In the last couple of posts we talked about the significant subset of women who suffer from debilitating emotional swings during the menopausal transition—and also about their loved ones who suffer right along with them.
It’s a Catch-22. You truly can’t control the hormonal storm that lashes you with sudden waves of uncontrollable rage, sadness, irritation, anxiety, and depression. Yet, you really can’t unleash these emotions on the people closest to you. People whom you love and have no wish to harm.
If you are caught in that cycle, there is work to be done, stat, to stabilize your emotions and allow you to get through this transition without further disruption to your life or hurt to your closest relationships.
I’m going to lay out your options, but you also need to have a conversation with your doctor, who will assess your risk factors and monitor your response to treatment.
Before you consider medications, you must lay a foundation of good health habits, if you haven’t already. I’ve mentioned this, oh, maybe a thousand times before, but that’s because it’s so important. Good health hygiene is even more critical now because some of those bad habits could be messing with your mood.
Exercise regularly. Just 30 minutes of moderate daily exercise improves circulation, relieves stress, improves sleep, makes your heart stronger, and more to the point, improves mood by releasing endorphins, which gives you a little euphoric lift.
You also have to eat moderately and healthfully. That means cutting down on sugar and caffeine, which causes mood and energy to peak and crash. In Great Britain, fish and veggie-eating folks had fewer depressive episodes than their junk-food-eating colleagues. In Spain, those who filled up on nasty trans-fats from pastries and fast food were 48 percent more likely to be depressed than those who ate good fat, such as olive oil. (And these folks weren’t even menopausal!) Magnesium is also linked to mood and sleep, so a magnesium supplement might be in order.
At the risk of being an absolute killjoy, you also have to stop smoking and cut back on alcohol, both of which affect mood. Alcohol, of course, is a depressant. I’m not talking about a glass of wine with dinner, but about regular and/or heavy drinking.
A further brick in that health foundation is to develop a strategy for relieving stress—meditation, yoga, mindfulness practice, or another religious practice that is meaningful to you. These are known to relieve stress, stabilize mood, relieve pain, including psychic pain, and generally make life more hopeful.
I am not for a minute saying that an honest self-improvement plan will be easy or immediate—in fact, it’s a lifelong endeavor. I’m also not saying that good health alone will adequately address your menopausal mood swings. But I can assure you that getting in shape, eating well, and implementing a spiritual practice will absolutely help, both now and later.
Now let’s address the medical options. Your healthcare provider will need to work with you to find the best treatment. So it’s time for a heart-to-heart with your doctor. Ask her about:
Medication isn’t a substitute for those common-sense efforts to improve your overall quality of life, but they can help you get through this bad patch.
This is a long journey, ladies, accompanied by a lot of turbulence and change. Life will be different—and very likely better—on the other side.
Ever have a medical professional say to you, “This procedure is a piece of cake. You’ll be back on your feet in a couple days,” only to be popping Tylenol and cursing the day you were born fully a week later?
Ever step off the plane into a throng of strangers and realize you really should have researched this off-the-beaten-track destination a whole lot more before you booked the flight?
I don’t know about you, but before I venture into uncharted territory, whether It’s a medical procedure or a new travel destination, I like to talk to someone who’s “been there,” who knows what she’s talking about and is willing to tell it straight. The voice of experience is always reassuring.
So for Part 2 of our discussion on testosterone therapy, we bring you the voice of one of my patients who is on testosterone therapy and who was kind enough to share her experience with us.
As I mentioned in Part 1, in my clinical experience about 40 percent of women aren’t helped by testosterone therapy at all. A few others experience unpleasant side effects, and others still, like this patient, experience additional positive effects. While each woman’s experience is unique, many really do benefit from small dosages of the hormone.
Here’s a Q&A from one who did. Let’s call her Elaine.
MiddlesexMD: What were your expectations of menopause? Did you have a general idea of what to expect?
Elaine: The only idea I had of menopause was what is popularized by general media: hot flashes, temperamental moodiness, weight gain, fatigue, dry vagina, low sex drive. I didn’t want that to be my experience, and I decided I would do all I could not to have that be my story, but I really didn’t know what that would mean. Lucky for me, I have a smart, proactive health care provider that has always felt like she was on my team with my health story.
MiddlesexMD: What was your experience of menopause?
Elaine: My complaints were: intermittent feelings of anxiety, which I had never experienced before. Also I experienced somewhat diminished sex drive, but worse than that, when my hubby and I did have sex, it was SO MUCH WORK to achieve orgasm for me. Exhausting. I am so glad I am a runner and in good shape, because there is no way an out-of-shape me could even hope to work that hard without having a heart attack!
Then finally the orgasm was very flat and not very satisfying. Also I experienced some mild general fatigue; almost daily I would require a 10-minute nap, which never bothered me, but was relatively new to me.
MiddlesexMD: What was the problem--or set of problems--that you wanted to solve by seeking medical help?
Elaine: I described the symptoms listed above (anxiety, diminished sex drive, flat orgasm, some fatigue), without really expecting a solution. I expected Dr. Barb to say, “Yep, that’s menopause! Most women experience those things.” I thought she might recommend some herbal remedies, at most. I was obviously delighted with the solution she prescribed!
MiddlesexMD: What was the impact on your relationship of the symptoms that you had?
Elaine: My sex drive is improved, and the quality of orgasm is VERY much improved. Also, it doesn’t take forever for me to achieve orgasm. I almost never require a nap anymore, can’t think of the last time I took one, actually.
MiddlesexMD: Any other effects of testosterone therapy for you?
Elaine: The following are the unexpected effects: My anxiety symptoms, which were mild, are gone. I have noticed that mentally I feel more assured; I am able to more clearly see the forest for the trees; I am able to make confident decisions more quickly. I also have noticed that I am less likely to worry about whether people agree with me, or if they like what I have to say. I feel I can make intelligent decisions without being bogged down by wondering how my responses are received and if people agree or like me more or less for what I say.
I feel I am more able to present my true, authentic self/opinions. I am able to make decisions more quickly and with more confidence. I notice I don’t tolerate as much B.S. as I used to. (I am not rude, but I don’t go down that road with people anymore?) I feel somehow more clear and comfortable in my skin. I never expected this, but I love it.
I also have noticed that my muscle tone is improved, nothing freakish or dramatic, but I do notice it. I am running a tad bit faster, and I have more energy after a long run. I am no longer whipped for the day following a long run. I have noticed I have more overall energy, actually. I still sleep well at night, always did. I have experienced no other side-effects, such as extra hair growth or acne. I have noticed no negative side effects, actually.
MiddlesexMD: Does this experience suggest anything that you wish other women knew or were told?
Elaine: It sure makes me happy that I have such a great health care provider who is on the cutting edge with drug therapies, knew about this option, and took the time to explain it to me. I have mentioned it to several friends, and they have never had such a discussion with their health care providers. I wish women knew that all the stories about menopause (icky side effects, moodiness, weight gain, etc.) are not necessarily the experience of every female.
I love options. Moose Tracks or Mackinaw Island Fudge? Mocha or machiatto? Phillips screwdriver or allen wrench?
Mostly, I like having options for my patients. At this awkward middle-age time of life, issues are complex and solutions are rarely straightforward. So I like to have a toolbox of treatment options to choose from. If one method doesn’t work, maybe another will.
To be clear, I always start with the most natural, straightforward treatment possible, postponing pills, prescriptions, and hormones. To this end, a healthy lifestyle is the first and most important contributor to a good sex life. Along with lavish use of moisturizers, lubricants, toys, and imagination.
But when these things fall short, it’s nice to have options.
That’s what testosterone therapy offers—another tool. Another treatment regimen that might fan a faltering libido and fading intimacy in an otherwise healthy relationship. Like any treatment, this isn’t a silver bullet or a magic pill. In fact, it’s controversial. There just isn’t a lot of research on long-term use or even on how testosterone functions in women. (Spoiler alert: a lot different than in men.) It isn’t FDA-approved, although it’s been prescribed “off-label” for decades in the US and is prescribed legally in Europe and elsewhere.
In women, testosterone is produced at much lower levels than in men, mostly in the ovaries and adrenal glands. As we age, and especially if our ovaries have been removed, testosterone levels drop sharply. This isn’t the only reason for diminishing sexual desire but it may be part of the picture. (In medicalese, a distressing loss of libido is called hyposexual desire disorder—HSDD.)
Since declining testosterone levels, menopause, and HSDD tend to happen in tandem, maybe a causal link exists among them, so the thinking goes. Obviously, it’s more complicated than that, but for some women, a little testosterone boost just seems to work. As a recent bulletin from Harvard Medical School states: “…in some but not all studies, testosterone therapy has been shown to be an effective treatment for HSDD in carefully selected postmenopausal women.” In my clinical experience, testosterone therapy improves libido, desire, and/or the ability to orgasm in about 60 percent of the women who take it.
So, what are those “carefully selected” qualities that make a patient a good candidate for testosterone therapy?
First, testosterone won’t cure difficulties in a relationship that may be contributing to intimacy problems. Other libido-killers include depression, fatigue, anxiety, certain medications, and the usual menopausal suspects: loss of estrogen, night sweats.
In the absence of physical or psychological factors, women who are distressed by their lack of libido (the classic definition of HSDD) might find relief with a little extra testosterone in their system. I monitor blood levels during treatment with the goal of restoring testosterone to the level you probably had when you were 25 years old.
Some women (about 20-30 percent of my patients) experience some added benefits, such as improved mood and more energy, while another 10 to 15 percent have less positive side effects, like unwanted hair growth or acne. And for about 40 percent of my patients, testosterone therapy isn’t helpful at all.
Testosterone can be safely applied topically; I usually prescribe a gel, the same FDA-approved topical gel that is used by men, but at one-tenth the dose, which I find offers a safe and consistent delivery of the medication.
For some women, testosterone is a game-changer and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy is a solid treatment option. A woman who’s tried it will tell her story in our next blog post.
Before we begin, I just want to reiterate our long-held position here at MiddlesexMD: Natural is always better. By that I mean, if you can ease vaginal pain and enjoy sex comfortably using non-hormonal products like moisturizers and lubricants, that is always the first and best option.
That is also the position taken in a new report issued two weeks ago by the American College of Obstetricians and Gynecologists (ACOG). But when the non-hormonal route just doesn’t cut it, when the pain of vaginal dryness and atrophy is unpleasant enough to interfere with life and good things like sex, then the ACOG committee says that topical estrogen treatment is a good option even for breast cancer survivors. (Check out this link on our website for tons more information.)
Let’s dig into this.
For a long time, doctors focused on simply helping women with breast cancer to survive. Now, the good news is that women who have had breast cancer are indeed surviving for years longer. So the focus has shifted to quality of life—like making sure that sex is comfortable, for example.
This can be tricky, because we all know that estrogen is a bad thing for breast cancer survivors. In fact, a type of breast cancer, called “estrogen-receptor positive,” which unhappily is more common in postmenopausal women, has special receptors that are sensitive to estrogen. With this type of cancer, estrogen acts like fuel, making the cells grow more quickly. That’s why ongoing treatment for women who have had this type of cancer includes Tamoxifen or “aromatase inhibitors” that block estrogen activity.
Problem is, of course, estrogen is a good thing for our vagina, among other parts, and a lack of estrogen wreaks havoc on that sensitive system. Thus, drugs that block estrogen activity also cause urinary tract infections and painful vaginal dryness and atrophy. These side-effects can be so severe that 20 percent of women simply stop taking the drugs.
We know that oral estrogen replacement therapy—taking estrogen pills—increases systemic estrogen levels, but what about localized estrogen that’s used externally to treat vaginal dryness and atrophy? Does that increase estrogen levels in the body? Does it increase the risk of relapse?
While there hasn’t been a lot of research on the subject, ACOG released its committee report early in February stating: “Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.”
The ACOG guidelines recommend using the lowest effective dose for as little time as possible. And while the hormone comes in three forms: cream, ring, and a vaginal tablet, the lowest rates of absorption and the most accurate dosages occur with the ring and tablet.
For women whose symptoms are severe and who aren’t sufficiently relieved just by vaginal moisturizers and lubricants, it’s nice to know that there are other options. If you’re a breast cancer survivor who is suffering from vaginal dryness and painful sex, it’s time for a sit-down with your doctor to discuss treatment options. It’s time to start living well again.
One of the joys of the work I do is hearing from women about how what I do—through my practice or MiddlesexMD—helps them with their health and intimacy. Often, I hear those stories in conversations, and as good as my intentions are (because I believe in sharing our stories), by the time I get back to my office, I forget to take good notes. But a letter! Remember how lovely it is to get letters? Here’s one I can share with you!
Dear Dr. Barb,
I loved your blog post “Don’t be a Stranger.”
It was timely for me. I thought I was doing this all pretty well. Three years ago when my primary care doctor retired, I chose my new provider carefully. I told her I’d been following MiddlesexMD since the blog launched in 2010, and that I was interested in keeping my sex life healthy. I asked her not to shy away from anything she thought I should know, and that I intended to try to be as proactive as I could be.
It was a good start. I’m relatively healthy, so I have seen her only on an annual basis since. I have vibrators and dilators and use moisturizers. Most important, I have a good partner!
And life went on. My husband travels a lot. My father died. I went on Medicare (which somehow managed to administratively change my primary care provider – requiring 8 phone calls and numerous interruptions). Job changes and financial stresses complicated my life.
At my visit in January (before your blog post), my doctor and I worked to figure out how to make sure my medical care didn’t get disrupted. We reviewed all of my “checkpoints” – mammogram (sister is a breast cancer survivor), pap test (I’ve had cervical “pre-cancer”), bone density, skin check, high cholesterol testing, blood screens, etc., etc.
Only when I thought the exam was about to end, did I blurt out, “I’m unhappy with my sex life.” So much for proactive.
To her credit, she stopped. And she started asking me questions. After a little exploration, she asked, “Have you ever tried topical estrogen?”
I had. But not for years.
After a little examination (serious atrophy) she prescribed a cream.
Three weeks later, my sex life had taken a new (and better) trajectory.
So, I want to echo your advice to keep the conversation going – because I can’t keep it in perspective by myself, no matter how good my intentions are!
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:
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:
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.
You've noted that in addition to vaginal dryness, you're now using drops for dry eyes, a treatment for dry mouth, and more hand lotion than ever before. Yes, dryness is generalized in menopause, because the estrogen receptors we have from head to toe (and especially in genital tissues) have far-reaching influence! As we lose estrogen, we lose moisture in all kinds of tissues.
Systemic estrogen is a possible solution; it can make remarkable improvement. Every woman is different, though, in the extent of the effect, so a three-month trial might be considered to see if there is a notable benefit.
Otherwise, it sounds like you're taking advantage of the topical solutions available to you—moisturizers for every body part! This is a good time of life to develop a good hydration habit, too, if you don't have one already.
You say a prescription for estrogen seemed to increase your libido at first, but that effect has diminished. No, you haven't become immune to estrogen. Unfortunately, libido is a bigger and more complicated issue than just one hormone. Many women don't find any improvement in libido with estrogen; I tell patients it certainly won't make it worse, and it may make it somewhat better. And it's not uncommon for the initial effect perceived from a new treatment to wane over time.
You also ask whether where you apply the estrogen cream makes a difference to its effect on your libido. The medical answer is that because its effect depends on its entering the blood stream, it can be applied to skin anywhere it is likely to be absorbed. If you have pain with intercourse or dryness because of menopause, applying the cream to genital tissues may help, but that's a different issue than libido.
Women's libido is complicated (several hormones and numerous neurotransmitters in the brain are involved, as well as emotional and psychological factors), and the treatment options for low libido are currently limited. We offer a number of suggestions on our website, but I also encourage women to talk frankly with a menopause care specialist.
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.
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.
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.”