I Will Ask My Doctor about that Embarrassing Problem

Resolution #4

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.

Doctors have heard it all. That's our job.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.

  1. I’ve never had an orgasm. Is that weird? No. Female orgasm is a tricky business. Most women fake an orgasm at some point; about 5 percent of women never have one. But just because you’ve never had an orgasm doesn’t mean you never will. Here and here is some starter information. With some coaching, some understanding of your physiology (most women orgasm clitorally, not vaginally, for example), and some practice, chances are good that you’ll awaken those slumbering nerve endings.
  2. Do I look normal? “Normal” encompasses such broad and beautiful variety that there’s almost no such thing. Vaginas and labia, breasts and bellies come in a wide range of sizes, shapes, and colors. They aren’t often symmetric, and size and color can change with age and sexual activity.  Don’t believe me? Take a look at this art installation of real female genitalia. 
  3. Why am I growing facial hair? This is another side-effect of normal, hormonal changes during menopause. Often, facial hair becomes thicker and coarser as well. You should mention this to your doctor just to monitor the changes and rule out other causes. 
  4. Does it matter if I use drugs recreationally? Yes, it matters to your doctor. We need to know what’s going into your system, so we can correctly diagnose problems and be aware of possible interactions with other pharmaceuticals. This has nothing to do with law enforcement and everything to do with your healthcare—and sometimes even your life. We need to know about even benign recreational drug use, such as marijuana. 
  5. Sometimes I leak and sometimes I smear. Female urinary incontinence is very common. The number of people who suffer from fecal incontinence, however, is harder to estimate because, surprise!, patients are too embarrassed to talk about it, and their doctors don’t ask. If either is problematic for you, ‘fess up. Talk about it. Treatment is available.
  6. I’m postmenopausal, and I’m bleeding. Definitely an issue to discuss with your doctor. Most postmenopausal bleeding is a result of thin, dry vaginal tissue, but more serious causes have to be ruled out.
  7. Why does my vagina make a strange sound during sex? Vaginal tissue is made of pockets and folds. (That’s how it expands to accommodate an 8-pound baby!) When air gets trapped in the pockets, penetration can push it out. The sound is called queefing, and it happens to lots of women. 
  8. Am I ejaculating during sex? It’s possible. Female ejaculation is defined as fluid ejected from the urethra during climax. Colloquially, it’s called squirting. The phenomenon isn’t common but has been reported often enough that it isn’t a myth, either. Frankly, not much is known about why it happens or what the fluid is, exactly. Consider yourself special and stay tuned for more information.

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.

 

 

 

Q: What do you advise for my wife, who’s not interested in sex?

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 asked. Dr. Barb answered.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.  

 

 

December 29, 2016

0 comments

gratitude ›   health care ›   menopause ›  


So Grateful for You!

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!

Here's to good health and good sex.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.

 

 

December 22, 2016

0 comments

health care ›   menopause ›   NAMS ›  


Q: How do I find a menopause doctor in my city?

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.

You asked. Dr. Barb answered.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.

Q: Do you recommend water pills for bloating?

I rarely recommend water pills unless a patient is in heart failure and we need to decrease the fluid load on her heart and kidneys.

Bloating is usually related to gastrointestinal issues, and water pills don't address those issues. When the kidneys are functioning properly, they're getting rid of excess fluid; water pills put you at risk for depleting needed fluid or becoming dehydrated. Better options are to reduce salt intake and (counter-intuitively) to drink water.

My take on water pills for weight loss is the same: It's not a safe long-term solution.

What do I recommend? So sorry, but there's no magic! Eat well, exercise often, and see your health care practitioner to diagnose and find healthy and long-term ways to address symptoms!

Needle in a Haystack: Looking for a Health Care Provider

We’ve discussed when you might want to look for a new health care provider. MiddlesexMD advisor Dr. Sheryl Kingsberg minces no words on that point: If your health care provider isn’t addressing your sexual health concerns, find a new one. If your current physician isn’t listening or is talking down to you, find a new one. If you are uncomfortable and can’t communicate with your provider—you guessed it—find another.

Gulp.

Changing physicians is a daunting task. The process is fuzzy, and credible information is hard to come by. Maybe that’s why we put up with less-than-ideal situations for so long.

But the relationship with your doctor is too important to settle for an uneasy status quo. Trisha Torrey, who writes extensively about the issue, says it’s like choosing a spouse, except that you may be more intimate with your provider.

If you’ve been dissatisfied with your provider or are just putting up with a situation because you’ve been avoiding the task of finding a new one, here’s a plan of attack.

If possible, out of fairness to your current physician, try to address with him or her the reason for your dissatisfaction. If you aren’t a good “fit” with her personality or style of practice, a heart-to-heart might not be very productive. It’s unlikely that he can change such basic traits. But if you have a problem with her staff or have health care issues (such as sexual complaints) that haven’t been addressed, you should give your doctor an opportunity to discuss the causes of your dissatisfaction.

Also, as Torrey points out, “nice” doesn’t necessarily equal “competent.” A good bedside manner is pleasant and soothing, but for my money, I’d rather have competency.

If you’re convinced that you need a different provider, don’t leave your old provider until you’re sure you have a new one. You don’t want to come down with a cough or find a lump without a regular physician. According to a 2008 article in the New York Times, “Studies have found that it is hard to get an appointment at short notice when cold-calling, and that patients with a regular source of care get better care, even when they are uninsured.”

Then, as you begin your search, consider these issues:

  • Insurance and hospital affiliation. Finding out what providers are covered by your insurance is probably your first order of business, unless you’re okay with paying for medical service out-of-pocket. Call your company for a list. Does the hospital a physician is affiliated with make a difference to you? That could also factor into your search.
  • Age. Do you want an older person with more experience but who may or may not be as familiar with the latest treatment options? Or do you want a younger provider, who may be around for your golden years, but who lacks long-term experience (at this point).
  • Language-gender-culture. Are any of these variables important to you? Would you prefer a provider of the same gender? Do you have religious or cultural preferences or prohibitions? Do you have a hard time understanding accents?
  • Special health concerns. If you have diabetes or allergies, do you want your primary care provider to have more expertise in that area? Some general practitioners have extra training in various subspecialties.
  • Location and hours. Do you want a provider near at hand, or are you willing to travel to someone you’re comfy with? Would evening hours be a bonus so you don’t have to take time off work?

Once you’ve mulled over these parameters, your next challenge is to find solid, trustworthy information about the providers on your short list. The bad news is that it may be easier to get information about a washing machine you want to buy than about a doctor you’re considering. Websites that provide information and ratings on physicians are in their infancy, and sites that feature patient reviews have to be carefully vetted for objectivity.

“The truth of the matter is that people are hard pressed to make well-informed decisions when they choose a doctor, and they’re doing it blind,” said Joyce Dubow, a senior adviser in the office of policy and strategy at AARP in an article in the New York Times.

When you call your insurance company for participating providers, ask if they have a review system or an “honor roll” of providers. Some companies are starting to do this.

Some online sites rate physicians, but they vary in quality and credibility. You wouldn’t trust a review of a washing machine from the company that sells it; neither should you find a doctor on a site hosted by a pharmaceutical company. Pay attention to who created the website, who funds it, who makes money from it, how complete it is, and how current it is. Check out healthgrades.com for basic information and some reviews or healthline.com.

Doctors must be licensed to practice in a state, but board certification indicates a higher level of competency. Most providers are board-certified, and yours should be as well, either with the American Board of Medical Specialties for MDs, the American Osteopathic Organization for DOs, or the American Board of Physician Specialties, which accepts both disciplines. A doctor may be certified with other boards as well, but these three are widely recognized and demand a certain level of competency and achievement. To find a health care provider with specific menopause-care knowledge, you might start with the North American Menopause Society's website at menopause.org; there's a practitioner search you might find helpful.

Word of mouth is still a common and effective way to get information about local providers, especially if the word comes from someone in health care. I found a terrific dentist from a hygienist who taught at a dental school. Another woman found her internist from a trusted pharmacist. Ask family and friends who they see and how they like the person.

Check social media sites and search engines like Google. It’s easy and worth a shot, just make sure you’re getting information about the right person.

Finally, schedule consultations with the providers on your short list. You’ll probably have to pay for the appointment, but you’ll be able to assess the provider’s attitude and personality, the office environment, and, very importantly, the attitude of the staff.

Bring a list of questions, such as whether she schedules same-day appointments for illness, how he handles emergencies, whether you’ll see the doctor or members of the staff (physician’s assistants or nurse practitioners), how she handles prescriptions, where he went to medical school, how long she’s been in practice (if you haven’t ferreted this out already). Ask about board certification and any special training. And tell him or her you want to feel free to discuss matters of sexual health.

Finding a provider is a challenge, but it’s a critical and long-term relationship, so it’s worth putting in the effort upfront in order to avoid ongoing dissatisfaction down the road. And take heart from Dr. Sheryl: “If a women is smart enough to have found the MiddlesexMD website, she’s savvy enough to ask friends and other health care providers and to do some basic research to find someone she’s comfortable with.”

When to Say Goodbye—to Your Health Care Provider

The provider-patient relationship is delicate and fraught with opportunity for misunderstanding. On one hand, you have a busy professional in a somewhat risky, stressful profession who is pressed for time and is trained to speak a foreign language—medical mumbo-jumbo.

On the other, you have ordinary people who may or may not be good at communication and who are paying a lot of money to entrust to this person their most precious possession—their health.

On one hand, it takes time to become familiar with someone’s personality and communication style. And it takes time to develop trust, which is a critical ingredient in any relationship that will last a long time, including this one.

But on the other hand, the stakes are too high to overlook for very long a bad attitude, questionable treatments, or ongoing discomfort on your part.

So how do you know when to finally pull the plug and find another health care provider? And how do you go about that process, anyway?  We’ll answer the first question in this post and the second in a later post.

The top reasons to look for another health care provider:

  • Your health care provider interrupts or doesn’t listen. Your questions are prepared and succinct. You aren’t rambling on or complaining about your job, yet your provider is glancing at the clock, seems preoccupied, or keeps checking his or her Blackberry. Or—you’ve barely begun to ask your questions, and your health care provider interrupts. (Some studies indicate that providers interrupt their patients within 23 seconds after a conversation begins.)
  • Your health care provider is arrogant, argumentative, or unapproachable. Your health care provider must be able to listen to challenging questions and to answer them thoughtfully and without defensiveness. A health care provider who doesn’t welcome questions from his patients, who blames the patient, or who becomes hostile, defensive, or argumentative either has a personal problem or doesn’t understand the first thing about a professional relationship. If you like being bullied, stick around; otherwise, head for the hills.
  • You can’t get in for an appointment. You may have to schedule a routine physical several weeks in advance, but you want to be able to see your health care provider when you’re ill. At that point, even a few days are too long. If you can’t see your health care provider when you need to, that’s a problem.
  • Your health care provider’s staff is unfriendly, unhelpful, or incompetent. Unreturned calls, lost paperwork, billing errors, curt or snippy responses to questions, and long stretches on hold—these annoyances seriously impede your relationship with your health care provider. You owe it to your provider to let him or her know about your experience with the staff, but if nothing changes over time, you’ll have to assess whether the relationship is worth the aggravation.
  • And finally—your health care provider is unwilling or uncomfortable addressing your sexual health. Sexuality is a big part of your identity and a major contributor to your quality of life. Yet, as we’ve discussed before (and will again), most providers don’t bring it up. And they should. Dr. Sheryl Kingsberg, sex therapist and MiddlesexMD advisor, takes no prisoners on the issue. (More on this later, too.) “If your health care provider is that uncomfortable or indifferent to your quality of life, then I’d consider getting a new provider.”