Q: Can I enjoy intercourse again without expensive prescriptions?

You asked. Dr. Barb answered.You say you’re hoping to enjoy intercourse again after a five-year hiatus, but that you experienced some discomfort with your last gynecological exam. The prescriptions offered to you (which I assume were localized estrogen) are not in your budget, so you’re wondering about other options.

A vaginal moisturizer, used regularly, can help you regain some tissue elasticity. Any of the moisturizers we offer might be an option for you; they’re intended to be used regularly, from daily to several times a week.

Along with thinner and fragile tissues, in menopause, without estrogen and without sexual activity, the vagina will become more narrow and shortened. You may need the gentle stretching of dilators to help restore vaginal capacity.

I’m hopeful that, with some effort and regular attention, you can restore vaginal health to resume pleasurable intercourse!

December 15, 2016

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estrogen ›   hormones ›   HT ›   menopause ›  


Q: Should I Go Back on HT?

The symptoms you describe--moodiness, depression and anxiety, hot flashes, sleep interruptions, less sensitivity in nipples and clitoris--are all consistent with stopping the hormone therapy (HT). Sensitivity to the effects of hormones varies among women, and you’re definitely in the “responder” category!


You asked. Dr. Barb answered.You mention that you discontinued the HT because of concerns for long-term health. It’s important to consider the form of HT you’re using: The Combipatch that you were using is a transdermal estrogen (and progestin) delivery method, and that method has significantly less risk for stroke or thrombosis. If estrogen is taken orally, it is metabolized through the liver, which increases a blood clotting factor and puts women at a slightly greater risk for stroke and blood clots. Transdermal (through the skin) delivery doesn’t pose the same risk, because it bypasses the liver metabolism and enters the bloodstream directly.

You’re in your 50s, fit, and low risk: You’re a perfect person to consider continuation of HT for all the reasons you mention. It sounds like HT definitely improves your quality of life, which is to me a determinative factor. We don’t really have a clear time frame in which we know that HT starts to pose additional risk.  

September 04, 2015

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hormones ›   hot flashes ›   menopause ›  


Let’s Not Grin and Bear It

I’m an optimist by nature.

And that’s a good thing. I saw an article this week headlined “Women are not getting treated for menopausal symptoms.” It outlines the research behind the statement, research done in Australia but believed to be indicative of the reality elsewhere, including the U.S. and the U.K.

The researchers surveyed nearly 1,500 women who were 40 to 65 years old. Some of the results:

  • Up to half experience “vasomotor symptoms,” which include hot flashes and night sweats.
  • Seventeen percent said their vasomotor symptoms were moderate to severe.
  • Eighteen percent reported moderate to severe sexual symptoms.
  • Only 11 percent of respondents said they were using any hormone therapy.
  • Less than one percent were using non-hormone therapy.

This is, sadly, in line with other research I’ve seen over the past few years. Too many of us are taken by surprise by menopause symptoms. Too many of us expect the symptoms to pass in a month or two, when in actuality they may last for years. Too many of us suffer in silence (in one study, only 14 percent of men and women over age 40 had talked to their doctors about sexual health). And too many of our doctors lack either the information or the confidence to help us navigate these years.

And there are options available. The initial “alarming” findings from the Women’s Health Initiative regarding systemic hormone therapy have been largely disproved, put into a broader context of the trade-offs between quality of life and symptom management. The North American Menopause Society points out that breast cancer risk associated with systemic hormones doesn’t usually rise until “after 5 years with estrogen-progestogen therapy or after 7 years with estrogen alone”—which is likely long enough to weather the worst of menopause symptoms.

Localized hormones are an option for some symptoms; because they’re applied directly in the vagina, very little is circulated throughout the body. That limits or eliminates the risk of side effects, while still offering benefits in maintaining or restoring vaginal tissues.

New nonhormonal options for menopausal symptoms are also available, approved by the FDA. Osphena is a “selective estrogen receptor modulator” (SERM) that targets the vagina and uterine lining. Duavee is another medication in the SERM category that can be effective for hot flashes, with potential benefits for bone density. Brisdelle is an antidepressant that’s been prepared at a dosage that can help with hot flashes while minimizing its occasional side effects of weight gain and loss of libido.

Those are all prescription options, and there are plenty of steps women can take on their own, as well. That’s really our entire message, but if you’re looking for a place to start, these are the products women find most immediately helpful:

  • Lubricants make uncomfortable sex immediately more comfortable.
  • Moisturizers have longer-lasting effects, and can be used with lubricants to counter vaginal dryness.
  • Vibrators, as I tell women in my practice, are the reading glasses for diminished genital sensation.
  • And Kegel exercise tools help women keep their pelvic floors in shape, which is good not only for sexual response but for managing incontinence.

See how many things we can do? We don’t need to “grin and bear it,” as researcher Dr. Susan R. Davis, from the Monash University in Melbourne, fears we think. Step one is to believe—share some of my optimism!—that something can be done.

And then learn what you can, talk to your health care provider about your history, symptoms, preferences, and risks. Feel free to experiment until you find some options that make you smile.

Q: As a breast cancer survivor, can I use localized estrogen?

You say you've completed five years of regular tamoxifen, and your doctor has suggested Vagifem 10 mcg to address symptoms of dryness and itchiness. Vagifem 10 mcg is a very, very tiny dose of bioidentical estrogen, delivered as a tablet to dissolve in the vagina. I have many, many breast cancer patients who use it or other "localized estrogen" or "vaginal estrogen" options. Like you, they've had significant issues without it; over the counter creams, lubricants, and moisturizers may have had some benefit, but over time they've not done enough.

From what we know, localized estrogen doesn't enter the blood stream and get disseminated throughout your system; it is absorbed only in the genital area where it's needed. I like Vagifem because the dose is very low and there appears to be consistent absorption. But it is still estrogen, and there is sometimes reluctance to add this to a woman's regimen, especially after breast cancer.

There is a new non-estrogen treatment option for this condition. Called Osphena, it is a SERM (Selective Estrogen Receptor Modulator), the same class of medication as tamoxifen. They both target tissue and affect estrogen activity: tamoxifen targets breasts to block; Osphena targets the vagina to activate. Osphena is oral, daily, and in my practice has been well tolerated and effective. While it's been on the market for two years or so, it has not specifically been trialed in breast cancer patients (and nor have other medications, a reality I hope will change—and soon). There's not yet data on safety for women like you, but other SERMs on the market are favorable for breast health, it makes sense to think this one may be, too.

We don't have all the answers yet, unfortunately! Ultimately, the decision comes down to quality of life for you, and I'm glad it sounds like you have a health care provider who is helping you consider your options.

A Very Happy, Non-Hormonal Holiday to You!

I recently read a book review recounting one woman’s harrowing passage through perimenopause. The Madwoman in the Volvo is a graphic and humorous account of emotional upheaval, distress, seismic life changes, and finally, the author is cast gently upon the slightly less fraught shores of menopause. Perhaps sadder (or more thoughtful), probably wiser, and definitely optimistic about the future.

So, in honor of this season, which is guaranteed to nudge all but the most stoic among us off the ledge, I have two messages for all of us hot-flashing, sleep-deprived, hormonal gals.

If you feel as though you’re losing your mind, you aren’t alone. Hear that? You are not alone. In fact, you are legion—there are many of us.

Google “crazy menopausal women.” Read the forums. Check out the Fourteen Best Menopause Health Blogs of the Year. Take heart. You’re in abundant, albeit somewhat unhinged, company.

There are, in fact, a silent (or, more likely, howling) army of women who feel just like you. I recall the patient who was referred to me by her new therapist, who had refused to treat her until she got her hormones straightened out. (Previously, she had been told to see a therapist by the police.)

I recall a close friend, the very picture of motherly benevolence, who hissed in my ear, “If that kid doesn’t stop yammering at me, I’m going to tape her mouth shut.” She was referring to her sweet but talkative adolescent daughter. I was shocked. A few years later, I was feeling like that myself.

You can assess your lifestyle and experiment with healthy change. You can eat kale and take vitamin B12 and black cohosh. You can meditate and do yoga. You can stop smoking and reduce your alcohol and caffeine intake. You will feel healthier, and your symptoms might become more tolerable. In case you haven’t noticed, I’m a big advocate of healthy lifestyle choices.

But, if you, like many other women, continue to feel like you’re hanging on to sanity with bloodied fingernails, and those you love are suffering right along with you, by all means see your doctor and find out what pharmaceutical options might help you.

Read this article, written by a woman with access to all the current research on hormone replacement therapy (HRT) and an enviable journalistic pedigree. Here’s what she has to say about her decision to go back on HRT:

I would like to be able to tell you that I weighed these matters thoughtfully, comparing my risks and benefits and bearing in mind the daunting influence of a drug industry that stands to profit handsomely from the medicalizing of normal female aging. But that would be nonsense, of course. I was too crazy. I went straight to the pharmacy and took everything they gave me.

Perimenopause—the hormonal roller-coaster years preceding menopause—can be a long and bumpy ride. It usually begins somewhere between 45 and 55, but can start much earlier. These are the years of unpredictably cresting and crashing hormones, when the crazies come out in all their glory. This stage can last from 2 to 10 years.

Menopause officially beings in the thirteenth month (one year) after your last period.

Which doesn’t mean you’re out of the woods. Many women still have hot flashes and emotional turbulence. But life should slowly settle down as your body adjusts to its new, post-hormonal self.

So, that’s my second holiday message: You aren’t crazy, and eventually you’ll be okay. Wiser, maybe more self-actualized, and really, really okay.

With that, a very happy holiday from MiddlesexMD to you. And as the Madwoman in the Volvo said, “Have some cake, for God’s sake.”

Q: Where does the pendulum of perimenopause symptoms stop?

Given all of the unpredictability of perimenopause, you're wondering which symptoms carry over into menopause and which are resolved: Will you feel your best all the time? Or your worst?

I so wish I could give you a solid answer. The reality is that multiple factors are at play, and your genetics, overall health, and lifestyle will affect how they combine.

What's happening during perimenopause is that your hormone levels fluctuate wildly. Symptoms will vary, from person to person and from week to week. The key issue with the transition into menopause is the drop in estrogen. At the time of that change, in early menopause, many women experience the most symptoms: hot flashes, irritability, sleep issues, memory and concentration, dry skin, joint pain, and weight gain.

Most of those symptoms "resolve," as we medical people say, which means they diminish or go away entirely. The two areas where the loss of estrogen has continued effect for post-menopausal women are bone health and genital tissue (especially what we recognize as vulvar and vaginal dryness).

So back to those other symptoms: If it's irritability you're wondering about, you're likely to come "back to center" on mood, assuming that there aren't other unresolved (or, heaven forbid, new) issues in your life. For memory and concentration, remember that staying mentally engaged and challenged is important for brain health for both men and women!

And, because I'm a physician, I need to reiterate: A healthy diet and regular exercise minimize symptoms at any point.

Not a Straight Path

Many of the women I see in my office would like a black and white answer: Where, exactly, are they on the path to menopause? What, exactly, can they expect? Unfortunately, I can’t really give them a solid answer, and here’s why.

Perimenopause—that period (no pun intended!) between regular menstruation and menopause—isn’t a steady progression. It’s more like two steps forward, one step back. Sometimes, one step forward, two steps back. You may have some signs along the way, like moodiness, insomnia, irregular periods, hot flashes, lack of interest in sex, or vaginal dryness.

Sometimes FSH tests are used to help fill in the picture, providing one more data point. I don’t often recommend these tests, though, because although the tests are accurate at that moment on that day, they can be wildly misleading—unless you’re not yet in perimenopause (in which case the test can point to other issues) or you’re in menopause—which you already know because you’re not menstruating.

Here’s what’s happening with FSH (follicle stimulating hormone): The pituitary gland sends out FSH to tell the ovaries to make estrogen, which helps eggs grow (stimulating follicles!) and thickens the uterine lining. The pituitary gland acts like a thermostat: if it senses estrogen production is low, it “kicks on” and releases more FSH.

But as I said, the path to menopause is not a straight one; most women have erratic periods before menopause. So even if you are 52 and have every other symptom of perimenopause, if you take the test during the one time in six months you happened to ovulate, your FSH levels would suggest you’re not menopausal. Lifestyle-related factors like stress and smoking also affect FSH levels, making them even less helpful.

Check out the graphic to see the kind of unpredictability that’s typical. The first graph shows regular Typical Hormone Fluctuationshormonal fluctuation when you’re having regular cycles. The second graph shows how wildly all four hormones may vary over six months. The last graph shows that a consistently high level of FSH accompanies menopause. But, again, if you’re not having periods, you don’t need a hormone test—either from a doctor or an at-home saliva test—to tell you you’re menopausal. (If, by the way, you’ve had a hysterectomy, endometrial ablation, or another procedure that’s eliminated periods but you still have ovaries, you have the same unpredictability in hormone levels. Charting your symptoms for a few months may be the most helpful approach.) I understand that the ambiguity of perimenopause bothers some women. As a physician with a pretty good understanding of all the pieces at play, maybe I find it too easy to recommend that women tune in to their bodies and take it a month at a time. I'd love to hear from women who've found ways to be "in the moment" with The Change!

We Shall Overcome: Dryness

Itchy beyond words. Crotch of underwear rubs painfully against labia. Sensation of being on the receiving end of a vulvar wedgie. Feels like tiny razor blade nicks in my vagina during intercourse without lube or adequate foreplay. Also difficulty with penetration.

Doesn’t that sound awful? If that were you, I wouldn’t be surprised that you’re not thinking about sex. Just as awful, about half of us think that vaginal dryness is something we just have to live with—and about the same number of us are hesitant to raise the topic with our doctors.

The truth is that vaginal dryness does not need to end the intimacy you have with your partner—or the afterglow you experience yourself after sex.

First, a word about what’s happening: Yes, it’s likely hormones. As estrogen levels decline, the vaginal lining changes. It becomes more delicate and less stretchy. There’s less lubrication and less circulation. Vaginal dryness is a typical first sign of vaginal atrophy, when vulvo-vaginal tissues shorten and tighten. It’s common; you’re not alone, and you’re not deficient.

pink 2013.02If you’re just beginning to notice some discomfort, you can take the easy step of adding lubricant to your foreplay. Lubricants come in three types: water-based, silicone, and hybrid. My patients with dryness issues typically like the silicone and hybrid best, because they last the longest without reapplication, and because they seem just a little bit slipperier to some. Lubricants are made specifically for safe use on and in your vagina; if you want to experiment with a few, you can try our Personal Selection Kit (and read more about it here).

Next, you can add a vaginal moisturizer. While lubricants provide temporary comfort, reducing friction during sex, moisturizers work to “feed” and strengthen vaginal tissues around the clock. Moisturizing here is just like moisturizing your neck or your face: You have to be faithful! I recommend application at least twice a week. Moisturizers need to be placed directly in your vagina, which can be done with an applicator or a clean syringe you reserve for that purpose.

For some women, these two products—and the right amount of foreplay—are enough to make a difference. If they don’t do it for you, please talk to your health care provider, even if you think it will be awkward: Your sex life is important! There are localized estrogen products and a relatively new oral medication (called Osphena) that may be helpful for you, but you’ll need a consultation with your physician and a prescription. This isn’t the end; it’s only a transition, which we as women have a lot of practice with. Take heart and take charge!

Bioidentical Hormones Revisited

Recently, I was browsing through an online discussion board about the pros and cons of hormone replacement therapy. I ran across this comment from a participant: “I’m going to try bioidentical hormones like Suzanne Somers. I’ve heard they’re safer.”

Whoa! I thought. Let’s do some objective homework first, and weigh the risks before you jump in.

Celebrity endorsements notwithstanding, bioidentical hormone replacement therapy (bHRT) is neither the miracle cure nor fountain of youth touted by Ms. Somers. Nor is it some kind of snake oil concocted by salacious quacks or unscrupulous doctors and pharmacists.

The truth is, of course, much more nuanced.

As a physician, I’d always opt for more treatment choices when it comes to helping women with the unpleasantries of menopause. I want more drugs in the arsenal, more ways to treat hot flashes, sleeplessness, and loss of libido. However, the entire topic of bioidentical hormones is so laden with emotion and misinformation that it takes a very fine point to tease fact from hyperbole.

We laid the groundwork on bioidenticals before, but the issue continues to befuddle and mislead, so let’s circle back and fill in some gaps.

Any hormone therapy, whether bioidentical or synthetic, is only intended to ease menopausal symptoms. Hormones were never meant to keep your memory sharp or your hair shiny or your skin taut. Hormones are not a fountain of youth. The latest medical guidelines state that hormones should be taken at the lowest possible dose for the shortest period of time needed to ease symptoms. This is because hormones, whether bioidentical or synthetic, are drugs and they interact with other systems in the body, sometimes in ways that are not well understood.

Point #1. Menopause isn’t a disease; it’s a natural transition. Hormone therapy is intended neither to keep your hormones “in harmony” nor to keep menopause at bay indefinitely. Hormone therapy is intended to ease the symptoms of the menopausal transition when they are interfering with your life.

Next, bioidenticals aren’t necessarily “natural” and therefore “safer.” The marketing message that hooks women is that bioidentical hormones are derived from “natural” sources and are therefore safer than hormones from other sources.

Bioidenticals are estrogens that are indeed made from plant sources, but they are processed (synthesized, if you will) to create a hormone that can be absorbed by humans. “All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product,” writes Dr. Oz in this article.

With bioidenticals, however, you end up with a molecule that is exactly like (identical to) human hormones, whereas non-bioidentical hormones are similar but not identical.

Any hormone, whether those your body produces or those you ingest, affects your body. Also, the delivery method, whether a patch, pill, or vaginal cream, also affects the way your body absorbs and responds to the hormone.

Point #2: Don’t equate “bio” with something “natural” and therefore risk free. Taking any hormone involves some risk. (Decisions about hormone therapy need to be based on careful consideration for each individual—understanding both the potential risks and benefits for that woman.) Bioidentical hormones are so-called because the molecule is identical to the human hormone and because they are derived from plant sources, even though they must be synthesized to be useful.

“So ‘natural’ doesn’t necessarily equal ‘safe’—and may simply be a euphemism for ‘unregulated,’” according to this article in the Harvard Women’s Health Watch.

You can, we should note, get bioidentical hormones that are FDA approved and regulated. Many familiar brands of hormonal rings, creams, patches, pills, and gels are both commercially manufactured by pharmaceutical companies and bioidentical. These include Estrace, Femring, Vivelle, Vagifem, and Prometrium, and more. You know what you’re getting with these products.

You know that the active ingredient is in the form and dosage that the label says it is. That kind of uniformity and “safety” is the assurance provided by FDA testing and approval.

Point #3: Many major brands of commercially manufactured hormones are both bioidentical and FDA approved.

Next, let’s understand what “custom-compounding” means. Many bioidenticals are touted as natural, safe, and custom-made just for you to bring your hormones back in balance. Custom-compounded drugs are made in small, customized batches by pharmacies that specialize in custom-compounding. They can be prescribed by a clinician.

Custom-compounding is very helpful when a patient needs a special dosage of a medication, or a different delivery method, or is allergic to a filler in a commercial drug. Maybe, for example, you need a lower dose of progesterone than is commercially available, or you need it in a vaginal cream, and the big pharmas only make it for administering orally.

However, neither the process nor the product is FDA-regulated or approved, and in fact, studies have shown that they are much less consistent than commercial products. In a few highly publicized cases, contaminated medications distributed by custom-compounders have been responsible for serious illness, infection, and death. An example is the outbreak of fungal meningitis in the fall of 2012.

The problem with custom-compounded hormones arises with claims of customized products that are safe, natural, and that will restore hormonal balance, among other things.

In actuality, it’s not possible to accurately pinpoint hormonal levels in an individual because they are constantly changing. The hypothalamus, pituitary and ovaries (the HPO axis, as we call it) work in a very integrated and precise way to direct hormone production. Our replacements aren’t able to replicate that concert of events, but we can do a good job of replacing the hormones more consistently, which many women prefer to the ‘ups and downs’ we’re familiar with. The only way to determine an effective dose is through symptom control—the lowest dose that relieves a woman’s symptoms. “Salivary and blood testing of hormone levels used by custom compounders is meaningless for midlife women as their hormone levels vary throughout the day, and from day to day” is the North American Menopause Society position.

“This doesn’t mean that you shouldn’t consider compounded hormones. Just realize that, in a real sense, you’re going to be an experiment of one,” says the Harvard Medical Watch article.

Also realize that custom-compounded drugs usually aren’t covered by insurance, and the regimen of testing and compounding gets expensive very quickly.

Point #4. Custom-compounding of drugs is a time-honored practice of making drugs in small batches or according to specific needs (while the processes and products aren’t subject to federal regulation or oversight). Claims that these products are healthier, safer, or somehow contain properties lacking in commercial products should be viewed with suspicion.

Baby Blues and Menopausal Depression: Part Two

Many women go through menopause with little more than irritability and hot flashes. In our last blog post, we reviewed research that suggests, though, that if you've experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause. Awareness and perhaps some preparation for this challenging transition might be prudent. It’s like an athlete training for a race. You want to be in shape before you hit the tarmac.

And even if you’ve never had a down day in your life, some commonsense lifestyle adjustments as you approach your “window of vulnerability” might ease the transition. What you absolutely do not want is to be taken by surprise at the intensity of your emotions, as this couple, tragically, was.

Forewarned, as they say, is forearmed.

So here are some suggestions for greater awareness and healthy lifestyle changes that, honestly, are never too late (or early) to adopt:

Nutrition. Eating sensibly is a good foundation for the inevitable metabolic changes that happen during menopause. Go heavy on whole grains and fresh fruits and veggies, ideally from local, organic sources. Lighten up on fats and sugar. Take your vitamins.

If you need to lose some serious weight, now’s the time to get serious about it, before menopausal changes really kick in.

Get moving. Lack of social connection and daily activity intensifies a sense of isolation and lethargy. Create a routine of exercise and involvement. Volunteer for a few organizations you believe in or enjoy. Exercise regularly. Get outdoors—don’t just walk from house to car. Surround yourself with healthy activity and people you like.

Explore treatment options. Some studies indicate that, for perimenopausal depression, hormone replacement therapy, sometimes in conjunction with antidepressants, can ease the mood swings, hot flashes, and insomnia, especially during the early stages of menopause.

St. John’s wort may also relieve mood swings and anxiety during menopause. (But don’t take any natural remedy without talking to your doctor first.)

Build your network. It’s comforting to know that people you trust have your back. And it’s a lot easier to find helpers before you’re in the thick of things.

Maybe find a therapist you like. Maintain connections with good friends.

And if you find yourself overwhelmed with feelings of unworthiness, or are unable to get out of bed or to function normally, for heaven’s sake, tap into that support system. Call your therapist or doctor. Call someone you love.

Menopausal depression is treatable and usually resolves itself once you’re through the change. Then you’ll be back to your sunny, even-keeled self.

In the meantime, it’s just your hormones talking.

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