Q: What help is available for difficulty penetrating?

Tightening of the vaginal opening is one of the effects women can experience from the loss of estrogen. The type of lubricants that offers the most "slipperiness" and the least resistance is silicone; Pink and Uberlube are  the most popular at MiddlesexMD in that category.

It is possible to gradually, gently, and comfortably stretch the vaginal opening by using vaginal dilators. These are available in a set of graduated sizes; start with the smallest (and plenty of lubricant) in daily exercises and, when comfortable, progress to the next-larger size.

Only rarely is surgical modification appropriate for addressing this condition. With patience, women can typically achieve comfort with dilators and lubricants.

Q: Can I revive my sex drive and orgasm after a hysterectomy?

There are a number of pieces to this puzzle--we women are complicated! First, because your hysterectomy was "complete," you no longer have ovaries, which are a major source of testosterone (up to 50 percent) for women. Losing that testosterone can be a major hit to women's desire, arousal, and orgasm. Some women benefit from adding back testosterone, but it's not FDA-approved in the U.S. and not all practitioners are familiar or comfortable with prescribing it for women.

If you're taking oral estrogen, some complicated biochemistry is at play that can further decrease your testosterone. Replacing estrogen by a means other than oral--skin patch, spray, gel--is important.

If you're not taking estrogen, orally or otherwise, that may be a contributing factor, too. Losing estrogen leads to less blood supply to the genitals, which makes arousal and orgasm more difficult.  Localized vaginal estrogen works for many women, and it's not absorbed system-wide.

Beyond the hormonal pieces of this puzzle, I often recommend warming lubricants or arousal oils, which use a stimulant to bring more blood supply to the genitals. Using a vibrator can also help; the more intense stimulation can make a difference. And I encourage women to explore self-stimulation: What you require now may be different from what it was, and the better you understand yourself, the more you can help your partner meet your needs.

Best of luck! It will be worth the time and effort to revive this part of yourself!

Q: Are the changes I see in my vaginal skin normal?

You say the skin is becoming lighter and sometimes is dry, sometimes moist or itchy. That sounds completely consistent with the changes of vulvovaginal atrophy (VVA), which results from the absence of estrogen. It's a gradual progression; it may not be particularly bothersome at first but may be more noticeable in the months and years to come.

The consequences of lost estrogen are often most noted in the vulva or vaginal tissues. Our bodies have lots of estrogen receptors, meaning estrogen plays a role there--from head to toe. But there are more estrogen receptors concentrated in the vagina and the vulva than in any other part of the body. \In and of itself, VVA doesn't require treatment. If you have uncomfortable symptoms, there are treatment options, including localized estrogenvaginal moisturizers, and more.

You might also be aware that natural vaginal pH levels rise in the absence of estrogen, which means a woman can be more susceptible to infections. Symptoms to watch for are discharge, irritation, and/or odor.

Q: Could my HPV diagnosis be behind pain after sex?

HPV is an unlikely cause for pain with or after intercourse. It's associated with abnormal pap tests, which may require further investigation—like the biopsy you say you had. Much less commonly, it can cause genital warts. If the warts happen to be at the opening of the vagina, they can become irritated and cause discomfort, but that's really very rare.

It's more likely the discomfort is related to the atrophic changes of menopause, which you may not have been aware of between relationships. In the absence of estrogen, the tissues become thin and less distensible—meaning less stretchy and able to expand—and also more fragile and easily injured. This can happen even if you don't perceive dryness.

You didn't say how long you've been sexually active; this problem may resolve itself: It's the opposite of "use it or lose it"! But because menopausal tissues don't rejuvenate quite as well as younger, fully estrogenized tissues do, you might consider using a moisturizer or localized estrogen. But I wouldn't worry about HPV being a cause.

Bioidentical Hormones: Flap? Or No Flap?

Suzanne Somers touts them in her bestselling book, Ageless: The Naked Truth about Bioidentical Hormones. Oprah promotes their use. On the other hand, the Harvard Medical School, the North American Menopause Society, and the Endocrine Society take a more cautionary position toward compounded bioidentical hormones. And I find that many of my patients are just confused.

So what are bioidentical hormones and what’s all the controversy surrounding them?

We’ve written a lot on Middlesexmd.com about the importance of estrogen to vaginal health and sexual function. We’ve also discussed various options for replacing estrogen and enhancing vaginal comfort. And we explored the latest thinking about hormone replacement therapy (HRT).

In a nutshell, estrogen is critical to sexual comfort and function, and that’s the hormone we lose during menopause. Most therapies revolve around replacing estrogen to treat menopausal symptoms.

For many years, Premarin was the estrogen replacement of choice. This is a synthetic estrogen made from the urine of pregnant mares, which, according to the Harvard Women’s Health Watch,  “contains a mix of estrogens (some unique to horses), steroids, and various other substances.”

Bioidentical hormones, on the other hand, are defined by the Endocrine Society as “compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body.” Bioidentical hormones are usually extracted from plant sources.

Moderation in all things.Pharmaceutical companies manufacture many brands of bioidentical estrogens, such as Vivelle, Elestrin, Divigel, Evamist and one brand of bioidentical progesterone (Prometrium). These are FDA-approved bioidentical hormones. About 95 percent of my patients are on these FDA-approved bioidentical hormones. All hormones, whether they are synthetic or bioidentical, are labeled with the black-box warnings mandated since the massive Women’s Health Initiative study linked slightly higher rates of breast cancer, blood clots, and heart disease to hormone replacement therapy.

So far, so good.

Confusion enters in when bioidentical hormones are custom-compounded by pharmacies. Sometimes there are good reasons for a doctor to prescribe a custom-compounded hormone, if a patient is allergic to some agent in the FDA-approved hormones, for example, or if her dosage can be lower than those produced by pharmaceutical companies.

But hormones made by custom compounders aren’t subject to FDA oversight, nor must they adhere to FDA-approved processes. These custom hormones don’t come with black-box warnings because they don’t fall under the FDA umbrella.

In actual practice, there may not be that much difference between custom hormones and FDA-approved hormones. According to the Harvard Women’s Health Watch, in a 2001 random test of 37 hormone products from 12 compounding pharmacies, almost one-quarter (24 percent) were less potent than prescribed, while 2 percent of FDA-approved products were less potent.

The other problem with custom compounds is cost. Health insurance usually doesn’t cover them, so the regimen gets expensive very quickly.

While custom compounds may be a helpful option for some women, the controversy surrounds the claims about them made by celebrities like Suzanne Somers and even by some clinicians.

In the introduction to her book, Somers writes, “This new approach to health [bioidentical hormone replacement therapy] gives you back your lean body, shining hair, and thick skin, provided you are eating correctly and exercising in moderation. This new medicine allows your brain to work perfectly and offers the greatest defense against cancer, heart attack, and Alzheimer’s disease. Don’t you want that?”

Well, who wouldn’t? But like most claims that sounds too good to be true, so is this one.

The truth is that bioidentical compounds, no matter how “natural and safe” they may sound, are still drugs. There’s no scientific evidence that their effect is any different than synthetic hormones. Also, because hormonal levels vary from day to day, even from hour to hour, attempting to customize hormonal treatments is tricky business. “There’s no stable ‘normal’ value at all for salivary or blood levels of these hormones or levels that correlate with symptoms,” says the Harvard Women’s Health Watch.

The current medical advice is to take the lowest possible dosage of any hormone—synthetic or bioidentical—for the shortest period of time to alleviate menopausal symptoms. There is, unfortunately, no way to turn back the clock—"natural" or otherwise. In the meantime, the hormones that work for a woman can significantly improve her quality of life.

E Is for Estrogen

Estrogen is the queen of hormones. From our brains to our bones to our bottoms, estrogen keeps our systems regulated, lubricated, elastic, and running smoothly. Estrogen doesn’t just trigger sexual development in our breasts, uterus, vagina, and ovaries (although it does that, too), but it also regulates the production of cholesterol in our liver; it affects mood and body temperature from the brain; it protects again loss of bone density; and it keeps our sexual organs responsive and functional.

Estrogen is actually a category—a group composed of three chemically similar hormones. Estrone and estradiol are mostly produced in the ovaries, adrenal glands, and fatty tissue of all female mammals. Estriol is produced by the placenta during pregnancy. These estrogens circulate in the bloodstream and bind to receptors located throughout our bodies.

Not surprisingly, most of those estrogen receptors are located in the vulva, vagina, urethra, and the neck of the bladder, and that's  why we talk about estrogen so much in this blog and at MiddlesexMD. It’s the critical hormone that keeps our sexual apparatus healthy and functional.

Before menopause, a healthy vagina has

  • thick, moist “skin,” or epithelium
  • tissues with many folds (rugations) that allow the vagina to expand and become roomier
  • differentiated layers of cells—superficial and intermediate
  • secretions from the vaginal walls and cervix that help maintain a slightly acidic pH balance
  • an increase in blood flow and lubricating secretions during sexual arousal
  • toned pelvic floor muscles that help to hold our internal organs in place

So, ladies, it’s easy to see that when our estrogen levels drop dramatically during menopause, virtually all of us will experience significant change to our vulvovaginal tissue. The umbrella term for that change is “vulvovaginal atrophy.” Here’s what happens to our genital area when we lose estrogen:

  • the epithelium becomes pale, thin, and more likely to tear
  • the vagina shortens and narrows
  • vaginal walls lose rugations (those folds or pleats) and become smooth
  • cells become less differentiated—there are more intermediate and fewer superficial cells
  • the vagina becomes dry without secretions to maintain a good pH balance or to lubricate during sex
  • the vulva shrinks and pubic hair thins
  • the pelvic floor loses muscle tone, so organs relax and sometimes sag (prolapse)

It’s not a pretty list, but it’s our new, postmenopausal normal. Vaginal atrophy can bring more frequent vaginal and urinary tract infections as well as more painful sex. And since painful sex usually means less sex, both our relationship and our quality of life can suffer.

Fortunately, as we’ve discussed many times in this blog and at the MiddlesexMD website, there are simple and effective ways to ease the effect of estrogen loss. These include using moisturizers and lubricants or topical estrogen products, doing our kegels, and talking to our doctors about vulvovaginal changes.

Losing estrogen and its beneficial effects is inevitable as we grow older, but losing function, sexual or otherwise, isn’t. Sex—and life—can be just as enjoyable. They just take more maintenance now.

Estrogen Where It’s Needed

Okay, so you’ve tried everything. You regularly use a good, natural moisturizer, plus a lubricant during sex. No soaps, sprays, scents, dyes, or synthetic underwear ever touch your bottom. You’re the queen of vaginal hygiene. And still you’re troubled by dry, itching, or inflamed genitals and painful penetration.

What now?

Talk to your doctor about using a localized estrogen product for your vagina. These medicines deliver low dosages of estrogen right where it’s needed: the vagina and vulva. Not only is localized estrogen medication very effective at relieving the discomfort of vaginal inflammation or atrophy, but it also restores natural vaginal lubrication and elasticity. In fact, while it won’t relieve other menopausal symptoms—like hot flashes—low-dosage vaginal estrogen is sometimes more effective in relieving menopausal genital problems than systemic hormone replacement therapies (HRT). Moreover, the dosages are so low, the side effects and complications so negligible, it is often used by breast cancer survivors.

Vaginal estrogen comes in several forms: a cream (used twice a week), or slow-release tablets (used twice a week), or a ring (which needs to be replaced every three months). Don’t, however, confuse the Estring vaginal ring with Femring, which is the high-dosage HRT in a vaginal ring form. (Confusing? It can be.) Your doctor will tailor the amount and frequency of application for the maximum effect at the lowest possible dose. It may also take several weeks for treatment to become fully effective.

A few precautions:

  • Avoid applying your estrogen cream right before intercourse, since your partner can absorb it through his penis. Estrogen rings and tablets are meant to stay in place and don’t have this effect.
  • Continue to use non-hormonal lubricants and moisturizers if necessary.
  • Have regular vaginal intercourse to augment natural lubrication and a healthy vagina.
While localized estrogen may not be the first line of defense against the unpleasant genital changes related to menopause, it’s an important option when simpler methods (like vaginal lubricants or moisturizers) fail.

Q: Can I use a vibrator with my new estrogen cream?

Yes, your vibrator or other toys are safe with estrogen creams, often prescribed for vaginal dryness.

What you'll want to be careful of is silicone-based lubricants. Whether they're safe to use with your vibrator depends on the materials used; silicone lubes will ruin the surface of a silicone toy. The instructions that came with your vibrator (or are available online) will usually tell you what's safe and what's not.

I've seen patients have good results with estrogen cream; hope you have the same!

Q: Could I be allergic to estrace cream?

Estrace, or estradiol, is an estrogen that was circulating in your bloodstream, produced by your ovaries, for 40 years or so! Any allergy is likely to be to the "vehicle," the substance that contains the estradiol as an active ingredient. I assume your reaction was local--in the area where you applied the cream.

An option that may work for you is Vagifem, a bioidentical estradiol in tablet form that you place in the vagina twice a week (usually after starting with daily use for 14 days). Vagifem comes with a very slim applicator to place it in the vagina.

Another choice might be Estring, another bioidentical estradiol in the form of a ring. The ring is placed in the vagina for 90 days and is then replaced.

Take the time to find an option that will work for you!

July 01, 2010

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