April 15, 2015

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health care ›   intimacy ›  


Q: Which of my medications is inhibiting my orgasm?

You say you’re taking daily doses of Wellbutrin and Effexor. Effexor is the likely culprit, since Wellbutrin is actually “pro-sexual.”  Wellbutrin increases dopamine, a neurotransmitter beneficial for sex; Effexor increases serotonin, a neurotransmitter that is negative for sex—in that it can decrease libido or ability to experience orgasm.

If you can decrease the dose of Effexor without an increase in other symptoms, that may help. Decreasing the dosage may mean other symptoms comes back, or that orgasm is still out of reach or diminished. In those cases, I offer Viagra, used off-label for women. A number of clinical trials have shown Viagra to be helpful when SSRIs (selective serotonin reuptake inhibitors, a class of treatments for depression and other disorders) lead to an inability to experience orgasm.

A newer SSRI, Pristiq, is reported to have fewer negative sexual side effects. I’ve seen that to be true, but also have worked with patients who found that health insurance was not supportive, since newer drugs are often more expensive. It may be worth exploring!

Another alternative that works for some women is to take a ‘drug holiday': skip the daily dosage of the SSRI on a weekend day when they are more likely to be sexual. This doesn’t work for everyone. Some people have withdrawal symptoms or other unintended side effects with the ‘holiday approach.’

I encourage women in my practice to consider using a vibrator, which can increase sensation and sometimes lead to orgasm. At midlife, it’s important to stay sexually active (that ‘use it or lose it’ thing), so it’s worth the effort to experiment.

I see how frustrating this dilemma is for women to manage through! I wish you patience and perseverance to find the right balance of overall health and intimacy for you.

March 16, 2015

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conditions ›   health care ›   learning ›  


Real Women, Real Answers: Live Webcast on Sex after Menopause

We women deal with many physical and emotional changes during and after menopause. Both in my medical practice and as part of the MiddlesexMD team, I'm alert for "kindred spirits" who understand the transition—and are willing to talk about what changes in hormones mean for real women leading real lives. The people at Vibrant Nation, the leading online community for women 45 and older, have been among those kindred spirits. I published articles on the VibrantNation.com site for almost five years and had some of our liveliest online discussions there. (They have recently changed their platform and, unfortunately our content is no longer available on their site.)

Among the things we've talked about is how hormonal changes—and the painful or less pleasurable sex that can come with them—can take a real toll on our relationships. And I know from the women I see in my office and the emails I get from around the world (literally!) that we're not talking enough about how sex changes and what we can do about it. We're not talking enough to our doctors, to our partners, not even with our girlfriends.

VN-BSB-ad-15_01-v7-300x250And for many of us, it's hard to find straightforward, trustworthy information about how to deal with issues like pain during intercourse, diminished orgasm, and changes in libido.

That’s about to change. I'm excited to have been asked by Vibrant Nation to lead a panel of women who will share their stories and advice for getting that spark back in the bedroom. Vibrant Nation is having its first-ever live webcast discussion, Sex After Menopause, on March 31, 2015, at 1:00 p.m. EST. We'll have real women telling their stories, with experts providing perspective and solutions. And you can participate! Pre-register by following this link (Online Form - Pfizer Attendees List - Pre-event - Barb Depree) and you'll have the opportunity to submit your own question or story and to win a $100 Amazon gift card.

Join us. Let's stop the silence and extend the conversation. Let's support each other by sharing our questions, our successes, our struggles. Let's build the community of kindred spirits!

Disclosure: This post is part of a Vibrant Influencer Network campaign. MiddlesexMD is receiving a fee for posting; however, the opinions expressed in this post are Dr. DePree's. Neither MiddlesexMD nor Dr. DePree is in any way affiliated with Pfizer and does not earn a commission or percent of sales.

March 12, 2015

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health care ›  


Q: How would I work with a menopause care provider?

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.)

December 22, 2014

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conditions ›   health care ›   learning ›  


Repurposing Pharmaceuticals: “New” Drugs for Menopausal Symptoms

Low-fat mocha or chai tea latte? Caramel-cashew delight or plain vanilla?

Everyone likes choices. As a physician, I really like to have options in my toolkit. If one drug doesn’t work or causes unpleasant side effects, it’s nice to be able to offer my patients something else.

Recently, the FDA approved two new drugs for treatment of menopausal symptoms. Of course, they come with caveats, including questions on how truly effective they are, but I love having relatively safe options for my patients with unpleasant and sometimes difficult menopausal symptoms.

The ironic part is that both drugs are old friends in new packaging—one combines estrogen with a new non-hormonal compound; the other is an antidepressant that happens to be good at alleviating hot flashes.

The first, Duavee, was developed by Wyeth, a subsidiary of Pfizer, and came on the market last year. This drug takes a different approach to the traditional estrogen/progestin combo for women who still have their uterus. The estrogen part, Premarin in this case (called “conjugated estrogen”), eases the menopausal unpleasantness, while the progestin protects endometrial hyperplasia—the overgrowth of endometrial cells. (That’s why women who have undergone a hysterectomy can take estrogen-only drugs—they no longer have a uterus.)

Duavee replaces the progestin with bazedoxifene, a nonhormonal drug with the cumbersome classification of a selective estrogen receptor modulator or SERM. A SERM acts like estrogen in some tissues and it acts just the opposite in others, so bazedoxifene is also called an estrogen agonist/antagonist. It “selects” a tissue to either promote estrogen effects or block estrogen effects.

Yeah. Confusing. I know.

Here’s how Dr. Seibel, a well-known specialist in menopause and reproductive health, puts it, “The excitement about this medication is that bazedoxifene acts like a progestin, meaning it blocks the potential negative side effects of the Premarin [the estrogen component], but lets the Premarin continue to do its good stuff.”

The bazedoxifene component in Duavee does some other good stuff as well: It also protects against postmenopausal bone loss and “significantly increases bone mineral density,” according to Pharmacy Times.

So, according to the FDA, it can be prescribed for prevention of osteoporosis for at-risk women after other options without estrogen have been considered.

There are still risks to taking hormones, and the FDA still advises that, like any estrogen compound, Duavee be used at a low dosage for the shortest possible time for relief of menopausal symptoms.

For women who want to get away from hormones altogether, now there’s Brisdelle. Developed by Noven Therapeutics, Brisdelle is another old friend in new dress-up clothes—paroxetine, better known as Paxil. The “new” part is the very low dose.

Gynecologists have been aware for a while now that antidepressants can be helpful in relieving menopausal hot flashes, night sweats, and the sleeplessness associated with them. So sometimes we’ve prescribed antidepressants off-label.

The problem with that approach has been that the dosage for depression is higher than the dosage required for relief of menopausal symptoms (10 mg. rather than 7.5 mg.). The side-effects of that higher dosage can be weight gain and, god forbid, loss of libido. “The last thing a menopausal women needs is a drug that might sabotage her diet or an already waning sex drive,” says Dr. Streicher in this article.

Amen to that, sister.

With a dedicated drug like Brisdelle, you not only get the correct dosage to douse the flames of hot flashes, but you also avoid the confusion of being diagnosed with a completely different condition. A generic prescription for paroxetine would still be cheaper, but Brisdelle provides the right dosage for the right problem (hot flashes, not depression).

No drugs are perfect, but these two “new” drugs at least have a track record. They’re relatively safe and effective, and they add a couple of good options to the arsenal.

Nothing wrong with more choices, after all.

December 12, 2014

5 comments

conditions ›   health care ›  


We Can Each Decide

In October, I traveled to Washington DC to participate in a public meeting and scientific workshop on female sexual dysfunction. The meetings came about because questions had been raised about whether the FDA was paying enough attention to women’s sexual health, and whether they’d set the bar higher for products for women than for comparable products for men (think Viagra or the 25 other prescription drugs for erectile dysfunction [ED]). ABC’s 20/20 found the meetings newsworthy enough to do a segment on the pursuit of “pink Viagra.”

I’m a pragmatic, Midwestern menopause care provider. I see women who are at all points of the spectrum from mild discomfort to despair. I make recommendations and write prescriptions for quite a range of options—from use of lubricants and vibrators to off-label testosterone. I certainly know that there’s no one-size-fits-all solution, no silver bullet, no magic pill that’s going to make every woman’s sexual experience legendary—or even comfortable.

As we’ve said before, women’s sexual desire, arousal, and response are complicated. Emotional security and intimacy, sexual history, and relationship satisfaction can make an already-complex reality even more difficult to untangle. Every woman deserves an individual approach. Every woman deserves a health care provider who can capably represent the options for treatment, when that’s needed—including describing the benefits and drawbacks. Every woman deserves to make her own choices to govern her quality of life—including her sex life.

So I watch with interest the discussion that’s transpired since the October meetings, reinforcing the messages I heard there. Sexual dysfunction is as real for women as for men. Yes, it’s true that some women find relief without pharmaceuticals. Yes, it’s true that there’s a profit motive for pharmaceutical companies. Yes, there’s a hazard in “medicalizing” women’s sexuality; we are not only biological systems. Yes, it often seems “pharma” is marketing out of control; I know I’ve seen enough ED commercials to last me the rest of my life.

And yet—if the FDA is charged with looking out for all of us, why wouldn’t that include women? And if they’re concerned with all health conditions, why wouldn’t that include sexual health? And if a pharmaceutical option is developed, and found by fair and rational standards to be both effective and healthful, why shouldn’t that option be made available to women who might choose to take advantage of it?

The FDA is accepting comments from the public—especially seeking insight from women who’ve suffered from sexual dysfunction—until December 29. You can read the questions in the FDA’s document online, and then submit your comments by clicking on the blue button at the right on this page on Regulations.gov.

Your story can help make clear what #WomenDeserve.

October 03, 2014

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conditions ›   health care ›   learning ›  


Think about What #WomenDeserve

This summer, in a blog post on the absence of pharmaceutical options for my treatment of women with hypoactive sexual desire disorder (HSDD), I said “I’m not in the room for the FDA discussions.” Thankfully, that’s about to change.

I’ve written here a number of times (as early as 2010 and as late as earlier this year) about the progress with the pursuit of “pink Viagra” and its frustrating setbacks. My message has consistently been that women’s sexuality is complicated, and no pill is going to fix everything for everyone.

But because of that very complication, as a physician, I value having options available. For one woman, simply thinking about intention and follow-through is enough to change the equation. For another, a combination of moisturizer, lubricant, and a powerful-enough vibrator is restorative. A third may require localized estrogen to rejuvenate tissues and restore comfort. You get the idea.

What that means is that the more options I have, the more likely I am to be able to work with a woman to maintain or restore the level of physical intimacy and sexual activity she wants. And I’m increasingly aware that while there are 26 drugs approved by the FDA for men’s erectile dysfunction, there is nothing that’s been approved for women facing comparable issues.

It’s not for want of trying. From the outside, it looks as though the bar is set higher for drugs for women than drugs for men. The side effects noted for drugs recently considered seemed more mild than that list we can all recite from hearing Viagra commercials since 1998. It doesn’t matter whether this is an intentional bias; what matters is that the FDA assure that it’s even-handed and supportive of women and their sexual health moving forward.

And that’s where the change comes in. Later this month, I’ll be traveling to Washington, DC, to attend a public hearing and then a workshop of women’s health experts, both intended to establish the reality of women’s experience (43 percent of us suffer from some sexual dysfunction!) and how the FDA can productively respond.

You can lend your voice to the proceedings. There’s a consortium of us who are concerned with women’s sexual health. We’re gathering signatures to a petition so that it’s clear to the FDA when we meet that this is a real problem, suffered by real women who seek a range of solutions. Add your voice at EvenTheScore.org or sign the #WomenDeserve petition at Change.org. Follow the discussion at the WomenDeserve Facebook community.

And I’ll keep you posted on the progress your voice has supported!

December 26, 2013

0 comments

health care ›   weight ›  


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!

Q: What stopped my orgasms?

You mention a variety of things that play a role, all coinciding with the change in hormone levels that comes with menopause, which you'll reach in a few more months (the milestone is one year without menstruation).

The Vagifem that's been prescribed for you should be having some positive effect with vaginal dryness; it should not interfere with orgasm. Vagifem is a very, very low dose of estrogen, delivered directly to the vagina and surrounding tissues. This is partial compensation for the estrogen delivered through the whole body when ovaries are intact and functioning.

SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant), which you mention taking, can be a barrier to orgasm. If you've taken them for a while and only recently have had issues, it could be that the combination of the SSRIs and the lower hormone levels of menopause is now problematic. There is limited evidence that Viagra can help women on SSRIs experience orgasm. It's not just estrogen that declines with menopause: Testosterone also declines. You might talk to your health care provider about testosterone therapy; among my patients, many who trial testosterone note sexual benefits, usually describing more sexual thoughts, more receptivity (a patient recently told me she's "more easily coerced"!), and more accessible orgasms.

You also said that vibrator use has become ineffective for orgasm. Among midlife women, I find that the specific vibrator really counts. There is a definite range of vibration intensity, and as our bodies change, that can make all the difference. Lelo has just doubled the "motor strength" of two of their already powerful (and MiddlesexMD favorites) vibrators for the Gigi2 and Liv2.

Best of luck! My work with women every day says it's worth exploring your options. (And, to take the pressure off, remember that intimacy without orgasm is still intimacy!)

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

November 06, 2013

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health care ›   hormones ›  


Q: Will I need frequent testing if I use localized hormones?

In my practice, I typically ask to see a patient again three months after I've prescribed localized hormones. That's so we can check in to see whether the therapy is addressing the symptoms as we intended. If it's not, I typically look for other underlying causes or try other treatments; I've found these hormone products to be very effective and generally well tolerated.

Once we've found the right therapy, I typically see women annually to update their general health status and see whether treatments are still accomplishing their goals.

If your practitioner is suggesting something more, I'd suggest that you ask for clarification about the kinds of tests and reasons for them.

Sex after Her Heart Attack: New Research; New Guidelines

Life is scary after a heart attack. You’re not sure what to expect. You may be depressed. You’re probably on several medications. You may be confused about what you’re allowed to do and when.

Like sex. When is it safe to have sex again?

Chances are, your cardiologist hasn’t discussed that topic. For one thing, your doctor is probably more concerned with saving your life at first, and then with the details of your recovery, like rehab and medications. When to resume your sex life just isn’t high on the radar of topics to discuss post-surgery.

And for another, most physicians don’t bring up the S-word at any time, as we’ve discussed before. But a new study of women who have had a heart attack confirms that “most women don't have discussions with their doctors about resuming sex after a heart attack, even though many experience fear or other sexual problems,” says Emily Abramsohn, one of the study’s researchers, in this article from Medical News Today.

Patients are often uncomfortable broaching the topic, and their caregivers also hesitate to bring it up. Their partners may also be afraid to do anything that might cause pain or induce another attack. “I had to convince my husband that I wasn’t going to die in bed,” said one woman in the study.

Now, new guidance for doctors from the American Heart Association (AHA) encourages doctors to discuss sex with their post-surgical patients and to advise them about when it’s safe to resume their sex life and how to do it.

The guidance, which is based on a review of scientific literature and is the first statement of its kind from the AHA, acknowledges the importance of resuming an active sex life. Sex is a return to normalcy and re-establishment of intimacy, and as such is an important element in the healing process.

Along with the position statement from the AHA, a new study from a group of researchers at the University of Chicago surveyed 17 women who had survived a heart attack within the past two years. The average age was 60. The study found that:

  • Most women were fearful about resuming their sex life
  • The doctors discussed sex with about one-third of their female patients
  • Frequently the conversation was initiated by the patient, who generally found the information to be unhelpful
  • Most women began having sex about a month after their heart attack; all but one had resumed sex within six months

The AHA guidelines could clear up some hesitation and confusion among physicians as to what, exactly, to tell their patients. The guidance states that sex is safe for most patients who are stable and without complications. If you can climb two flights of stairs, you can probably have sex, which is considered only moderate exercise.

But if you’re scared or unsure, then ask. “Know that you’re not alone in having fears surrounding sexual activity,” Abramsohn said. “And if you are concerned, bring it up with your doctor.”

“Dr. Ruth” Westheimer even weighed in on the topic in this article, “What I suggest is that people write down their questions and send it to the doctor in advance of their appointment. That way they'll be sure the question gets asked, and the doctor will have had time to get prepared to answer it."