MiddlesexMD

Normalizing Menopause in the Workplace

For our mothers, pregnancy was the workplace unmentionable. Once a married woman began to “show,” she was expected to leave her job and begin her new life as a stay-at-home wife and mother. Now, our daughters often have family leave time, breastfeeding rooms at work, sometimes even on-site daycare.  

Still, we have a long way to go. Despite progress on many fronts, menopause remains the workplace unmentionable. It makes people uncomfortable. It can be embarrassing; it isn’t well-understood; it is the butt of stereotypes and jokes; it is inevitably linked to being old, infertile and irrational. Heck, too often, we don’t even understand it ourselves.

In the workplace, the universal approach to menopause seems to be “don’t ask; don’t tell.” If you can’t see it, it ain’t happening.

There are, however, a few problems with this approach.

In our mother’s time, women over 50 were a rarity in the workplace. Our mothers didn’t talk about menopause. They didn’t discuss it with their doctors, spouses, or with us, by and large. There weren’t many options for treatment, anyway.

Now, however, while menopause is still in the closet, a lot of valuable employees at the peak of their careers are going through it. Now, most (75 to 80 percent) of women of menopausal age are working. If menopausal symptoms affect job performance and satisfaction, and if many of these problems could be addressed with more flexible policies and a supportive environment, then why isn’t it happening? Why are so many women struggling through the workday when fairly simple solutions could be implemented?

Menopause is prolonged and unpredictable. There is no handbook; it isn’t over in nine months—it can, in fact, last anywhere from four to eight years! Some women sail through without missing a beat while others struggle mightily with emotional swings, sleep issues, brutal hot flashes and night sweats, and a severe hit to self-confidence. Most of us fall somewhere in the middle, and most of us would appreciate a little understanding on the job.

Because we are numerous and at the peak of our career, one would think that accommodation, or at least conversation, would be happening in the workplace. But alas, in the US we are far behind our Western counterparts overseas. In Europe, awareness may be in its infancy, but at least it’s on the radar.

For example, a poll of just over 1,000 women between 50 and 60 conducted by BBC Radio in Great Britain found that over 70 percent of women didn’t discuss their menopausal symptoms with their employer and about 33 percent hadn’t talked about it with their doctor, either. Half of the women surveyed said that menopausal symptoms had affected their mental health and one-quarter said that it made them want to stay home.

"It was such a waste of all that talent and experience that these women had in serving the public,” said Sue Fish, the former police chief who established the force’s first menopause policies in this article. "I was horrified to find out women were leaving early because of the severity of their symptoms. Some had been rebuffed by line managers or they'd chosen not to talk about what they were going through.”

It’s a touchy issue, to be sure. Most of us wouldn’t want to be singled out for special treatment, and most of our colleagues and bosses wouldn’t want to draw attention to our difficulty or make suggestions about fixing it. Yet, competent, productive women still struggle through work situations that could be made bearable with some awareness and a few, simple adjustments.

A web entrepreneur says in this article, “I have friends in senior roles who have had to attend meetings with closed windows where they were almost expiring from heat and drenched in perspiration, fearing that wet patches might appear – but this does not prevent them from continuing to work effectively.”

So, what’s the balance, and how do we begin to move the needle so our daughters don’t have to sweat it out (pun intended) in an oblivious workplace?

The Faculty of Occupational Medicine (FOM), the educational body of the Royal College of Physicians in the UK, has put together some fairly commonsensical suggestions in its “Guidance on Menopause in the Workplace” that were adapted from the European Menopause and Andropause Society.

The guidelines are addressed to both employers and to menopausal-aged female employees, since both sides share ownership of a solution. Guidance for employers emphasizes an atmosphere of openness and dialog, along with training for management. It also suggests that employers provide some access to ventilation and temperature control, some flexibility in work hours, choice in types of fabrics and the ability to layer clothing when a uniform is required, and some ability to move around for sedentary workers.

Menopausal employees are encouraged to learn about this transition and to reach out to their doctors for help and information, to develop techniques, such as note-taking and using a calendar, to compensate for memory lapses, to reach out to colleagues, sympathetic managers and HR personnel for help and camaraderie when possible rather than trying to suffer in silence. The guidelines also suggest using mindfulness techniques to reduce stress and to consider lifestyle changes that are known to ease symptoms: weight loss, not smoking, reducing alcohol use, and exercise.

Working toward a workplace that is accepting and open to menopause is a worthy goal, and now, given our numbers, is an opportune time to crack that resistance. We did it before, and for our daughters’ sake, we can to do it again.

Q: How can I restore arousal after a complete hysterectomy?

The loss of hormones (estrogen and testosterone) with a hysterectomy and bilateral salpigoophorectomy (removal of ovaries) is definitely a “hit” to sexual function for women (I assume based on your message that your ovaries were removed). The genitals are, as we say in medicine, abundant with hormone receptors. In other words, hormones play a big role in the health and function—both urinary and sexual—of the genitals. So now, moving on without those hormones, what to do?

For most women, it’s direct stimulation of the clitoris that leads to experiencing orgasm. In the absence of estrogen, there is less blood supply, and, in turn, loss of sensation and ability to arouse or orgasm.

• A warming lubricant can stimulate circulation and therefore sensation.
• If your orgasms are weak, you might use the Intensity regularly on your own to build your pelvic floor muscles, which are what enable us to experience orgasm.
• Probably the most reliable tool to help in achieving an orgasm will be a vibrator. The genitals need more direct and intense stimulation now, and a vibrator is usually a great solution. There are many great options to consider on the website.

This can also be a time to consider treating the genitals with prescription treatments such as localized estrogen or the non-estrogen options, Osphena or Intrarosa. Using testosterone off-label can help women with arousal and orgasm as well.

I’d encourage a conversation with your healthcare provider to see if there are options that may be helpful for you. 

Good luck! I’m glad to hear that your husband is supportive in addressing this frustration for both of you!

Q: Can antidepressants have caused my husband’s loss of desire?

I’m so sorry that you’re experiencing this loss in your relationship. Both depression and the medications used to treat it can be culprits in a loss of desire, and given the relatively short time frame in which you noted the change (one or two weeks), the antidepressant is the likely explanation for your husband.

The situation that you describe is probably best addressed with the help of a therapist; someone who does sex therapy would be most helpful (you can find one certified by the American Association of Sexuality Educators, Counselors, and Therapists through their website).

As you’ve begun to experience, the longer this dynamic goes on, the more anger and resentment builds. Having a therapist to help you navigate the conversations is extremely helpful. And your suggestion of a therapist sends your partner the clear message that intimacy is really, really important for you and your relationship.

There’s some evidence that Stronvivo, a nutritional supplement for cardiovascular health, can improve both libido and function in both men and women; that could be a consideration as well.

Good luck!

Sex and Your Hysterectomy: Getting Sexy Back

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.

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.

Q: What size dilator should be my goal?

I wish there were an exact “science of measurement” that would answer your question definitively. The vagina is typically elastic--especially when we’re younger--and will stretch to accommodate any (or nearly any) size required, but there can be male/female matches that are outside of that range.

As we get older, our vaginas become less distensible and less elastic. The tissue itself becomes less elastic as we lose estrogen, and we lose the “pleating” we had when we were younger (I’ve used the analogy of going from a pleated skirt to a pencil skirt). Dilators work by gently and gradually stretching the vaginal walls, making them open enough (called patency) to allow for comfortable intercourse.

Because of the variations in tissue elasticity, atrophy, a woman’s anatomy, and her partner’s anatomy, the goals are comfort and pleasure, not a specific dimension. Dilators come in sets of graduated sizes, so a user can move from one to the next-larger as she gains comfort with each. Some women will progress through the entire range of sizes; others will be satisfied before that.

We offer a variety of dilators, because women’s preferences vary. Our most popular, the Amielle kit, includes five sizes and a removable handle that provides more length for maneuvering. For those who prefer a solid dilator, we offer a six-inch-long option in a set of five or a set of seven, again depending on need. And for some women, the texture of silicone and its ability to be warmed makes the Sinclair Institute set of five their preference.

I hope this is helpful! I’ve very happy to hear that you’re still tending to your sexual health.

Sex and Your Hysterectomy: The Options

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.

Sex and Your Hysterectomy: A Primer

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.

Q: Will vitamins be effective for hot flashes and other symptoms?

You mention joint pain, weight gain, and food cravings in addition to hot flashes as symptoms of menopause. Menopause has such a variety of symptoms, depending on each individual. Lifestyle matters more; exercise is more important; adequate sleep and good nutrition—all of these have a greater impact to quality of life now than they did previously.

I wish I could tell you there is good data suggesting vitamins have a favorable impact on menopausal symptoms, but the trials looking at the specific supplements you mention and others suggest no benefit greater than placebo. But, hey, placebo has about a 30-percent response rate in any trial, so there is certainly no harm in using them. They provide some general vitamins that will not be harmful, and may help if you aren’t getting them in your diet.

The symptoms you mention could all potentially benefit from hormone therapy (HT). The loss of estrogen is huge for most women, and the loss of progesterone to some extent as well. For many women the only way to address symptoms adequately is to consider HT. More and more data suggests that HT is beneficial for women specifically with weight gain; that was a lead article in one of my journals just this week.

It’s a complicated journey that is nuanced, and each woman needs to assess her own symptoms and goals and determine the best approach to managing through menopause. It’s difficult to address all of the treatment options in a single Q&A. You might find the North American Menopause Society (NAMS) website helpful: menopause.org. They cover many issues related to menopause.

Good luck!

Got that “Not-So-Fresh” Feeling?

Humankind has been trying to cover up its natural odor ever since we crawled out of the cave. Maybe this made sense when bathing was considered dangerous and soap was made from animal fat and wood ash. But in our obsessively hygienic and more enlightened time, why all the fuss about odor, specifically that of our nether regions? And why all the products meant to make our bottoms smell like a spring breeze, whatever that means? (Watch this Saturday Night Live clip for a hilarious take on the topic.)

As far as I can tell, these products follow a long, inglorious line of more or less successfully convincing women that they stink. In a 1930s ad, the “Love Quiz” asks why her man is avoiding his lovely wife’s embrace. The answer is that he’s no longer happy in the marriage because she’s neglected “proper feminine hygiene.”

The solution? “Every wife can hold her lovable charm simply by using ‘Lysol’ disinfectant as an effective douche.” Yeah, that Lysol.

You can’t make this stuff up.

Eighty-odd years later, have we really come such a long way? We may not be squirting floor cleaner up our yoni, but there are no lack of products on the market to camouflage our natural odor. Now, just as back in the day, the intent is to make us feel self-conscious and embarrassed about ourselves. To shame us into buying products we don’t need and that sometimes aren’t good for us.

Our vaginas don’t smell like a spring breeze, nor should they. Our vaginal smell comes from a delicate balance of certain bacteria called lactobacill—the same bacteria found in yogurt. When you think about it, a natural vaginal odor has that same slight pungency. In the vagina, lactobacilli produce lactic acid and hydrogen peroxide, to give us a slightly acidic garden that works with our bodily ecosystem to keep out bad bacteria and the fungi (yeast) that produce the really smelly stuff, sometimes accompanied by a ferocious, burning itch.

While our vaginas are quite resilient, if enough lactobacilli are killed off by medication, those nice-smelling douches, excessive sugar in our diet (encouraging sugar-loving yeast), trapped moisture in our crotch, or even blood or semen, which are fairly alkaline, the resulting bacterial mash-up can cause both odor (fishy or foul) and itch.

In that case, your doctor may advise treating the bacterial or fungal infection or using an over-the-counter product, like Balance Moisturizing Personal Wash, to restore the natural pH balance in your vagina.  

Vaginal smell can also be affected by:

• Sweat glands. We have a lot of them in the crotch area—the same kind as those in our armpits. Just so you know, sweat is basically odorless, but the bacteria living on our skin like our sweaty selves and produce yet another substance that gives sweat its distinctive odor. Wear cotton panties, take a shower, and change underwear after a workout. Let your crotch breathe—don’t wear tight clothes or pantyhose; go pantless when you can.
• Medications. Obviously, antibiotics can change vaginal flora. If you take antibiotics, ask your doctor about replacing vaginal (and gut) flora with probiotics, yogurt, or RepHresh. Antihistamines can dry the vagina. Some herbal therapies can change vaginal odor.
• Foods. If certain foods, such as asparagus, garlic, or curry, make your urine smell, they could also affect vaginal smell. No reason not to eat them, they just create a temporary odor.
• Hormonal changes. The vagina is exceptionally sensitive to hormonal changes, as you probably know all too well. Menstruation, hormone therapies, birth control, even sex can change the bacterial garden. Loss of estrogen during menopause makes vaginal tissue thin and dry, thus more susceptible to bacterial and yeast infection. With menopause, we may have to adjust our vaginal housekeeping somewhat with regular use of vaginal moisturizers, topical estrogen, and sexual lubricants.

Left to its own devices, our vaginas are hardy and self-sufficient. They wash away dead cells and grow new ones. They don’t require special hygienic measures—just the normal shower wash of the external parts with warm water and a gentle soap. Just make sure the soap is fragrance-free and not antibacterial.

I’m betting that by now most of us have grown comfortable enough in our own skins and with our own natural smells not to be overly influenced by commercial messaging. Not that it is any less relentless, nor is there any lack of products and procedures to alter our appearance. By and large, we’ve just become wiser and less susceptible to the barrage. So maybe pass along the message to our younger sisters that they are beautiful and smell fine just the way they are.  

Q: What can you tell me about Intrarosa?

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.