November 27, 2014

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hormones ›   intimacy ›  


The Monogamy Drug

Looking for a warm and cuddly holiday season? Try a little oxytocin spritz along with the turkey.

Oxytocin is a hormone produced by the pituitary gland that activates certain reward receptors in the brain. It makes people compassionate. It makes women love their babies. It’s released during orgasm and causes couples to feel close to one another, thus its nickname, “the cuddle drug.” It’s also involved in addictive behavior, along with dopamine, another “feel-good” neurotransmitter.

A couple of recent experiments by Dr. Rene Hurlemann at the Bonn University Medical Center, however, suggest that oxytocin is a hormone that keeps men monogamous. Contrary to all kinds of evolutionary thinking, which would suggest that men would be driven to spread their seed in all directions, oxytocin appears to increase a man’s attachment to his sexual partner.

Monogamy is rare in the mammalian world. Only 3 to 5 percent of warm-blooded creatures pair up for life.

In his first experiment, Dr. Hurlemann spritzed a few men with oxytocin and then introduced them to an attractive woman. The men in monogamous relationships stayed 6.5 inches farther away, on average, from the woman than single men did. When the same partnered men weren’t spritzed, the extra distance disappeared.

Dr. Hurlemann decided to investigate further.

In his second experiment, the male subjects, who were all in permanent relationships, were hooked up to a brain scan. First, they were spritzed with oxytocin, and then they were shown photos of their partner, of other attractive women, and of female acquaintances.

Sure enough. The parts of the brain associated with reward (the nucleus accumbens) and motivation (ventral tegmental area) lit up at photos of the partner, but not at the strangers or at female acquaintances. Under the amorous effect of oxytocin, these guys also felt that their partners were more attractive than photos of the other women.

The researchers hypothesize that this hormone that is released during close physical contact and that tickles our pleasure center reinforces monogamy this way: A man may limit the spread of his genes by sticking with one partner, evolutionarily speaking. But by sticking around to create a stable environment and helping to rear his offspring, he increases the likelihood that they will survive to reproduce. So, rather than feckless promiscuity, evolution takes a different tack and oxytocin is the carrot.

And while that’s a cold, scientific view of the situation, lots of touching, cuddling, massaging, and good old sex will keep your man’s pleasure centers (as well as your own) well-lubed and attached to the source of the goodies! In Dr. Hurlemann’s research, even the close presence of the partner was enough to release oxytocin, giving new meaning to the saying, “stand by your man.”

While you’re basting that turkey, keep in mind that our traditional holiday fowl is also high in dopamine, which might be well-poised to edge out Valentine’s Day (even in spite of the afternoon football) as the season of love.

November 20, 2014

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comfort ›   hormones ›   women's sexual health ›  


Q: Is there an over-the-counter product for elasticity?

You ask whether there's an over-the-counter hormonal cream to restore vaginal elasticity. You're finding intercourse painful and experiencing dryness.

Vaginal moisturizers will help to retain some moisture, but none of them will reverse the process—which is, medically speaking, atrophy given the loss of estrogen. The combination of moisturizers and lubricants will keep things comfortable for a while, but most women eventually need more.

Localized estrogen or the new pharmaceutical Osphena are effective; either requires a consultation with your health care provider. I'm not aware of any hormone-based medication available over the counter and, in fact, encourage a consideration of your medical history and current factors before use.

October 09, 2014

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hormones ›  


Q: Would using estrogen cream more often be more effective?

Most topical or localized estrogen creams are prescribed to be used twice a week, which is the level at which they typically provide the most benefit with the fewest unintended consequences. If the usual application isn't helping you regain comfort, a conversation with your health care provider could be in order.

Localized estrogen is most effective for vaginal atrophy; if you have other "systemic" symptoms of menopause, like hot flashes or night sweats, systemic estrogen may be worth considering. Systemic estrogen also improves vaginal health, but because it enters the system (as opposed to "localized" estrogen), there are more overall health considerations for its use.

If we had a conversation about how you measure "more effective," I might suggest other, nonhormonal options that could be helpful to you. Moisturizers can improve tissue health, lubricants increase comfort and pleasure, warming products and vibrators enhance sensation, and massage oils encourage intimacy, for example. I encourage women to experiment with all of them!

September 30, 2014

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anatomy ›   conditions ›   hormones ›   learning ›  


Q: Am I shrinking down there?

You've noted that your clitoris appears to be smaller, which is a normal part of aging. With the absence of estrogen, it's estimated that a woman loses 80 percent of her genital volume—unless there is some intervention. The two most effective ways to minimize this diminishment are to remain sexually active (that "use it or lose it" thing I've talked about before) and to use localized estrogen. Both help to maintain the integrity of the genital tissues.

Our intent is not to "prevent" menopause, because it's a normal part of our lives. With my patients, my aim is to mitigate enough of the symptoms of menopause to be able to maintain the sexual intimacy that's an important part of life for many of us.

More often than you'd think, a patient who thought she was "done with sex" comes to me for help when she enters a new relationship. It's possible to reverse some of the atrophy that happens naturally with inactivity, but it's more difficult than maintaining sexual health along the way. If a woman is certain that she has no interest in being sexually active, there's no negative health effect of the genital atrophy—beyond the loss of the positive health benefits of sex.

September 25, 2014

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hormones ›   intimacy ›   sensation ›  


Q: Why am I "skipping" orgasm?

What you describe is going from arousal to "resolution," without experiencing what you used to as orgasm in between.

The first thing I'd check if you came to my office is whether you're on any medications that could interfere with orgasm. The biggest class of medications in this category are the SSRIs—antidepressants like Prozac and Zoloft. If you are, you can talk to your health care provider about alternatives that would have the effects you need without the same side effects.

Difficulty with arousal and orgasm are more common as our hormones change through menopause. The loss of estrogen diminishes blood supply to the genitals, which affects sexual response. There are a few ways to counter that loss:

  • More direct clitoral (external) stimulation can help—and not all of us are accustomed to needing that. A good vibrator is effective; we encourage women to consider vibrators with stronger-than-average vibration strength, and choose the products we offer at MiddlesexMD with that in mind.
  • Localized vaginal estrogen can also be helpful; you'll need to talk to your health care provider to see whether a prescription is appropriate for you.
  • Keeping the pelvic floor muscles in shape is a critical piece of enjoyable sex, too. Strong muscles are part of strong orgasms--as well as preventing incontinence. We offer a new product, the Intensity pelvic tone vibrator, that uses electrical stimulation to contract the pelvic floor muscles in addition to its vibration patterns.

One more thing to consider: Women have at 50 about half the testosterone she had at 25, and testosterone plays a critical role in libido and ability to orgasm. There's no FDA-approved product for women, unfortunately, but I prescribe testosterone off-label for patients with good results. Off-label use of Viagra or Cialis is also helpful to a few women. All of these off-label prescriptions require a conversation with your health care provider—and consideration of your overall health.

There's every reason to be optimistic about regaining satisfying orgasm!

June 04, 2014

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hormones ›   learning ›  


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.

May 27, 2014

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hormones ›  


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!

May 09, 2014

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comfort ›   conditions ›   hormones ›  


Q: Does a blood clot limit my treatment options?

The dryness, discomfort, and frequent infections you describe are consistent with vulvovaginal atrophy (now sometimes called "genitourinary syndrome of menopause") and, possibly, vulvodynia. The mainstay of treatment for these conditions is to "estrogenize"--add estrogen to--the vagina.

It was once thought that all estrogen posed some vascular risk, so I understand the hesitation about continued use for you after a blood clot. More recently, though, localized (placed directly in the vagina rather than taken orally) estrogen has been shown not to raise the risk of thrombosis. Estrogen products still carry the "black box warning," regardless of the method of administration. About a month ago, though, additional data were presented to the FDA asking them to remove that "class labeling," since the means of administering makes such a difference. We'll see what happens, but you can ask your health care provider to reconsider.

In addition to continuing the use of a vaginal moisturizer, you might also use a silicone lubricant (Pink is a favorite at MiddlesexMD). That type of lubricant reduces friction and gives more glide or slipperiness. And you could ask your health care provider to prescribe a topical xylocaine, an anesthetic that you can apply to the area to make you more comfortable during and after intercourse.

Have another discussion with your health care provider, and try all your options! Comfortable sex is possible for you.

March 31, 2014

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comfort ›   conditions ›   hormones ›  


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!

January 13, 2014

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anatomy ›   arousal ›   comfort ›   conditions ›   hormones ›  


Q: Why do I have pain and hypersensitivity?

What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There's also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you're looking for pleasure will certainly affect your sex drive and arousal!

Localized estrogen is the option that works best (and it's often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.

A vaginal moisturizer can also help you restore those tissues, but I suspect you'll find that most effective in combination with localized estrogen.

Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I'm hopeful that your sex drive will rebound.