Current guidelines call for Pap screening every three to five years, depending on your age and other health conditions—and there’s a lot of agreement about that from the American Cancer Society, ACOG, the American Society for Clinical Pathology, and, likely, your insurance company.
But! This doesn’t mean that there’s no need for an annual “well-woman” visit, including a pelvic exam. Exactly what happens at each annual visit should vary according to your age and your health history. What’s common, though, in addition to updating overall health statistics, is a thorough inspection of the vulva and vagina, including palpation of the area, including the lower abdomen, rectal, and bladder regions. We’re looking for any early indication of abnormality, but if your general health is such that you wouldn’t treat a condition if discovered, no further evaluation is necessary. A clinical breast exam is also part of the annual exam.
In addition to the “clinical” part of the exam, though, there are benefits that you can especially appreciate as you navigate perimenopause and menopause. First, your body is changing, so having an annual “date” to check in on your body helps you be aware of what’s happening. When you share your observations with your provider—which I hope you do—they’ll be part of your medical record, which gives you both a view of trends over time. With our busy lives (jobs, parents, kids, grandkids, volunteer projects), without a checkpoint, we can find we’re simply adapting to changes without even being conscious of them.
And the second benefit is that, with regular communication, your health care provider can be a genuine partner in keeping you healthy—physically, emotionally, and sexually. Seeing him or her at least once a year is part of that; the other part is setting the expectation that your appointment includes answering your questions—about everything from your tennis elbow to your vaginal dryness.
If you don’t find that expectation being met, get bossy. An annual exam—and, just as important, the conversation that goes along with it—is part of managing your own health. Having a health care provider with the time, expertise, and patience to answer your questions is not too much to ask. And when you’re comfortable with and confident about your health care provider, you won’t be a stranger.
We women deal with many physical and emotional changes during and after menopause. Both in my medical practice and as part of the MiddlesexMD team, I'm alert for "kindred spirits" who understand the transition—and are willing to talk about what changes in hormones mean for real women leading real lives. The people at Vibrant Nation, the leading online community for women 45 and older, have been among those kindred spirits. I published articles on the VibrantNation.com site for almost five years and had some of our liveliest online discussions there. (They have recently changed their platform and, unfortunately our content is no longer available on their site.)
Among the things we've talked about is how hormonal changes—and the painful or less pleasurable sex that can come with them—can take a real toll on our relationships. And I know from the women I see in my office and the emails I get from around the world (literally!) that we're not talking enough about how sex changes and what we can do about it. We're not talking enough to our doctors, to our partners, not even with our girlfriends.
That’s about to change. I'm excited to have been asked by Vibrant Nation to lead a panel of women who will share their stories and advice for getting that spark back in the bedroom. Vibrant Nation is having its first-ever live webcast discussion, Sex After Menopause, on March 31, 2015, at 1:00 p.m. EST. We'll have real women telling their stories, with experts providing perspective and solutions. And you can participate! Pre-register by following this link (Online Form - Pfizer Attendees List - Pre-event - Barb Depree) and you'll have the opportunity to submit your own question or story and to win a $100 Amazon gift card.
Join us. Let's stop the silence and extend the conversation. Let's support each other by sharing our questions, our successes, our struggles. Let's build the community of kindred spirits!
Disclosure: This post is part of a Vibrant Influencer Network campaign. MiddlesexMD is receiving a fee for posting; however, the opinions expressed in this post are Dr. DePree's. Neither MiddlesexMD nor Dr. DePree is in any way affiliated with Pfizer and does not earn a commission or percent of sales.
The conversation about women’s sexual health has continued, sometimes with heat, sometimes with light. For the first time I can remember, the International Society for the Study of Women’s Sexual Health, of which I’m a member, responded directly to a New York Times op ed piece, calling it false and demeaning (The New York Times published a number of responses this weekend).
I’m grateful to my colleagues who are setting the record straight.
As a practicing physician, I have conversations every day with women who are navigating changes in and challenges to the intimacy they want.
Some women have no problem wanting sex. They may encounter pain with intercourse, diminished capacity, or more difficulty experiencing orgasm. As a doctor, I have plenty of treatments options I can recommend and see what works best. Many of the options are neither prescription-only nor pharmaceutical: moisturizers and lubricants, dilators, and vibrators can do a lot. If those don’t work, there are some drugs that could.
Other women, though, come to me because while they love their partners, they no longer get the sexual urge. They find it difficult to respond when their partners initiate. If I close my eyes, I can see their faces, hear the grief in their voices. They’ve told me about their own sense of loss, of incompleteness; they’ve told me their concerns about the unintended messages their partners are receiving; they’ve told me about their fears for their relationships.
And of course I do the obvious assessments, ask them the obvious questions, make the obvious suggestions. I check their overall health to see if there’s an underlying condition that could explain their loss. I check out—and ask them about—medications they’re taking, which sometimes have unintended consequences. I probe for signs of depression. I inquire about their relationships, alert to any clue that it may not be a healthy one.
And sometimes, I do find an underlying cause. I’m able to treat a medical problem, make a referral for counseling, provide compassion to a woman who acknowledges that a relationship is over.
But other times, there’s no apparent reason for a loss of desire. And for those women, it doesn’t occur to me to say “Nothing is wrong with your sex drive,” which is what the New York Times op ed piece asserted. If nothing were wrong, they wouldn’t be in my office, asking—sometimes pleading—for help.
There’s not a lot in my toolkit to respond to those women. And I’d like some options, because I think #womendeserve them. There have been very few silver bullets in my line of work—solutions that work all the time for every woman. I don’t expect that. I do firmly believe that women—with support from their health care providers—can make decisions about what might help them and the trade-offs that affect their quality of life.
Each woman can decide. For herself. From among options not limited by lack of priority or double standards at the FDA. And not limited by the opinions, however well-intentioned, of other women or men.
A heart attack, whether it’s your partner’s or your own, is a devastating challenge for any couple. Recovery may be slow. Anxiety and fear are inescapable. Depression is common. The partner who is suddenly thrust into the role of caregiver may, at times, feel overwhelmed. Amid so many physical and emotional challenges, sex may feel like a low priority.
But it shouldn’t. What both of you need most of all is comforting, and nothing comforts like the touch of the one you love.
Both partners may be afraid of risking a recurrence. Not knowing what to do, they wait. Sadly, most are not getting appropriate advice from their doctors. In a recent study of patients aged 55 or younger, only 12 percent of the women and 19 percent of the men talked to their doctors about sex, and patients were more likely than doctors to bring it up (and I'd wager the numbers grow smaller with older patients). As one man said, “The subject was never mentioned in ten weeks of after-care sessions for life style and food advice and recuperative gym exercises.”
When sex did get talked about, two-thirds of the doctors gave advice that was more restrictive than the American Heart Association guidelines. Jalees Rehman writes, “The kind of restrictions recommended by doctors in the study—and presumably by medical practitioners who weren’t polled—are not backed up by science and place an unnecessary burden on a patient’s personal life.”
Blanket restrictions are unreasonable because every patient and every heart attack is different. It’s vital to discuss with your doctor your case in particular. After an uncomplicated heart attack, one week may be long enough to wait. Or you may need longer. The important thing is to be guided by where you are in your recovery.
Having sex is like doing mild to moderate exercise. If your doctor gives you the okay—and ask if he or she doesn’t give you the answers you need!—and if you can handle such activities as climbing stairs and carrying groceries without chest pain or feeling out of breath, sex should be fine as well.
You will be adjusting to new medications. Antidepressants may lower libido, and beta-blockers may interfere with erections. If you’re in open communication with your doctor about sexual issues, dosages may be adjusted or medications switched.
Various stressors are unavoidable, but sex can relieve stress and soothe both patients and their partners. The years of cultivating awareness of your own and your partner’s body will pay off. Care in tending to your relationship in the years before a crisis is like money in the bank. You never know when you might need it.
Sex is exercise, and exercise strengthens heart muscle. Sex also strengthens relationships. It’s a medicine no couple should be without for long.
When the one you loved—and the one who loved you—has died, how do you get through Valentine’s Day? If you’re in this situation, please accept our condolences. Perhaps just when it seems it couldn’t get any more difficult, you’re assaulted by images of love everywhere. Cards, ads, commercials, conversations are all painful reminders of the love you’ve lost.
There’s probably nothing that will ease the pain, but there may be a way of slightly shifting the way you experience it, if you’re up for trying.
First, have a plan. Ask yourself, “How do I want to spend the day? What are the things that help me?” Sometimes, that’s being with others who have gone through what you’re going through. If you can’t find that among your friends, consider looking for an online grief group, which can be a wonderful source of support.
“Isolation is such a huge part of grief,” says Ann McKnight, an experienced social worker and psychotherapist in my community. “Part of the depth of the pain of grief is feeling alone, like you’re the only one who has ever felt this way.” Connecting with others going through the same thing will help you feel less isolated. (Ann recommends GriefShare.org for a range of resources.)
If you do decide to spend time with friends, choose a friend who won’t have any expectations of you and who will give you room to do what you need to do, whether that means crying during your time together or canceling at the last minute. “Hold whatever plans you make loosely,” says Ann, knowing that you may want to change them—and that’s fine, too.
Second, remember that love comes in many forms. On Valentine’s Day, the focus is on romantic love, so it’s easy to lose sight of that. “We don’t only receive love,” Ann says. “We are also a source of love for other people in our lives.” If you have the energy, show your love to someone—a friend, a sibling, a mentor. It doesn’t have to be a big gesture. Even reaching out with a short phone call can help shift the focus of the day from what’s missing to what you still have.
Finally, don’t be surprised if the actual day isn’t as bad as you fear it will be. Ann says that many people find the anticipation of a holiday to be more difficult than the day itself. “So if on Valentine’s Day you think, ‘Hey, I’m not having a horrible day,’ that doesn’t mean you didn’t love the person you lost,” Ann says. “Grief cannot be predicted.”
Do you have suggestions that might help others? Please share them!
No conversation about dementia is easy, especially when it regards someone you love. Talking about sex is no piece of cake, either. But any conversation about Alzheimer’s or dementia ought to include sex.
Because sex will very likely be an issue that caregivers have to deal with at some point. A recent patient told me that sex remains a very special connection with her husband, who is in the early stages of Alzheimer's; she looks to preserve that connection as long as possible.
We are sexual creatures all our lives. Alzheimer’s doesn’t change that fact, although it will alter the experience and expression of sex in a relationship—both for the person with dementia and for the partner. It’s better to be emotionally prepared and to have your resources in place than to be taken by surprise by loss or uncharacteristic or embarrassing behavior.
So, let’s talk.
A diagnosis of Alzheimer’s disease is heartbreaking. Its progression is long and unpredictable. There is no cure, although some drugs slow its advance. As one daughter said, “It’s like my father was taken away, little bits at a time.”
Unfortunately, it’s also becoming more common. In 2014, 5 million Americans over 65 were living with Alzheimer’s disease, two-thirds of whom were women. With the graying of America, those numbers will only increase.
You can’t predict the course of the disease or how it will affect your partner’s sexuality. Sex may be something that brings you both comfort, as my patient found. The body has its own memory, and the familiar movements and routines, the physical contact, may be reassuring and helpful to both of you.
But your partner may also become cold and withdrawn, confused and clumsy, or aggressive and uninhibited as the disease progresses.
He or she may lose interest in sex or become unresponsive—neither resisting nor responding nor initiating physical contact. This hurts, and it feels like rejection, even though you know it’s the disease talking. It may help to remember that intimacy comes in many and varied forms—as simple as brushing his hair behind his ears or a reassuring squeeze.
For all of us, touch remains a primal and powerful form of human connection. Your partner may be comforted by gentle, loving touch, and it may be an important way for you to stay connected as well. Hold hands, hug, cuddle, rub his or her back.
As your partner becomes more dependent and childlike, or the burden of physically caring for him or her becomes more demanding, you may lose interest in sex as well. Or you may lose interest in sex with your partner. You may feel guilty about this, but you may also feel frustrated or even turned off by your partner or by the intimate tasks of daily care.
This is normal and understandable. It’s tough to cope with daily life, with the grief of witnessing the transformation and ultimate loss of a lover and life-partner.
But there is another moral and legal morass to be aware of as well as you juggle your own sexual and emotional needs with the changing and sometimes ambiguous needs of your partner. Marital sex has to be consensual, but what happens if your partner no longer has the capacity to consent? Laws against marital rape at that point become murky, as this unsettling story illustrates.
At the other end of the spectrum, people with diseases like Alzheimer’s may lose inhibitions, especially sexual inhibitions. They may strip or fondle themselves in public; they may become sexually aggressive or make inappropriate comments to family, caregivers, and strangers. They may want to have sex, and then forget they just did. They may ask who you are while you’re having sex.
These actions are embarrassing, painful, frustrating, exhausting, and even scary. It’s hard to know how to respond and keep your cool.
Sometimes, your partner may not be acting out sexually at all, but may simply need to go to the bathroom or be wearing clothes that are hot or uncomfortable. You’ll need to assess these needs quickly, while both reassuring your partner, deflecting his or her confusion or embarrassment and dealing with the reactions of others.
Did I mention that you’ll need physical and emotional resources in place before the disease gets too advanced?
You may need help figuring out how to engage and reassure your partner, how to shield others, like grandchildren and caregivers, from inappropriate behavior, and how to maintain your own equilibrium during it all.
To comfort and engage your partner and to maintain intimacy and connection, you could
And please don’t neglect your own health and emotional well-being. Alzheimer’s disease is long-term, and you’ll have to seek out long-term ways of coping.
Like you, I feel the pull of the New Year, the impulse to fresh determination and resolve. (It partly comes, I think, from the satisfaction of packing away the Christmas decorations—much as I love them during the holidays!) I see the January magazine covers with headlines that offer a more organized, less stressed, healthier life.
And I see evidence of the season in the order trends here at MiddlesexMD. There are clearly a number of us who are making resolutions, and our fresh-start, new-focus impulse includes our sexual health.
As we’ve said before, being specific helps when making resolutions. So I dug into the data to see what other women have been choosing during this season of self-improvement. Here are the most popular choices, consistent over the past three years, and the reasons why I’d guess they land at the top of the list:
Vaginal moisturizer: I love that this lands at the top of the list. Moisturizers are used regularly (we put lotion on other body parts daily!) to strengthen vaginal tissues and keep them healthy. They supplement the moisture that we lose as our estrogen levels decline. Yes Water-Based moisturizer is our most popular, but we offer other options as well.
Lubricant: Lubricants are the very easiest defense against uncomfortable sex, which many of us experience with vaginal dryness. The most popular resolution purchase is the Personal Lubricant Selection Kit, and for good reason, I think. With the kit, you can sample seven different varieties, and then receive a full-size bottle of your favorite. If lubricants are new to you, this is especially helpful: The drugstore options are overwhelming, and I hate to buy a full-size bottle of something I end up not liking! All of our lubricants are selected for safety, efficacy, and fit for the needs of midlife women.
Kegel tools: I’m also happy to see these among the most-purchased at this time of year. Our upper arms are more visible, so we get a visual prompt to add them to our tone-up list. Our pelvic floors are out of sight and often out of mind—until we’ve lost enough muscle tone to experience incontinence or diminished orgasm. Strong pelvic floors do so much for us! And Kegel tools help us focus on the right muscles to flex, as well as reminding us to do those pesky flexes. Luna Beads Vaginal Weights are among the products most purchased at this time of year (and are actually the most popular of our Kegel tools throughout the year).
Just because these have been popular, of course, doesn’t mean they’re right for you; take some time to think about your own starting point and priorities. But you can also take some comfort in knowing there are simple steps you can take, and you’re not alone in the journey!
I recently read a book review recounting one woman’s harrowing passage through perimenopause. The Madwoman in the Volvo is a graphic and humorous account of emotional upheaval, distress, seismic life changes, and finally, the author is cast gently upon the slightly less fraught shores of menopause. Perhaps sadder (or more thoughtful), probably wiser, and definitely optimistic about the future.
So, in honor of this season, which is guaranteed to nudge all but the most stoic among us off the ledge, I have two messages for all of us hot-flashing, sleep-deprived, hormonal gals.
If you feel as though you’re losing your mind, you aren’t alone. Hear that? You are not alone. In fact, you are legion—there are many of us.
There are, in fact, a silent (or, more likely, howling) army of women who feel just like you. I recall the patient who was referred to me by her new therapist, who had refused to treat her until she got her hormones straightened out. (Previously, she had been told to see a therapist by the police.)
I recall a close friend, the very picture of motherly benevolence, who hissed in my ear, “If that kid doesn’t stop yammering at me, I’m going to tape her mouth shut.” She was referring to her sweet but talkative adolescent daughter. I was shocked. A few years later, I was feeling like that myself.
You can assess your lifestyle and experiment with healthy change. You can eat kale and take vitamin B12 and black cohosh. You can meditate and do yoga. You can stop smoking and reduce your alcohol and caffeine intake. You will feel healthier, and your symptoms might become more tolerable. In case you haven’t noticed, I’m a big advocate of healthy lifestyle choices.
But, if you, like many other women, continue to feel like you’re hanging on to sanity with bloodied fingernails, and those you love are suffering right along with you, by all means see your doctor and find out what pharmaceutical options might help you.
Read this article, written by a woman with access to all the current research on hormone replacement therapy (HRT) and an enviable journalistic pedigree. Here’s what she has to say about her decision to go back on HRT:
I would like to be able to tell you that I weighed these matters thoughtfully, comparing my risks and benefits and bearing in mind the daunting influence of a drug industry that stands to profit handsomely from the medicalizing of normal female aging. But that would be nonsense, of course. I was too crazy. I went straight to the pharmacy and took everything they gave me.
Perimenopause—the hormonal roller-coaster years preceding menopause—can be a long and bumpy ride. It usually begins somewhere between 45 and 55, but can start much earlier. These are the years of unpredictably cresting and crashing hormones, when the crazies come out in all their glory. This stage can last from 2 to 10 years.
Menopause officially beings in the thirteenth month (one year) after your last period.
Which doesn’t mean you’re out of the woods. Many women still have hot flashes and emotional turbulence. But life should slowly settle down as your body adjusts to its new, post-hormonal self.
So, that’s my second holiday message: You aren’t crazy, and eventually you’ll be okay. Wiser, maybe more self-actualized, and really, really okay.
With that, a very happy holiday from MiddlesexMD to you. And as the Madwoman in the Volvo said, “Have some cake, for God’s sake.”
Low-fat mocha or chai tea latte? Caramel-cashew delight or plain vanilla?
Everyone likes choices. As a physician, I really like to have options in my toolkit. If one drug doesn’t work or causes unpleasant side effects, it’s nice to be able to offer my patients something else.
Recently, the FDA approved two new drugs for treatment of menopausal symptoms. Of course, they come with caveats, including questions on how truly effective they are, but I love having relatively safe options for my patients with unpleasant and sometimes difficult menopausal symptoms.
The ironic part is that both drugs are old friends in new packaging—one combines estrogen with a new non-hormonal compound; the other is an antidepressant that happens to be good at alleviating hot flashes.
The first, Duavee, was developed by Wyeth, a subsidiary of Pfizer, and came on the market last year. This drug takes a different approach to the traditional estrogen/progestin combo for women who still have their uterus. The estrogen part, Premarin in this case (called “conjugated estrogen”), eases the menopausal unpleasantness, while the progestin protects endometrial hyperplasia—the overgrowth of endometrial cells. (That’s why women who have undergone a hysterectomy can take estrogen-only drugs—they no longer have a uterus.)
Duavee replaces the progestin with bazedoxifene, a nonhormonal drug with the cumbersome classification of a selective estrogen receptor modulator or SERM. A SERM acts like estrogen in some tissues and it acts just the opposite in others, so bazedoxifene is also called an estrogen agonist/antagonist. It “selects” a tissue to either promote estrogen effects or block estrogen effects.
Yeah. Confusing. I know.
Here’s how Dr. Seibel, a well-known specialist in menopause and reproductive health, puts it, “The excitement about this medication is that bazedoxifene acts like a progestin, meaning it blocks the potential negative side effects of the Premarin [the estrogen component], but lets the Premarin continue to do its good stuff.”
The bazedoxifene component in Duavee does some other good stuff as well: It also protects against postmenopausal bone loss and “significantly increases bone mineral density,” according to Pharmacy Times.
So, according to the FDA, it can be prescribed for prevention of osteoporosis for at-risk women after other options without estrogen have been considered.
There are still risks to taking hormones, and the FDA still advises that, like any estrogen compound, Duavee be used at a low dosage for the shortest possible time for relief of menopausal symptoms.
For women who want to get away from hormones altogether, now there’s Brisdelle. Developed by Noven Therapeutics, Brisdelle is another old friend in new dress-up clothes—paroxetine, better known as Paxil. The “new” part is the very low dose.
Gynecologists have been aware for a while now that antidepressants can be helpful in relieving menopausal hot flashes, night sweats, and the sleeplessness associated with them. So sometimes we’ve prescribed antidepressants off-label.
The problem with that approach has been that the dosage for depression is higher than the dosage required for relief of menopausal symptoms (10 mg. rather than 7.5 mg.). The side-effects of that higher dosage can be weight gain and, god forbid, loss of libido. “The last thing a menopausal women needs is a drug that might sabotage her diet or an already waning sex drive,” says Dr. Streicher in this article.
Amen to that, sister.
With a dedicated drug like Brisdelle, you not only get the correct dosage to douse the flames of hot flashes, but you also avoid the confusion of being diagnosed with a completely different condition. A generic prescription for paroxetine would still be cheaper, but Brisdelle provides the right dosage for the right problem (hot flashes, not depression).
No drugs are perfect, but these two “new” drugs at least have a track record. They’re relatively safe and effective, and they add a couple of good options to the arsenal.
Nothing wrong with more choices, after all.
In October, I traveled to Washington DC to participate in a public meeting and scientific workshop on female sexual dysfunction. The meetings came about because questions had been raised about whether the FDA was paying enough attention to women’s sexual health, and whether they’d set the bar higher for products for women than for comparable products for men (think Viagra or the 25 other prescription drugs for erectile dysfunction [ED]). ABC’s 20/20 found the meetings newsworthy enough to do a segment on the pursuit of “pink Viagra.”
I’m a pragmatic, Midwestern menopause care provider. I see women who are at all points of the spectrum from mild discomfort to despair. I make recommendations and write prescriptions for quite a range of options—from use of lubricants and vibrators to off-label testosterone. I certainly know that there’s no one-size-fits-all solution, no silver bullet, no magic pill that’s going to make every woman’s sexual experience legendary—or even comfortable.
As we’ve said before, women’s sexual desire, arousal, and response are complicated. Emotional security and intimacy, sexual history, and relationship satisfaction can make an already-complex reality even more difficult to untangle. Every woman deserves an individual approach. Every woman deserves a health care provider who can capably represent the options for treatment, when that’s needed—including describing the benefits and drawbacks. Every woman deserves to make her own choices to govern her quality of life—including her sex life.
So I watch with interest the discussion that’s transpired since the October meetings, reinforcing the messages I heard there. Sexual dysfunction is as real for women as for men. Yes, it’s true that some women find relief without pharmaceuticals. Yes, it’s true that there’s a profit motive for pharmaceutical companies. Yes, there’s a hazard in “medicalizing” women’s sexuality; we are not only biological systems. Yes, it often seems “pharma” is marketing out of control; I know I’ve seen enough ED commercials to last me the rest of my life.
And yet—if the FDA is charged with looking out for all of us, why wouldn’t that include women? And if they’re concerned with all health conditions, why wouldn’t that include sexual health? And if a pharmaceutical option is developed, and found by fair and rational standards to be both effective and healthful, why shouldn’t that option be made available to women who might choose to take advantage of it?
The FDA is accepting comments from the public—especially seeking insight from women who’ve suffered from sexual dysfunction—until December 29. You can read the questions in the FDA’s document online, and then submit your comments by clicking on the blue button at the right on this page on Regulations.gov.
Your story can help make clear what #WomenDeserve.