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 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.
Your primary care provider will continue to be your health resource for the spectrum of things that can happen at any age and especially at midlife: hypertension, sinus infections, asthma, joint injuries, and so on. A menopause care provider is a specialist; gynecology is typically also supported through health insurance (but individual plans vary). Some insurance plans require that your primary care provider provide a referral for "menopause care," which I recommend begin as soon as women are aware of symptoms of perimenopause.
When you're reviewing options for menopause care, look for certification by The North American Menopause Society (and get help from the NAMS website to find a practitioner with the NCMP credential). Certification means a health care provider has completed extra training to gain competency in menopause. (Those who are "members" of NAMS have access to the specialized information the organization provides but are not certified.)
An older couple walked into the therapist’s office. The marriage had been a bit rocky from the get-go, but now the woman had completely lost interest in sex. The therapist recommended that the woman seek sexual counseling.
Now, that might have been all right except that the therapist had no understanding of the very normal changes to libido brought on by menopause and thus wasn’t able to address that possibility or access resources to either reassure or help the woman.
The couple never came back.
Sue Brayne, a British therapist and author of Sex, Meaning, and the Menopause, commented in her blog on a recent workshop she conducted: “…it continues to amaze me that in a room full of therapists on their way to fifty, or who are well into their fifties and even sixties, this workshop was the first time most of them had ever spoken about the menopause in any depth, or admitted to how it is affecting their lives.”
So, while many healthcare professionals have personally experienced menopause, very few have actually received professional training or information to help others.
In a survey of 900 women conducted by womentowomen.com, 80 percent visited their doctors for help with menopausal symptoms and 60 percent came away feeling as though they hadn’t had a “supportive, honest discussion about menopause options.”
Therapists in Brayne’s workshop complained that, “their GPs [general practitioners] had no interest in the menopause, and they were often ‘fobbed off’ with unwanted prescriptions for HRT [hormone replacement therapy].”
As patients, we are often shy about discussing sexual issues to begin with, and as we’ve mentioned before, doctors rarely initiate that conversation. Throw menopause into the mix, and you may be met with discomfort, avoidance, or the “fobbing off” that Brayne mentions.
Many doctors and therapists simply aren’t equipped to understand the array of menopausal symptoms. Menopause isn’t a disease or a medical condition. A doctor can’t “fix” it. Menopause is complex in that it affects a whole bunch of physical and emotional systems, and there’s no one-size-fits-all remedy.
That said, you have every right to expect your medical practitioner to knowledgeably address your menopausal symptoms during this transitional time. And you should be able to talk openly about them. Yes, that includes sex.
So, how do you get the ball rolling with your practitioner?
If you’re frustrated in your attempts to communicate with your regular provider, or you feel you’d benefit from a specialist with targeted knowledge about menopause, the North American Menopause Society has a menopause certification program as a way of assuring basic competency and assuring high-quality care. You can find a NAMS-certified practitioner in your area by searching here.
Medical professionals may sometimes struggle to find the information they need to support and treat their menopausal patients, but as patients communicate (nicely) that they expect support and knowledgeable treatment from their doctors, everyone is nudged along the road toward greater awareness.
And that can only help us all.
In January, I was working on an article I'd been asked to provide to OBG Management magazine. They'd asked me to talk about why I offer products through my practice—which was, actually, the same motivation that led me to found MiddlesexMD: There are some simple products available that can help women remain sexually active, but it's not always easy—or comfortable—to buy them.
As I wrote the article, I wondered how you as patients feel about products being offered through your doctors' offices, so I asked. And a number of you responded, either on the blog or directly, with your thoughts. You were overwhelmingly positive, assuming that your relationship with your health care provider was one based on trust to begin with (and I hope we're all that fortunate!).
OBG Management published my article, called "Vibrators, Your Practice, and Your Patients' Sexual Health," in their April issue. Read it if you like, and take a copy to your next doctor visit if you think it would be helpful in opening a discussion about how he or she can be more helpful to you and your sexual health!
Thanks to all of you who voiced your support or concerns. We'll keep learning together—and stay as sexually active as we choose!
I’d like to solicit your opinion.
As you know, (or… maybe you don’t) MiddlesexMD has an online store in which we sell all kinds of products geared toward the sexual needs and pleasures of older women—“for midlife women who want to enjoy sexuality for life,” as we say. And some products just for fun.
As I’ve explained before, I created this store for a generation of women who need more sexual stimulation, lubrication, and support, but who probably aren’t going to check out their local sex shop (assuming there is one) and who probably aren’t savvy or experienced shoppers when it comes to choosing items like vibrators or warming oils.
It wasn’t easy, let me tell you, but I’m proud of our selection, and I’m confident about the quality of their design and construction and the safety of their materials. Full disclosure: MiddlesexMD is a business, so there is some profit involved.
So what’s the problem?
Because I have this dual role—as a practicing physician and as MiddlesexMD, other health care providers ask my advice about product sales. I know that the doctor-patient relationship is a tender thing, and it’s based on trust. My patients trust me to use my skills on their behalf. They don’t want my commitment to their health and well-being diluted or divided by self-interest. Nor do I.
When doctors sell products, conflict of interest is always lurking. Can doctors be objective when they stand to make money by recommending this vitamin or that weight-loss aid? And wouldn’t patients feel some pressure to buy the product to please the doctor? Does the presence of the product in a doctor’s office imply that the doctor endorses it?
The fact that some doctors derive a significant portion of their income from selling these products in their offices reinforces that appearance of ethical shadow-boxing. A few “celebrity” doctors have become virtual mouthpieces for certain product lines, which often lack research as to their efficacy or even safety.
As you can imagine, the issue has engendered passionate discussion both pro and con within medical circles, and professional medical organization have yet to issue any guidance regarding the practice.
I can honestly say that my primary motivation for selling products that I’ve tested and sometimes use myself is to provide a tasteful, private, safe opportunity for women to buy intimate items that will help keep them sexually active and comfortable and that they’d have a hard time finding otherwise. I set prices comparable to other retail options.
I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. And I’ve seen first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. When my patients can walk out with products they’re ready to use, rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.
So I’d like to think I’m offering a valuable service to my patients, but can I truly be objective when I have something, however modest, to gain? Do my patients feel subtly obligated? Do I compromise my professional credibility?
What do you think? Service or self-serving? I’d really like to know.
I often recommend that people try the North American Menopause Society's (NAMS) website. NAMS has a rigorous process for certification, so the health care providers who are a part of it are likely to be committed to continuing sexual health for women like us. The website has a practitioner finder, too, so you can see whether there's a member in your area.
If that option isn't fruitful, we recently published a longer blog post with some other suggestions to explore.
Good luck, and keep looking! It's important to have a health care provider you're able to communicate and work with as you navigate the years ahead.
One of the advantages of having a medical advisor team is that I can hear reports from events I can’t attend! Michael Krychman, part of the team and medical director of The Sexual Medicine Center at Hoag Hospital and the Executive Director of the Southern California Center for Sexual Health and Survivorship, provides this update from a May meeting.
A resurgence of interest in female sexuality was apparent last month at the American Congress of Obstetricians and Gynecologists’ annual meeting. I had three presentations on female sexuality; menopausal sexual health and vaginal dryness were topics throughout the plenary and clinical courses. I completed a post-graduate course with Dr. Haywood Brown, Chair of Duke University, on Sexuality through the Lifecycle, which addressed topics like sexuality and pregnancy and postpartum; chronic medical illness and sexual function, including breast cancer; lesbian sexuality; and treatment paradigms for dysfunction. A brief, informative lecture on everything you always wanted to know about male sexuality for the female health care provider was also included in the core curriculum.
A sold-out luncheon session focused on emerging sexual pharmacology. Among the topics were new data about Flibanserin [which we’ve talked about before as “pink Viagra”]; intravaginal DHEA ovules, which may help with vaginal atrophy; PT141/bremelanotide as an option for arousal issues; and new lower-dose intravaginal estradiol for localized hormone treatment. There was also significant discussion about Osphena, which may be the first oral medication for vaginal atrophy.
A clinical seminar on Elderly Sexuality had over 100 attendees, who were very interested in learning about prevalence and incidence of sexual issues as women age; a comprehensive treatment paradigm was also presented. There were several updates on vaginal dryness and testosterone, too.
Even in the exhibit hall, sex was evident! Lelo, a premier self-stimulator company, was swamped with visitors during all hours. They introduced Intimina, their new sexual wellness line of products [which includes the Kiri, Raya, and Celesse vibrators]. Semprae Laboratories, makers of Zestra essential arousal oil, was swamped with interest over their new in-office physician retail program and distributed thousands of samples. The L’il Drugstore booth was busy with moisturizer Replens. Neogyn, a new vulvar soothing cream, was also on the exhibit floor. I even saw the Journal of Sexual Medicine floating around!
Medical support for women's sexuality has faced some challenges in the last few years. The FDA hearing on Flibanserin and the disappointing efficacy results of Libigel were a few recent set-backs, but in spite of them, attention to female sexual function and treatments for dysfunction looks to me to be going strong.
It is definitely an exciting and interesting time. The field of female sexual health and wellness is alive and thriving.
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.
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:
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; reviews are often available if you Google the doctor or practice name (just use your judgment on what's a credible review source).
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.”