You describe your experience as “incredible pressure and pain,” and “deep aching pain.” You also said that you’ve had some varicose veins in your legs and have had some removed. Your research led you to vulvar varicosities, which does sound like a possible answer. These are varicose veins in the vulva, which are not all that common but do occur (often during pregnancy).
There are two options I’d like you to consider: The first is a good pelvic floor physical therapist. She or he can assess structurally whether there is evidence of a source for your pain. A great therapist can work magic! Really, they can.
The second option is a vein specialist. They can do an ultrasound assessment of vein function, even in the vulva, and try to help understand if that is what might be causing your discomfort.
Good luck on your journey!
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.
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 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.
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. 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.
Estrogen, as you know all too well these days, does a lot of good things for your body and your mood. Maybe you didn’t know that it also does a lot of good things for your brain.
“In preclinical studies, estrogen was shown to improve energy production, reduce oxidative stress, increase brain cell survival during damage, enhance the release of protective chemicals, and improve memory,” according to this recent article.
So, you may ask, what the heck happens in the brain when estrogen disappears after menopause? Researchers are also asking if estrogen, or the lack thereof, plays a role in Alzheimer’s disease, the most common form of dementia, which disproportionately affects women.
Neither menopause nor lack of estrogen is directly linked to dementia, or specifically, to Alzheimer’s disease. No smoking gun or causal connection has been found despite numerous studies comparing women who have taken estrogen with those who haven’t.
“…Evidence from cohorts in Melbourne, the United Kingdom, and rural Taiwan suggests that the natural menopausal transition probably does not have important effects on episodic memory or most other cognitive skills,” states this National Institutes of Health (NIH) article.
So, what does happen in the brain when estrogen production declines after menopause? Are all those “senior moments” really the result of our estrogen-starved gray matter? Does estrogen replacement therapy (ERT), have any effect on brain health? Finally, although no treatment exists for Alzheimer’s disease, could estrogen play a role in preventing or delaying its onset?
While these are all tantalizing questions that researchers are beginning to tease apart, no actionable answers are forthcoming, yet. Frankly, research results are all over the map. You may remember the groundbreaking 2002 Women’s Health Initiative that was responsible for a seismic shift in the routine use of estrogen therapy after concerns about risk of breast cancer and heart disease--some of which were misunderstood or at least miscommunicated.
Less well-known was that a cognitive component to that study (the Women’s Health Initiative Memory Study) found that the risk of dementia increased, sometimes dramatically, for women over 65 who were on hormone therapy.
However, several recent studies suggest that beginning hormone therapy at a younger age may have a protective effect on the brain. A recent study in Norway and another in Finland determined that taking estrogen before and during menopause, resulted in increased brain volume, especially in the hippocampus, which is the area associated with memory and sense of place and which is most disrupted by Alzheimer’s disease.
These conflicting results have led to the “critical window” hypothesis: that at some points in the menopausal transition, estrogen may help preserve brain function while at others, not so much.
“Most researchers seem to accept the idea that a critical window exists during which estrogen treatment is most likely to be beneficial. ‘The question is, when is that window open, and when is it closed?’ ” said Roberta Diaz-Brinton.
Diaz-Brinton suggested that healthy cells may be more likely to respond positively to estrogen but older or “sickly” cells may not. This is the “healthy cell bias of estrogen.”
Frustratingly, for those of us approaching menopause, the data continues to roll in and not much is consistent enough to define a course of action. Obviously, a bunch of variables confound the picture: how the estrogen is administered (whether by pill or patch); what kind of estrogen is administered (bioidentical, equine, or some other formula); certain genetic factors; the combined effect of estrogen plus progestogen (for women who still have a uterus); plus all the other variables of country, culture, health, and lifestyle.
The current position of the NIH, which can be expected to take a conservative position, is that “it is unknown whether estrogen effects on Alzheimer risk are modified by age of use or by use during a critical window close to the time of menopause.”
Probably the most reasonable course of action is to continue to follow general medical guidelines to take the smallest dosage of estrogen for the shortest period of time to relieve menopausal symptoms. According to the most recent studies, that’s when it might do your brain the most good. Beyond the menopausal years, evidence suggests that it either has no effect or it has a negative one.
And, for our daughters’ sake if not our own, let’s continue to speak out about the importance of research in women’s as well as men’s health. We are not the same.
Regular or decaf. White wine or red. Chocolate or vanilla.
Choices abound. Some are inconsequential—the whim of the moment. Others matter, like your choice of health care provider. I’d like to make the case that, although you may be well past childbearing years, you haven’t outgrown being a woman. Ergo, you still have very unique and specific needs that are best served by a specialist with training and experience in all things feminine.
Most gynecologists see an abrupt migration of their older patients to internal medicine or family practice providers. “…between ages 45 and 55, you start to see a very sharp decline in the number of encounters between women and their ob/gyn--and a mirror-image rise in visits to internal medicine,” says Dr. Michael Zinaman, director of reproductive endocrinology at Loyola University Medical Center in this article.
Not for one moment am I suggesting that this is a bad thing. General practitioners take a broad and thorough approach to patient care. In a typical exam on an older woman, an internist would screen for diabetes, colon and other common cancers, osteoporosis, high blood pressure and cholesterol, anemia and other blood disorders—basically, the whole enchilada. Since heart disease is the #1 killer for women, it’s a good idea to have this type of broad screening every year.
Internists also counsel with patients about lifestyle issues, such as smoking or weight control, diet or exercise (which I also do regularly). And they might refer and coordinate a patient’s care with various specialists.
So, why might a woman who no longer needs reproductive care and who may or may not even have her reproductive organs continue to see a gynecologist? Well, for all the stuff we talk about on this website, for starters.
Older women have specific needs and vulnerabilities for which gynecologists have deep and specific training and experience. The incidence of breast and ovarian cancers increase with age, for example. And although internists may do pelvic exams (and note that “may”; even when, after age 65, we no longer need a pap smear, we still need regular pelvic exams) and order mammograms, gynecologist have years of practice in detection and treatment.
Then, there are all those everyday annoyances of menopause and an aging reproductive system—pelvic organ prolapse, incontinence, hormonal disruption, and all those vexing sexual changes we address here on MiddlesexMD. When it comes to treating these quotidian challenges to health and well-being, gynecologists are simply the specialist. We’re more likely to know about new treatments and medications; we’re more likely to catch anomalies; we’re very attuned to kinds of changes that can signal something serious.
But the bottom line? This isn’t one of those either/or decisions. You can choose between a chocolate sundae and a frozen yogurt, but the choice isn’t between a gynecologist and a general practitioner.
You need both. And both healthcare providers need to be working together for you. “A collaborative approach would be very good,” said Dr. C. Anderson Hedberg, head of general internal medicine at Rush-Presbyterian-St. Luke’s Medical Center.
In one study comparing the type of screenings women tended to receive from primary care doctors as opposed to gynecologists, researchers found that gynecologists were more likely to screen for cervical and breast cancers, and osteoporosis, while primary care doctors were more likely to test for colon cancer, high cholesterol, and diabetes.
I’m thinking you wouldn’t want to miss out on any of this fun stuff, and you sure want to know early on about issues or warning signs. But in the end, you make the judgment calls about your health. You decide what doctor to see and how often and whether or not to follow medical advice. That’s as it should be.
Having the right medical team on your side simply gives you the ability to make the best, most informed choices.
For this last of our January resolutions series, we’ll break from our discussion of underappreciated body parts but remain totally in keeping with MiddlesexMD’s tradition of confronting embarrassing issues head-on and unfiltered. Specifically, those we avoid talking about with our doctors.
Admit it, most of us don’t like to discuss topics having to do with sex, elimination, mental health, gender orientation, obesity. Often these topics are surrounded by social ambivalence or downright discrimination. We want to be healthy and normal. We don’t want to have problems, and we sure don’t want to air them with a semi-stranger.
The doctor/patient relationship can be clumsy, strained, uncomfortable or superficial. Some providers are simply more skilled at coaxing out and straightforwardly addressing your intimate questions. If you find that your doctor is abrupt or unapproachable, or if you just don’t have good chemistry, you ought to—and have every right to—change doctors. Along with your dentist and auto mechanic, this is one individual you have to trust.
I want to assure you that doctors have heard it all. Not only that, we want—and need—to know what’s bothering you emotionally or physically. That’s our job, and we can’t do it effectively if you decide to soldier on. Often, that embarrassing secret can be easily treated; sometimes, it’s a symptom of something more serious that needs further testing.
Too often, however, patients wait until the “doorknob moment.” The exam is all wrapped up, and the doctor is literally almost out the door when the real question tumbles out: Oh, and I have noticed blood in my stool a few times recently; or, is it normal to have pain with sex?
If you don’t mention it, you doctor can’t address it. And if you wait until the doorknob moment, you may have to schedule a second visit so your provider can adequately assess the problem.
Here are examples of some of the questions that are either quirky or hard to bring up. Feel free to add your own in the comment section—or email me for a personal reply. While I can give you my best response, this in no way lets you off the hook from getting in-depth, personalized information from your own doctor.
Pick up your courage and a pencil and do yourself a favor: Write down all the questions, sexual, messy, and embarrassing as they may be, to ask at your next physical. You can also answer the questions in this quick and easy Menopause Map to begin framing the questions.
“In the end, we all just have to become comfortable with the fact that sex involves the genitals and the genitals are down there. It’s a big, messy thing—but it’s worth it!” says Dr. Debby Herbenick, in this article.
I’m afraid this is a complicated issue. A dozen different contributing factors are possible, and the challenge you and your wife face may be a combination of them. You’re not alone, which is, I recognize, both bad news and good news.
I’ve addressed low libido and many of the contributing factors in blog posts before. Here’s the introduction to the topic on our website; here’s a blog post with additional explanation. Here is a list of answers to specific questions readers have submitted, including certain health conditions or medications which can inhibit libido as a side effect.
You didn’t describe your wife’s overall health; I hope she’s had a recent evaluation from her health care provider and has mentioned her loss of interest in intimacy. He or she can help to determine the cause, which will then point to the best options for treatment. You may also find a couples therapist or a sex therapist to be helpful, since emotional as well as physical factors come into play in intimacy.
I do wish you the best with finding the cause and some ways to address it! Physical intimacy adds meaningful dimensions to our relationships.
This is my quiet moment—the pause between the years, the time of taking-stock. One thing I know for sure—I have a lot to be grateful for this year!
It’s been more than ten years already since I decided to specialize in the sexual needs of women in midlife—women like you and me. As I mention here, I wanted to provide clinically sound, research-driven information to women who are caught in the throes of the menopausal transition. I wanted to address our sexual issues head-on, without embarrassment or beating around the bush. I also wanted to provide a safe, tasteful environment in which you could actually buy the products I was recommending—vibrators, lubricants, moisturizers, dilators, vaginal weights.
That was the rationale behind MiddlesexMD. I envisioned a space in which to communicate with a lot more of you than I could see in my clinical practice. A place where you can ask questions or start a conversation and where I can discuss whatever’s on my mind—from research on new drugs and therapies to tips on maintaining sexual intimacy. And we did put together a shop, where you can find those safe, tested, high-quality products, and have them mailed to you in discreet packaging.
It’s been a journey, that’s for sure—rewarding, challenging, busy, and sometimes unexpected. In 2013, the North American Menopause Society awarded me the “Certified Menopause Practitioner of the Year.” Late last year, I published my book, Yes, You Can: Dr. Barb’s Recipe for Lifelong Intimacy. The book uses my recipe for sexual health and draws from the accumulated wisdom on MiddlesexMD—your questions, the blog posts, and my own thinking.
Response to the book has been wonderful. It was a banner year for interviews on various media outlets about the book and my work. I’m grateful for these opportunities to communicate to a broader circle of midlife women that they have options, that sex can still be rich and fulfilling, and more importantly, that they are not alone.
When I began this endeavor, I couldn’t have anticipated how gratifying it would be to meet such resilient, independent, inquisitive women who are tackling life’s challenges gracefully and well. I’ve been honored to share this journey with you and to provide some support and information that may make the experience easier and, I hope, more joyful for you.
So, my friends, here’s to good health and good sex. Thank you for sharing your journey with me.
I know it can seem like ob/gyn offices are full of pregnant women! And while general practitioners can be extremely helpful, sometimes you want the extra training and focus of a menopause care specialist.
I recommend finding a menopause provider in your area by going to the North American Menopause Society (NAMS) website, where you can enter your zip code and specify a mile radius to find a practitioner near you. Note that you can also check the box (NCMP) to limit the search results to NAMS-certified providers, who have completed additional focused training and receive ongoing updates on research and recommendations from the society.
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.
The American Cancer Society has released new guidelines for Mammogram Screenings. We know you’ve likely read a lot about it. I thought I’d hand it over to our old friend and writer Julie, a longtime MiddlesexMD blogging pal, who has breasts of her own and some thoughts to share on what to do when new guidelines hit the airwaves.
Guideline Headlines!!! Okay girls! Grab them and run! But which way! When? Where? But wait!!! No!
No! These guidelines are saying to maybe squish less often? For some of us? Really? To not start so soon? Who are these people?
With the latest release of Breast Cancer screening guidelines from the American Cancer Society, it’s easy to feel a little—entangled—in questions of when and whether to handle our screenings. And no wonder. The discussions are very much in the air, and the experts are agreeing to disagree. Very politely.
It wasn’t the intention of the committee to create this confusion, of course.
They truly wanted to offer up more leeway in guidelines, particularly for women with average risk of developing breast cancer—and that’s most of us. But leeway is very hard for most of us to interpret. Most of us just want very clear direction. We want safety and assurance. We want to avoid unnecessary exposure to radiation and unnecessary medical procedures. That’s not too much to ask, is it?
Well, we can’t have absolute assurances from medical guidelines. It would be so nice if we could. We can only get the best advice from smart committees working from what data they have to keep the greatest number of us safe most of the time.
So the new guidelines ease up on the youngest women, aged 40-45, saying they don’t need to start screening if they have average to low risk of breast cancer. Of course we women in menopause are already screening our breasts, have already been at it for years by now. Now we are wondering what to tell our daughters. And we will be getting different advice from at least three of the six breast-cancer-guideline-writing organizations in the US alone.
In fact all of those concurrent guidelines exist out there already, in our doctors’ heads. And online. And in our restless heads and hearts. So what do we do with all of this various information?
First… We breathe.
Then… We remember, that we are each in charge of our own bodies. Guidelines are there just as a framework of reference. In practice, we each are working on our particular realities, which must be dealt with in the particular, with a plan that takes in all of the unique, unusual, specific aspects of our own bodies, or our daughter’s, their daughter’s.
So, I’ll take me, for example.
Those guidelines would suggest, since my breasts have been around for 55 years (well, one of them. The other seems much, much older), and in my family there is no history of breast cancer at all, and I have no current cancer markers, good and good. But… I’ve had so many surgeries and lung problems my chest as been radiated enough in my lifetime to light up Tokyo on a moonless night, which is not so good, and I’ve had to have a few lumps biopsied here and there, which have markers they like to peek at now and again, so….. Yeah I’m signed up for annual scans. Am I worried? Not really. But I’m committed. My sister, with the same family history, may logically choose to scan less often. Because she’s been much healthier throughout her life.
A young relative in my family? Just turned 40. Did she need to go for her first exam? Not really, but she and her friends made a party of it at the local breast exam clinic. Wine and bites and breast squashing in paper robes. She could have put it off another 5 years, but she prefers to get this ball rolling. Preference plays a roll here. She is being cautious.
You see how this rolls. Family history + conference with your physician over your own medical history + your own ideas and feelings about medical tests at this time in your life, taken together with a careful review of the recommendations = your best plan for screening. That plan for screening? It changes year over year as you age. That’s how you do this. Review your plan each year for you. Discuss it with the women in your family. And your friends. Like. Discuss it. Out loud. Over coffee or tea. Like, “What’s your breast scan plan, Mom?”
It’s not rude.
No. It’s not.
Happy deciding, everyone.