Doctors and Shopping: The Follow-Up

In January, I was working on an article I'd been asked to provide to OBG Management magazine. They'd asked me to talk about why I offer products through my practice—which was, actually, the same motivation that led me to found MiddlesexMD: There are some simple products available that can help women remain sexually active, but it's not always easy—or comfortable—to buy them.

As I wrote the article, I wondered how you as patients feel about products being offered through your doctors' offices, so I asked. And a number of you responded, either on the blog or directly, with your thoughts. You were overwhelmingly positive, assuming that your relationship with your health care provider was one based on trust to begin with (and I hope we're all that fortunate!).

OBG Management published my article, called "Vibrators, Your Practice, and Your Patients' Sexual Health," in their April issue. Read it if you like, and take a copy to your next doctor visit if you think it would be helpful in opening a discussion about how he or she can be more helpful to you and your sexual health!

Thanks to all of you who voiced your support or concerns. We'll keep learning together—and stay as sexually active as we choose!

Q: Should I be concerned about abnormal Pap test results?

"Concern" is a relative term. If you mean should you lose sleep, no. If you mean should you work with your health care provider for an explanation or monitoring, yes.

Pap tests (also called a Pap smear or cervical cytology screening) are used to look for changes in the cells of the cervix; abnormal cells can be identified early and treated appropriately. Pap tests provide information on both whether cells have changed and how much cells have changed, so  "abnormal" covers a range of possibilities.

The most common cause of abnormal Pap results is HPV (human papillomavirus) infection, and HPV also suggests a range: there are many types of HPV. Some lead to nothing at all, some are linked to genital warts, and some are linked to cancers of the cervix, vulva, and vagina. And, let me repeat, some lead to nothing at all.

When a Pap test returns an abnormal result, it's typical either to monitor (repeat the Pap test in six months or a year) or to take an additional diagnostic step. A colposcopy is the most common; it sounds scary, but it's really only a close visual exam of the cervix with a magnifying device. There are several tissue sampling procedures that take cells for additional lab examination.

About 70 percent of mildly abnormal results revert to the "normal" range at the next screening. That said, it's important to follow your health care provider's recommendation for a follow-up test. This is not the time to procrastinate on that office visit!

Make a “WISH” for Awareness of Women’s Sexual Health

Actually, do more than wish. Be active.

Sign this online WISH petition to add your voice to others advocating for greater attention to women’s sexual health needs. The WISH petition is sponsored by the International Society for the Study of Women’s Sexual Health (ISSWSH), which is a professional organization for those of us who work in the field of women’s sexual health.

The petition supports ISSWSH’s position that “female sexual disorders are valid conditions that warrant assessment, diagnosis and appropriate therapeutic intervention.”

But WISH is more than a petition. It’s an initiative dedicated to bringing “the medical community together with the public to recognize the importance of female sexual health, so that it is no longer considered a ‘lifestyle choice,’” according to MaryAnne McAdams, director of the WISH Initiative. The group even has a Facebook page.

As a professional in the field, I feel strongly about the need for more recognition, more acceptance, more treatment options, more research, and more pharmaceutical options for women who experience sexual dysfunction.

There are many of you. The numbers vary greatly (another area for research, perhaps?), but it is estimated that from 19 to 50 percent of “normal” women experience sexual dysfunction, according to a 2000 article in American Family Physician. Predictably, that number increases when the physician actually asks the patient about her sexual health, which many don’t. (An area for physician education, perhaps?)

As I’ve said before, I’d like companies to develop more pharmaceutical options for women, and I’d like the FDA to consider them seriously and carefully. I know that it’s easier to make a drug to treat erectile dysfunction. I’m well aware that women’s desire/arousal trajectory is complex and multi-dimensional, but the more tools we have in the bag, the more successfully we can treat women with sexual issues.

It’s easier, of course, to fall back on the old “it’s in her head” or “it’s a lifestyle choice” crutch. Thankfully, that attitude is becoming discredited and debunked, but those voices are still around.

“In the last few years, there has been a small, but very loud group who have been given the chance to speak during FDA Advisory Meetings claiming that female sexual dysfunction is a made-up condition and is not ‘real,’” says WISH’s MaryAnne. “The WISH petition may be used as a source of documentation to dispute that erroneous claim.”

As a physician who treats women’s sexual health, I’d like more attention paid to the issue by government agencies, pharmaceutical companies, and my colleagues. I’d like women’s sexual issues to be acknowledged, respected, and treated with intelligence, competence, and sensitivity. And since at some point in your life, you’ll probably experience some lack of libido, difficulty with arousal or achieving orgasm, or some pain during sex, I’m sure this is an important issue to you, too.

If it is, sign the WISH petition. We know size doesn’t always matter, but the number of voices on this topic does count!

Our "Recipe"; the ARHP Assessment

Did you know that the whole idea behind MiddlesexMD is based on a recipe? You could call it the MiddlesexMD formula for really juicy sex. Officially, we call it “our recipe for women’s sexual health.”

We think our recipe is so important that our entire website is organized around what we’ve identified, after a lot of thought and research, as the five necessary ingredients for a satisfying love life at midlife. You can add your flavor of whipped cream and lingerie, but if those five ingredients aren’t in place, sex just won’t work very well.

These ingredients may be surprising (knowledge? emotional intimacy?), and some are unique to our stage of life (vaginal comfort, genital sensation, pelvic tone). We try to help you understand why they’re important and to give you tools and tips for understanding what they are and for incorporating them into your life.

Here’s a tool someone at a recent conference told us about; it reaches the same destination by a different path. It’s a fun quiz put together by the Association of Reproductive Health Professionals (ARHP). Sounds like place to get blood drawn, I know, but behind that bland façade is a sexy little quiz that reinforces a lot of the thinking behind our recipe.

To start, click on your age in the circle that says, “It [sex] could be better…” The questions cover a range of life issues, from physical health to libido to emotional well-being—because, as we’ve said, sex involves all our parts, including our psyche and our emotions.

While the assessment tool is meant to be light and fun, it also delivers good advice. Be honest with your answers (who’s looking, anyway?), and you’ll get some targeted, useful information to improve your sex life. And maybe the rest of your life.

You’ll discover, for example, that about 20 percent of women (of all ages) have a hard time getting turned on, and that it’s one of the most common sexual complaints. That a woman’s sexual response is complicated and affected by things like self-image and stress. (Click on the right-side box that explains how men and women are different.) The tool reassures you that most women can’t orgasm with penis-in-vagina sex alone, but need clitoral stimulation as well.

Nothing earth-shaking, but some nice reinforcement and some good tips. Take the quiz. Read the results, then dig around in MiddlesexMD for more in-depth information. We have lots of information about pain during sex. And we’ve certainly explored the female sexual response cycle. We’ve clarified the difference between moisturizers and lubricants, and we sell them both in our shop.

So, use the assessment as a fun way to pinpoint areas you might need to work on in your sex life, and then dig into our blog and website for the meat and potatoes.

Q: How do obesity and high blood pressure affect my menopause experience?

Sexual health always follows general health, so it's hard to enjoy sexual health with other chronic conditions. Obesity is a known risk factor for heart disease, stroke, sleep apnea and other breathing problems, and osteoarthritis, among other things, and is associated with depression. Unfortunately, not sexy things to think about! And even more unfortunate is the fact that weight gain is common among women experiencing perimenopause; some say that a woman in her 40s and 50s typically gains a pound a year.

High blood pressure is commonly associated with obesity. Antihypertensives, which are critical for your cardiac health, can interfere with sexual desire and response. Unattributed

I know it's hard to hear, but it's most important to put "first things first," to get regular exercise, achieve and maintain a healthy weight, develop and honor regular sleep habits, and eat healthily both in amount and type of food. Exercise and activity will benefit you most. Yoga might be a good starting point, since it's low impact; it's also been proven to help women sexually, including with pelvic health. If you start there, you can add more aerobic activities as you're able.

Having a health care provider who can help you untangle the issues associated with obesity and menopause can be extremely helpful. If you're not confident in your current resource, you might look for someone certified by the North American Menopause Society. NAMS has a provider locator on their website.

There's no easy single answer for any of us: We're complicated creatures. Start small and keep moving in the right direction—but, most importantly, start!

Loving Your Beautiful, Aging Body

Recently, I took a photo of my college-age daughter. I saw a beautiful young woman in a candid moment—smiling, long hair blowing in the breeze, everything youth should be.

Her reaction?

“Look how dumpy I am. Look at my belly. My boobs are so big.”

And at the other end of the generational divide, a grandmother in her early 80s complains about how fat she is and compares her breasts to “rocks in socks.”

Ladies, will we ever get beyond all this negative chatter and learn to accept, if not love, the only body we will ever have? Will we ever stop wasting valuable energy judging ourselves according to totally unrealistic cultural standards?

Unfortunately, I’m not that self-evolved. Are you?

Do you make love under cover of darkness (or maybe just under the covers) because you’re embarrassed by the cellulite and love handles? Have you avoided looking in mirrors ever since you saw your mother (and maybe now, your grandmother) looking back? Do you head for basic black and avoid wearing the colors and patterns you really like? Do you hate being photographed? When was the last time you wore a bathing suit?

In 2009, Glamour magazine repeated a survey it had conducted 25 years earlier. Sixteen thousand women were asked about their body image—how they felt about their looks; what they like and didn’t like. The results: “Sadly, more than 40 percent of women are unhappy with their bodies, a number virtually unchanged since 1984.”

Even more telling—women under 30 are now more likely to feel good about their bodies than older women, which is different from the 1984 survey.

It’s understandable, of course. We’ve been drinking the cultural Kool-Aid about youth and beauty since infancy. Now we’re staring down the final taboo: We’re growing old. Not only that, but those bodies we may (or may not) have reached an uneasy peace with are changing, too. They’ve developed bags and wrinkles, aches, pains, and excess avoirdupois. And no matter what we do to turn back the clock, this process will continue relentlessly and irrevocably.

Love yourself. Move your body. Watch your portions.This may be a good thing. This may allow us to finally claim who we are, undistracted and unburdened by the judgmental nattering all around us. When we can finally face down our shaky self-image and put our insecurities to bed. Perhaps we can appreciate and develop the things that really matters—our relationships and our own unique and beautiful selves. And maybe, having shaken off that critical voice, we can finally engage more freely in life and love and the world around us. 

Sounds like a worthy goal at least. Here are some ideas to get started:

  • Monitor your thoughts. To paraphrase an old saying: You are what you think. Do you cultivate a stream of negative thinking about yourself and others? Observe where your mind wanders and how you react to things. Try to turn negative thoughts and judgments in a positive direction.
  • Watch your mouth, too. Turn off the gossip and negative chatter—and that includes putting yourself down.
  • Cultivate friendships with joyful people who inspire you and are healthy to be around. Identify some unofficial life coaches who have experience, wisdom, and joy to share. Ideally, you’ll take your place among these mentors soon.
  • Identify things that make you feel good about yourself, whether it’s a massage, volunteer work, an afternoon with a special friend or an evening with your honey.
  • Don’t diet. Most people who diet gain the weight back anyway and are obsessed with weight, guilt, and counting calories. Instead, make your goal a healthy lifestyle. Focus on eating well and healthfully.
  • Do move. Getting active physically not only makes you feel better, but you’ll also feel better about how you look. “Being active in and of itself improves body image,” says Jim Annesi, PhD., in the Glamour article. And getting those joints moving increases flexibility and reduces the aches and pains, which incidentally helps with the next point…
  • Have sex. Paradoxically, the activity that is most likely to trigger our insecurities can also embolden us and restore our self-confidence. “Women who are able to get past those insecurities can find those fears are unfounded and realize how empowering it can be to experience pleasure and connection with another human being,” says gynecologist Hilda Hutcherson. So, after changing your thought patterns, developing a healthy lifestyle, and cultivating positive friends, the final payoff can be uninhibited sex with someone who ideally loves you just the way you are. With the lights on.

Have you noticed how attractive joyful people are? How age has its own special beauty? Have you noticed that beautiful woman with joy in her eyes and the wrinkles and lines of experience on her face?

That’s you.

Q: Where can I find a physician who shares your passion for remaining sexually active?

I often recommend that people try the North American Menopause Society's (NAMS) website. NAMS has a rigorous process for certification, so the health care providers who are a part of it are likely to be committed to continuing sexual health for women like us. The website has a practitioner finder, too, so you can see whether there's a member in your area.

If that option isn't fruitful, we recently published a longer blog post with some other suggestions to explore.

Good luck, and keep looking! It's important to have a health care provider you're able to communicate and work with as you navigate the years ahead.

Talking Sex with Your Health Care Provider

Dr. Sheryl Kingsberg is a MiddlesexMD advisor and a psychologist specializing in women’s sexual health. She talks to physicians a lot about why it’s important to at least ask about a patient’s sexual health and maybe take her sexual health history. So she’s very familiar with the view from the physician’s side of the desk when it comes to talking about sex with patients. Generally, she says, health care providers have little training in women’s sexual health, even though they deal with those organs all the time. So—“they’re not going to ask about a topic they don’t know much about because they feel like they’re walking into something blind,” Sheryl says. Plus, they’re probably embarrassed, and they’re afraid the discussion will take too much time. “All health care providers struggle with this issue,” she says. Patients are often embarrassed to bring up the S-word, too, even though they may have questions or problems. Or—they may think (studies prove this is true) that nothing can be done about the problem anyway. This is because, in general, women’s sexuality is complex and can be affected by everything from physical changes to cultural morés. There are treatments for women’s sexual problems, but they’re just not as simple as a pill, because, well, our sexuality isn’t that simple. As a result, sex is the elephant in the examination room. It’s the health care version of don’t ask, don’t tell. What Sheryl tells physicians is that not only is it important to give a woman permission to talk about sex and to be prepared either to treat her problem or to refer her to a specialist, it’s also their responsibility as a practitioner. Here’s how she puts it:
  • Sexual issues are very common. About half of women will have some sexual difficulty at some point in their lives.
  • Sexual health is a basic human right, according to the World Health Organization. It is the health care provider’s responsibility to be concerned about and to manage the patient’s sexual health.
  • Sexuality is important to a woman’s overall health and quality of life.
  • Patients are uncomfortable bringing up the topic. They don’t know if it’s appropriate, and they don’t think anything can be done to help them.
  • Patients won’t be offended if the provider asks about their sex life.
  • Asking about a woman’s sexual health doesn’t have to take a long time. At the very least, the health care provider should communicate that it’s okay to talk about sexual problems, and be prepared to refer the woman to a specialist.
That’s it. That’s the manifesto. It’s your right to have your sexual health questions and problems addressed, and if your physician can’t or won’t do that, Sheryl says: “Find a new provider.” The medical landscape is changing, she says. Rather than the old “doctor knows best” mentality whereby you, the patient, comply with the treatment regimen your doctor prescribes, now the approach is to work together with your provider to develop a regimen you can adhere to rather than passively comply with. Sexuality is important, and if your health care provider hasn’t asked you about this quality of life issue, bring it up. Then, if he or she doesn’t respond, well, there are lot of other providers in the pond.

When to Say Goodbye—to Your Health Care Provider

The provider-patient relationship is delicate and fraught with opportunity for misunderstanding. On one hand, you have a busy professional in a somewhat risky, stressful profession who is pressed for time and is trained to speak a foreign language—medical mumbo-jumbo.

On the other, you have ordinary people who may or may not be good at communication and who are paying a lot of money to entrust to this person their most precious possession—their health.

On one hand, it takes time to become familiar with someone’s personality and communication style. And it takes time to develop trust, which is a critical ingredient in any relationship that will last a long time, including this one.

But on the other hand, the stakes are too high to overlook for very long a bad attitude, questionable treatments, or ongoing discomfort on your part.

So how do you know when to finally pull the plug and find another health care provider? And how do you go about that process, anyway?  We’ll answer the first question in this post and the second in a later post.

The top reasons to look for another health care provider:

  • Your health care provider interrupts or doesn’t listen. Your questions are prepared and succinct. You aren’t rambling on or complaining about your job, yet your provider is glancing at the clock, seems preoccupied, or keeps checking his or her Blackberry. Or—you’ve barely begun to ask your questions, and your health care provider interrupts. (Some studies indicate that providers interrupt their patients within 23 seconds after a conversation begins.)
  • Your health care provider is arrogant, argumentative, or unapproachable. Your health care provider must be able to listen to challenging questions and to answer them thoughtfully and without defensiveness. A health care provider who doesn’t welcome questions from his patients, who blames the patient, or who becomes hostile, defensive, or argumentative either has a personal problem or doesn’t understand the first thing about a professional relationship. If you like being bullied, stick around; otherwise, head for the hills.
  • You can’t get in for an appointment. You may have to schedule a routine physical several weeks in advance, but you want to be able to see your health care provider when you’re ill. At that point, even a few days are too long. If you can’t see your health care provider when you need to, that’s a problem.
  • Your health care provider’s staff is unfriendly, unhelpful, or incompetent. Unreturned calls, lost paperwork, billing errors, curt or snippy responses to questions, and long stretches on hold—these annoyances seriously impede your relationship with your health care provider. You owe it to your provider to let him or her know about your experience with the staff, but if nothing changes over time, you’ll have to assess whether the relationship is worth the aggravation.
  • And finally—your health care provider is unwilling or uncomfortable addressing your sexual health. Sexuality is a big part of your identity and a major contributor to your quality of life. Yet, as we’ve discussed before (and will again), most providers don’t bring it up. And they should. Dr. Sheryl Kingsberg, sex therapist and MiddlesexMD advisor, takes no prisoners on the issue. (More on this later, too.) “If your health care provider is that uncomfortable or indifferent to your quality of life, then I’d consider getting a new provider.”

When Things Go POP

In a post last week I talked about the very important pelvic floor muscles—that springy base that supports our pelvic organs and controls the orifices that pass through it. While it’s pretty darned important to keep our pelvic floor toned and in good working order, that becomes harder to do as we age and absorb more of the slings and arrows of outrageous fortune. Or just of daily life.

One common side effect of aging on those muscles is pelvic organ prolapse—or POP. This is when one or more of the organs resting on our pelvic floor—the uterus, the bladder, and the bowel—sag into one another, sometimes causing the vagina to protrude. It’s like pebbles on an elastic surface. If the surface is taut, the pebbles stay in place; relax the surface, and the pebbles all roll toward the center.

When we were young, our pelvic floor muscles were taut and nicely toned, and our organs were all held in place by ligaments and the pelvic floor. Over time, those ligaments stretch and sometimes tear. The pelvic floor sags and loses tone, and the organs tend to drop, move around, and squish together.

Factors that cause or exacerbate POP are

  • vaginal delivery, especially of large babies
  • heavy lifting
  • chronic constipation
  • chronic cough
  • being overweight
  • menopause and loss of estrogen

Since virtually all of us have encountered (or will encounter) at least one of those conditions, pelvic organ prolapse is, as you might expect, extremely common. About half of us will experience some degree of prolapse in our lifetime. Not only that, it’s been around for a while, too; it was mentioned in literature as long ago as 2000 B.C.!

Often, the condition is mild and you may not even know you have a prolapse, in which case you don’t need to do anything. On the other hand, you may experience one or more of the following unpleasant symptoms:

  • difficulty urinating or having a bowel movement
  • leaking urine with any “bearing down” motion, such as running, sneezing, or coughing
  • a sudden urge to urinate and not quite making it to the bathroom
  • leaking small amounts of stool
  • frequent urinary tract infections
  • feeling as though something is falling out of the vagina
  • tissue emerging from the vagina
  • partner’s sensing “something is in the way”; more rarely, painful intercourse

Our organs can prolapse in several creative ways. The bladder can fall into the vaginal wall in front, which is called a cystocele. The bowel can tip into the vaginal wall behind, called a rectocele. Or, the uterus can fall down into the vagina, often squishing it out the vaginal introitus (entry).

Treatment options include lifestyle change, surgery, or using a pessary. Lifestyle changes can prevent further damage to the pelvic floor:

  • Maintain a healthy weight to relieve pressure on the pelvic floor
  • Don't smoke, which is often associated with a chronic cough
  • Avoid heavy lifting
  • Avoid constipation and straining with bowel movements
  • Do kegels. (Lots of kegels.)

Pessaries are simple silicone devices that are individually fitted and inserted into the vagina to hold it in place. They need to be removed and cleaned every few months, which can be done at home or in a doctor’s office. They’re usually effective, but they can limit the depth of penetration during sex.

Additionally, topical estrogen can help improve tone in the pelvic floor muscles and vaginal walls.

As a last resort, various surgical options can relieve the discomfort and distressing symptoms of prolapse. Sometimes this involves a hysterectomy and/or reconnecting the torn ligaments. Sometimes a synthetic mesh material is used to support the prolapsed organs.

Consider the surgical option carefully, however. According to the National Association for Continence (NAFC), about 11 percent of women have surgery for pelvic organ prolapse, and about 30 percent of those surgeries fail, necessitating yet another surgery. These failure rates have led some experts to consider POP a “chronic” condition. Additionally, a recent notification from the FDA warns against using the surgical mesh because of a high incidence of “serious complications.” Also, it may be impossible to remove the mesh once it’s in place.

Pelvic organ prolapse is common; it can cause embarrassing or annoying symptoms. It can interfere with sex, and it can even interfere with everyday activities. Once a prolapse has become severe, kegel exercises are less effective and treatment options are less reliable.

The best approach is to take care of your pelvic floor before things get out of hand. So, as we said before… start kegeling.