Sex and Your Hysterectomy: The Options

As I mentioned in the last post on this topic, even after you’ve decided to have a hysterectomy, a few critical questions remain. Time for a sit-down with your surgeon to hash them out.

First: How will he or she perform the procedure. There are three basic surgical options. The type of procedure your doctor chooses will affect the speed of your recovery, how long you’ll be in the hospital, and how much pain you’ll experience.  

  • Abdominal hysterectomy involves removing the uterus through an incision in the abdomen, usually along the bikini line. This route involves more risk, more pain, and a longer recovery period. Depending on your unique situation, this may be the best (or only) approach, but studies consistently show that, in most cases, the following two options are preferable.
  • Laparoscopic hysterectomy involves using tiny cameras and surgical tools—sometimes operated by a robot—inserted through small abdominal incisions, either to do the hysterectomy entirely or to assist in a vaginal procedure. This is less invasive with good outcomes.
  • Vaginal hysterectomy is just what it sounds like—the uterus is withdrawn through the vagina without requiring an incision. Generally, this procedure was found to involve fewest complications, to take less time to perform, and to offer the best outcome. Some factors, such as the size of the uterus or the shape of the pelvis, might prohibit a vaginal hysterectomy, but overall, this is the best choice.

You should discuss what procedure your surgeon recommends and why. The quality and speed of your recovery rests in his or her hands.

The second topic to thoroughly discuss with your doctor is what, exactly, he or she is taking out. Here are the three umbrella categories of hysterectomy.

Hysterectomy

Hysterectomy is the removal of your uterus and the cervix, which is the organ at the top of the vagina. A lot of discussion and very few facts surrounds the pros and cons of leaving the cervix intact. Unless there’s a problem with the cervix itself, there’s no biological need to take it out—or to leave it in. The preponderance of evidence suggests that the cervix has little to do with sex, and removing it doesn’t seem to change sensation or to affect orgasm.

Removing the cervix, however, can change the vagina: It can become shorter, although rarely enough to compromise sex; some nerves might also be affected, which could make the top of your vagina more sensitive, and not in a good way. But the vagina, as we know, is a very stretchy and forgiving organ, so with the use of dilators (and gentle, consistent sex) the situation can be remedied.

Often, the cervix is removed prophylactically, to avoid a small but real cancer risk. Without a cervix, there’s no longer a risk, ergo, no more pap tests. That’s one point in its favor.

Supracervical Hysterectomy

In the supracervical hysterectomy procedure, only the uterus is removed, leaving the cervix, fallopian tubes, and ovaries intact. In this case, you probably won’t experience much difference in your sexual activity unless you were accustomed to deep-muscle uterine contractions with orgasm. No uterus; no more muscular contractions. You might notice other changes, however, that we’ll discuss in the next post in this series.

Hysterectomy with Bi- (or Uni-) Lateral Salpingo-Oopherectomy

Hysterectomy with bi- (or uni-) lateral salpingo-oopherectomy. Yes, it’s unpronounceable. This is the removal of one or both ovaries and the fallopian tubes along with the uterus. Unless you’re well into menopause, this procedure can put a woman in a hormonal tailspin.

The ovaries are the seat of much of testosterone production (it’s also produced by adrenals) and estrogen production—all the good stuff that keeps the sexual apparatus and our moods humming nicely along. Removing them while they’re still functioning puts a woman into immediate and sometimes intense menopause. It’s called “surgically induced menopause.” For that reason, ovaries are left intact, if possible, especially in younger women.

The decision can be complicated, however. The ovaries themselves can be diseased. Also, some women carry a genetic trait called the BRCA mutation. They are at a much higher risk for breast and ovarian cancer. While breast cancers are often identified at early stages, no screening or early-stage detection exists for ovarian cancer. It’s usually discovered later, when it’s very hard to treat. For women without that genetic trait, the risk of ovarian cancer is low, but not zero.

When menopause is surgically induced, your sex life (among other things) is likely to be seriously impacted just as it is in menopause. You should prepare for low libido, a possible decrease in arousal, dry vagina—all the issues we cover so repeatedly here.

I’d strongly advise you to line up resources ahead of time. Make an appointment with a gynecologist who specializes in menopausal issues. You might be a good candidate for estrogen and/or testosterone therapy. Stock up on lubes and moisturizers. Fire up the vibrator. The hormonal transition could be rocky, but with support and medical oversight, you’ll get through it. Sex (and life) will be good again. Promise.

A lot of issues and options are involved with the decision to have a hysterectomy (beginning with the question of having one at all). Believe me, you want to understand the process, your options, and the possible outcomes. When it comes to this part of your body and your being, you want to know what’s going to happen and to minimize the surprise factor.

 

 

 

Don’t Be Like an Astronaut

Recently I had the privilege of interviewing Dr. Joan Vernikos for my podcast series “Fullness of Midlife,” which are conversations with interesting people about health, love, life, and meaning. Dr. Joan was director of Life Sciences at NASA until 2000 when she “retired” to write and speak (some retirement!) about some of the groundbreaking research she had conducted from her special perch at NASA.

You can listen to the entire interview here, but I wanted to also distill the pertinent bits for MiddlesexMD readers.

As you might imagine, the effect of gravity, or lack thereof, is a fundamental concern for scientists at NASA. Astronauts are exposed to low-gravity environments, sometimes for months at a time, which has wide-ranging and deleterious effects on bones and organs, blood and cardiovascular systems. During her time at NASA, Dr. Joan specialized in the effects of gravity on the human system.

But here’s the thing: Dr. Joan came to understand that gravity operates on earthbound humans in similar ways! When we are upright and moving around, we are subject to the full effects of gravity pulling us to the center of the earth vertically. But when we are horizontal, lying in bed, for example, gravity’s pull is spread evenly throughout our bodies and is much less intense—similar to the experience of astronauts. “…The changes that accompanied lying in bed… 24 hours a day… are very similar to those we see in astronauts. Granted, maybe a little less intense,” said Dr. Joan.

Interestingly, these metabolic changes don’t happen when we sleep at night. Normal sleep appears to have a restorative, “detoxing” effect on the body and the brain, which is also important to good health.

The body is designed to move all day long...Since the few astronauts who actually spent time living in micro-gravity were harder to find than subjects willing to lie in bed, Dr. Joan began studying the effects of long stretches of time spent horizontally. She found, for example, that after about four days “very significant changes” began to happen in the way her subjects metabolized fluids, in the cardiovascular system, and in stress responses. Of course, as with astronauts, these changes mostly were reversed when the test subjects got up and walked around or the astronauts came back to earth, and gravity took over.

Then, Dr. Joan visited a friend’s elderly mother who was bedridden, and she realized the low-gravity changes she’d been studying looked a lot like aging. Was there a link between our increasingly sedentary culture and the symptoms of early aging? Dr. Joan feels that the chronic diseases of the elderly—diabetes, cardiovascular problems, obesity, bone loss and muscle wasting—are happening at younger ages, even in childhood, because we no longer allow gravity to do its work. We sit too much and move too little.

Dr. Joan hypothesized that the body is meant to move all day long, and in the not-so-distant past, that happened pretty naturally. Our grandparents “…bent over and reached up and made beds and cleaned and washed and gardened. And went and bought groceries and walked home or rode a bicycle, or whatever.”

Following several studies, Dr. Joan feels that simply standing up is “fundamental” to countering the effects of inactivity. Simply standing up and then moving around reverses the micro-gravity effects of lying in bed—or of aging. Trouble is, we don’t live like our grandparents. More likely, we sit for hours in front of one screen or another in the office and at home. Then, if we’re disciplined, we might exercise a few times a week.

Exercising, while good in itself, isn’t enough to counteract the effect of sitting around for hours every day. Our bodies are designed to move, to work against gravity. That, not sitting, is our normal state, the result of eons of evolution.

After her 2011 book, “Sitting Kills, Moving Heals,” was published, a slew of new research supported the hypothesis she’d developed from her work at NASA: Long periods of inactivity have deleterious health effects. “…sitting makes worse absolutely everything. Whether you’re talking about cancer—prostate, breast cancer, cardiovascular conditions, stroke, metabolic conditions, diabetes, obesity—you name it, it makes it worse,” said Dr. Joan. (Here, for example, is NPR’s report on recent studies of aging subjects. The conclusion? If you don’t walk now, you might not be able to later.)

So, what should we do, especially if we’re still working and chained to a desk all day—but even if we’re retired and reading or knitting? Fortunately, the solution is simple. “Stand up!” says Dr. Joan. Go to the watercooler, the bathroom, just take a break every 30 minutes or so. You don’t need to hop on a treadmill or take a 30-minute walk, just stand up and move for a few minutes. You won’t lose weight or tone your muscles with this regimen; it isn’t meant to take the place of exercise and a healthy diet, but it’s a good habit to develop if you regularly sit for hours every day.

Gravity is your friend, says Dr. Joan. Embrace it!

 

 

Weight Gain: Dirty Menopausal Trick

As if the hot flashes, mood swings, night sweats, and sexual challenges weren’t enough, now you can add weight gain to the menopausal whammy.  

That’s right. In case you hadn’t noticed (fat chance!), women tend to gain about 10-15 pounds on average—from 3 to 30 pounds is the typical range—during and after menopause. And because our entire metabolic mechanism is different now, that weight is blessedly hard to take off.

“I feel like my body has betrayed me,” said one of my patients.

“Prior to menopause I was able to maintain a weight loss of 70 pounds. I see that 25 pounds have come back and nothing I seem to do is helping,” said another woman.

Weight gain during menopause isn’t totally related to “the change.” Lifestyle, genetics, and, yes, hormonal fluctuation all play their respective roles, for better or for worse. But the weight goes on, and the way that happens is different from weight gain in previous years.

So, if you’re accustomed to losing weight easily—or not gaining it in the first place—this development may come as a puzzling and unpleasant surprise. And if you struggle with your weight, be forewarned: The deck is about to be reshuffled, and that struggle may become harder yet. The single bright spot is that you’re in a very big boat with a lot of other menopausal gals—up to 90 percent of us gain weight during this transition, according to this article.

Menopausal weight gain is different because:

  • It’s slow and steady—one or two pounds per year. Not enough to really notice, but the cumulative effect sneaks up on you.
  • It accumulates attractively around the abdomen. Belly fat. The kind that’s linked to heart disease and diabetes.
  • Breasts are bigger and the back is fattier. This might be nice for those of us who’ve always been lacking in that department, except that now, accompanied by a slowly enlarging belly, not to mention the back fat, the overall effect is less than flattering to our contemporary visions. And for those who were always well-endowed, well, a little (or a lot) more may simply be overkill.
  • It’s hard to lose. While “hard to lose” is a functional definition of weight gain, this is different because it’s part and parcel of a more profound change in how your body processes energy.
  • Body shape changes. Previously, you may have been a string bean or a curvaceous plum. Now you’re a round apple.

In order to effectively tackle this unsettling turn of events and to grasp why the things you did before aren’t working now, it helps to understand the underlying mechanism.

For one thing, muscle mass, which is an efficient burner of calories, slowly decreases with age. Now, even your resting metabolism (when you aren’t active) is lower. Adding insult to injury, loss of estrogen compounds this effect. Studies of lab animals suggest that estrogen has a regulating effect on appetite and weight gain. Animals with lower estrogen levels ate more and moved less.

When the ovaries stop producing estrogen, fat cells tend to take over. Ovaries produce estradiol, a “premium” estrogen; fat cells produce estrone, which is a weak, inefficient estrogen. This hormonal change increases the body’s efficiency at depositing fat, especially, we find, around the abdomen.

What used to work in the past may not now.A recent study confirmed that certain proteins and enzymes that enable cells to store more fat and to burn it less become more active in post-menopausal women. “Taken together, these changes in bodily processes may be more than a little surprising—and upsetting—for women who previously had little trouble managing their weight,” comments Sylvia Santosa, assistant professor in Concordia University’s Department of Exercise Science in this article.

You got that right, sister.

Menopause packs a couple more weight-inducing changes: insomnia and stress. When you don’t sleep well (and who does, what with night sweats and cratering mood swings?), levels of ghrelin, known as the “hunger hormone,” rise and levels of the “fullness hormone” leptin drop. That’s why you get the nighttime munchies. A study of over 1,000 volunteers (The Wisconsin Sleep Cohort Study) found that those who slept less had higher ghrelin levels and lower leptin levels—and also had a higher body mass index (BMI), i.e. they weighed more.

And we all know what stress eating does to our waistline.

So, what’s a stressed-out, sleep-deprived, menopausal woman to do? It’s a challenge, without doubt. However, when we understand the mechanism—what’s happening to our bodies on a biological level—then we realize that doing what we did before isn’t going to work. We need to change up the paradigm if we want to control our weight and maintain a healthy, active post-menopausal lifestyle.

This paradigm shift involves a different approach to both diet (Note: I did not say dieting!) and exercise. No magic pharma pill or painless regimen. Still, we can regain control of the bathroom scales despite the slings and arrows of our slowing metabolism and estrogen-storing fat cells. And honestly, we might end up with better health habits than we ever had before. 

I Will Ask My Doctor about that Embarrassing Problem

Resolution #4

For this last of our January resolutions series, we’ll break from our discussion of underappreciated body parts but remain totally in keeping with MiddlesexMD’s tradition of confronting embarrassing issues head-on and unfiltered. Specifically, those we avoid talking about with our doctors.

Admit it, most of us don’t like to discuss topics having to do with sex, elimination, mental health, gender orientation, obesity. Often these topics are surrounded by social ambivalence or downright discrimination. We want to be healthy and normal. We don’t want to have problems, and we sure don’t want to air them with a semi-stranger.

Doctors have heard it all. That's our job.The doctor/patient relationship can be clumsy, strained, uncomfortable or superficial. Some providers are simply more skilled at coaxing out and straightforwardly addressing your intimate questions. If you find that your doctor is abrupt or unapproachable, or if you just don’t have good chemistry, you ought to—and have every right to—change doctors. Along with your dentist and auto mechanic, this is one individual you have to trust.  

I want to assure you that doctors have heard it all. Not only that, we want—and need—to know what’s bothering you emotionally or physically. That’s our job, and we can’t do it effectively if you decide to soldier on. Often, that embarrassing secret can be easily treated; sometimes, it’s a symptom of something more serious that needs further testing.

Too often, however, patients wait until the “doorknob moment.” The exam is all wrapped up, and the doctor is literally almost out the door when the real question tumbles out: Oh, and I have noticed blood in my stool a few times recently; or, is it normal to have pain with sex?

If you don’t mention it, you doctor can’t address it. And if you wait until the doorknob moment, you may have to schedule a second visit so your provider can adequately assess the problem.

Here are examples of some of the questions that are either quirky or hard to bring up. Feel free to add your own in the comment section—or email me for a personal reply. While I can give you my best response, this in no way lets you off the hook from getting in-depth, personalized information from your own doctor.

  1. I’ve never had an orgasm. Is that weird? No. Female orgasm is a tricky business. Most women fake an orgasm at some point; about 5 percent of women never have one. But just because you’ve never had an orgasm doesn’t mean you never will. Here and here is some starter information. With some coaching, some understanding of your physiology (most women orgasm clitorally, not vaginally, for example), and some practice, chances are good that you’ll awaken those slumbering nerve endings.
  2. Do I look normal? “Normal” encompasses such broad and beautiful variety that there’s almost no such thing. Vaginas and labia, breasts and bellies come in a wide range of sizes, shapes, and colors. They aren’t often symmetric, and size and color can change with age and sexual activity.  Don’t believe me? Take a look at this art installation of real female genitalia. 
  3. Why am I growing facial hair? This is another side-effect of normal, hormonal changes during menopause. Often, facial hair becomes thicker and coarser as well. You should mention this to your doctor just to monitor the changes and rule out other causes. 
  4. Does it matter if I use drugs recreationally? Yes, it matters to your doctor. We need to know what’s going into your system, so we can correctly diagnose problems and be aware of possible interactions with other pharmaceuticals. This has nothing to do with law enforcement and everything to do with your healthcare—and sometimes even your life. We need to know about even benign recreational drug use, such as marijuana. 
  5. Sometimes I leak and sometimes I smear. Female urinary incontinence is very common. The number of people who suffer from fecal incontinence, however, is harder to estimate because, surprise!, patients are too embarrassed to talk about it, and their doctors don’t ask. If either is problematic for you, ‘fess up. Talk about it. Treatment is available.
  6. I’m postmenopausal, and I’m bleeding. Definitely an issue to discuss with your doctor. Most postmenopausal bleeding is a result of thin, dry vaginal tissue, but more serious causes have to be ruled out.
  7. Why does my vagina make a strange sound during sex? Vaginal tissue is made of pockets and folds. (That’s how it expands to accommodate an 8-pound baby!) When air gets trapped in the pockets, penetration can push it out. The sound is called queefing, and it happens to lots of women. 
  8. Am I ejaculating during sex? It’s possible. Female ejaculation is defined as fluid ejected from the urethra during climax. Colloquially, it’s called squirting. The phenomenon isn’t common but has been reported often enough that it isn’t a myth, either. Frankly, not much is known about why it happens or what the fluid is, exactly. Consider yourself special and stay tuned for more information.

Pick up your courage and a pencil and do yourself a favor: Write down all the questions, sexual, messy, and embarrassing as they may be, to ask at your next physical. You can also answer the questions in this quick and easy Menopause Map to begin framing the questions.

“In the end, we all just have to become comfortable with the fact that sex involves the genitals and the genitals are down there. It’s a big, messy thing—but it’s worth it!” says Dr. Debby Herbenick, in this article.

 

 

 

I Will {Heart} my Heart

Resolution #3

This is the tough one, ladies, but it’s also the most important. Cardiovascular disease (heart attack and stroke) is the #1 killer of women today. One in 3 women die from it. By comparison, 1 in 8 women die from breast cancer.

The news gets worse: about 44 million women in the US are affected by cardiovascular disease right now. Ninety percent of us have at least one risk factor, such as high blood pressure, diabetes, smoking, or being overweight. We are less likely than men to survive our first heart attack.

Fortunately, perfection isn't required.But the really good news is that 80 percent of cardiovascular problems can be prevented by knowledge and lifestyle change, according to the American Heart Association (AHA). The other bright spot is that improving heart health also improves our brain health, because good brain function relies on good cardiovascular function. And we know that as we age, we are at higher risk for various dementias.

It’s important to honestly tackle those lifestyle changes right now because as we age, our risk factors for heart disease increase: cholesterol and blood pressure tend to rise; we tend to gain weight; sleep may be more difficult. So time, very literally, is of the essence.

Unfortunately, lifestyle change of the type required for good cardiovascular health is hard. Honest, systemic lifestyle change demands consistency, and self-discipline, and this is hard. Few among us achieve perfection when it comes to an overall health care regimen.

Fortunately, perfection isn’t required. Getting started and sticking to it is.

To get started, assess your current baseline. These are the most important numbers:

  • Total cholesterol less than 200 mg/dL
  • HDL (good) cholesterol 50 mg/dL or higher
  • LDL (bad) cholesterol less than 100 mg/dL
  • Triglycerides 150 mg/dL
  • Blood pressure less than 120/80 mm Hg
  • Body Mass Index less than 25 kg/m2 (Find your BMI here.)
  • Waist circumference less than 35 inches

Second: discuss your numbers with your doctor to get your marching orders: hash out what to focus on; what is possible, and how best to begin, especially regarding an exercise regimen.

And third: Get started! Every one of those important numbers measuring cholesterol levels, blood pressure, blood sugar levels, and weight can be moderated or controlled through diet and exercise. That’s it. A clean, heart-healthy diet and regular moderate activity could extend your life and help you to avoid the serious consequences of heart disease. Plus, you’ll feel better, experience less pain, and be more flexible.

This is a once-in-a-lifetime deal.

A heart-healthy diet for a woman over 50 should rely heavily on fresh fruits and vegetables, lean meat and lots of fish, whole grains, and unsaturated fat, such as olive oil. Cut way back on salt, sugars of all sorts, saturated and trans-fats.

Cook your own food so you know what’s in it. Processed foods are full of sodium and unpronounceable additives. Make eating out a rare treat.

Both Weight Watchers and the Mediterranean diet get high marks from nutritionists as being heart-healthy, not too restrictive, and easy to follow—thus good candidates for a successful lifelong change.

Drink lots of water (we lose the tendency to feel thirsty as we age) and take your multi-vitamins and supplements, such as calcium and vitamin D, as advised by your doctor. Here’s a ton more diet information from the AHA’s Go Red for Women campaign.

Exercise is the second leg of cardiovascular good health. It’s hard to overestimate the benefits of regular, moderate activity—it regulates blood pressure, strengthens your heart and other muscles, increases bone density, and improves your mood.

The trick with exercise is to get started and to keep going because you will use every distraction in the book to procrastinate. It doesn’t have to be hard or expensive. A brisk, 30-minute walk 5 times a week—that’s all! Start with 10 minutes if you’ve been sedentary, but keep challenging yourself.

If you live in an area with cold winters, you can walk in the mall or do cardio workouts at home with some of the very good fitness videos available online. Here’s a beginner workout from the inimitable Jane Fonda, who imparts salty health advice along with encouragement. Here’s a no-nonsense and very comprehensive set of workout programs to explore once you’ve built up some stamina. Stick with low-impact workouts, warm up thoroughly, and don’t overdo. Steady, consistent progress is better—and safer—than a jackrabbit start.

Finally, stop smoking. Not negotiable. Smoking adds incredible risk to your health. Do whatever it takes to eliminate nicotine from your life.

It’s January. This is a good time to seriously take charge of your health. Imagine how incredible you'll feel after spending the entire year working out and eating clean. Imagine actually witnessing the change in those numbers. Buckle up for a life-changing year.

 

 

 

Soy: The Royal Bean for Symptom Relief

Previously, we examined several herbal remedies that are commonly taken to relieve hormonal symptoms. Plants have been used since time immemorial for treating health conditions, and I have the utmost respect for plant-based medicine.

Except for three caveats: 1) botanical (plant-based) treatments can have side effects and drug interactions just like any other medicine; 2) their use, dosages, and efficacy in treating specific illnesses haven’t been rigorously studied; and 3) the manufacture of these products isn’t held to federal standards for safety or consistency.

So my general approach to botanical therapies has been to proceed with caution. Always tell your doctor what natural remedies you’re taking, buy products from reputable manufacturers, and pay attention to how they’re affecting you.

Except for soybean products. I withdraw most of my qualifiers for soy.

While soy has gotten a bad rap in some quarters, especially since most of the US-grown beans are from GMO seedstock, soy still comes close to being a superfood in my (and others’) playbook.

Another tick in the plus column is that soy has been subjected to numerous rigorous scientific studies. (Not to mention that it’s been consumed for millennia in Asian countries.)

My approach to botanical therapiesRecently, new studies have shed light on how soy might work to relieve menopausal symptoms, such as hot flashes and even vaginal dryness. Its effects aren’t always straightforward, as in “eat more soy, have fewer hot flashes” (although sometimes, it is just that straightforward), but it does clarify how soy is broken down in our systems and under what circumstances it seems to be effective.

When we consume soy products, such as tofu, soy milk, tempeh, edimame, it’s metabolized in our gut into two main isoflavones: daidzein and genistein. These compounds have phytoestrogenic properties, meaning that they mimic estrogen in some ways. (However, seem to carry less risk than estrogen,  related to estrogen, and in fact, some research suggests they may have some protective qualities.)

Some women (about 30-40 percent of North American and Europeans; significantly higher percentages of Asians) carry a gut bacteria that can metabolize daidzein into a substance called S-equol. And this, according to at least one recent study, is the bit that is strongly linked to relieving hot flashes and other good stuff.

Among the women who produce equol, those who ate the most soy and had the highest levels of daidzein, reported far fewer vasomotor symptoms (VMS--or hot flashes in common parlance) than equol producers who ate less soy. “Among equol producers, higher equol availability attributable to higher soy consumption contributes to decreased VMS,” the researchers concluded.

Among women who didn’t naturally produce equol, there was no link between higher levels of daidzein and fewer hot flashes. Either you could produce equol and reap the benefit of soy or you couldn’t. Until recently, the only way to find out, says North America Menopause Society executive director, Margery Gass, was to conduct your own personal experiment: Eat soy foods for 4 to 6 weeks, and if it didn’t help, you probably couldn’t metabolize equol.

You either had the right gut flora or you didn’t.

Recently, however, a Japanese pharmaceutical company, Otsuka (Pharmavite in the US) has developed an S-equol dietary supplement made from fermented soybean germ, so whether you are among equol-producing women or not, you have access to the same VMS-busting possibilities.

Studies are fragmentary and scattered, but the consensus seems to indicate that S-equol, either produced naturally or taken as a supplement, is a viable and safe way to reduce the frequency and severity of hot flashes. It also may have positive effects on skin health, including regeneration and thickening of vaginal tissues without the risks associated with hormonal supplements.

Theoretically, you can take 10-40 mg. of S-equol supplement per day for relief of hot flashes. Since it’s metabolized quickly, you should take it in several 10 mg. doses at different times. S-equol has no negative interactions with drugs or supplements, and its side effects are minimal, although research is contradictory, so women with a history of breast cancer are advised to avoid it.

So there you have it. No guarantees, but with very little risk or expense you can conduct your own naturopathic experiment in taming menopausal symptoms. Let us know how it goes.

 

Secrets for Our Daughters (and When to Fire Your Doctor)

The United State of Women “Healthy Women. Healthy Families.” summit in Washington D.C. didn’t focus specifically on perimenopausal and menopausal women, yet my conversation with attendee Marta Hill Gray naturally circled around to the topic of women, aging, and sexuality.

Marta, a women’s health advocate, worked behind the scenes to promote “pink viagra,” and she continues to be an insightful observer of women’s issues.

What have you observed about society’s view of women beyond the childbearing years?

As women age, society says we are supposed to suck it up and get on with it, but that doesn’t mean we are healthy and actually taking care of ourselves. For so many women, when you get to menopause no one has taken time to tell us what to expect.

After attending the event, what advice do you have for my readers?

Talk to daughters, sisters, nieces, and friends about the changes that are coming.Younger women need to know the time will come to a time when their bodies are going to change. As older women, we need to talk to daughters, sisters, nieces, and friends about the changes that are coming. Let them know that once you have your babies, it’s not over. We should really mentor them in being diligent about their bodies, so they ask better questions and they’re smarter than we were.  

Your mom may tell you about having their period but not about menopause… It is a big deal. And women need to know there are doctors like you, menopause providers, who can make it manageable, who can give you treatment options and care and guidance so you move through it gracefully.

Not all doctors are comfortable with women in menopause.

That’s true. And if you don’t have health care providers you can talk to you, you need to fire them and find one you can talk to. Yes, you can fire your doctor, it’s all right! Just because they wear a white lab coat doesn’t mean they know how to help. You should be able to comfortably discuss any topic including bowel movements, urine, sexuality … all of that is important.

There seems to be more openness to talking about sexuality and sexual health today than when I began my practice.

I agree. The fact is that we’re living longer, we look better, and we are more involved than previous generations of women our age.

We're living longer and are more involved than previous generations.It is such a life-affirming thing to be a sexual creature, yet so many women have painful intercourse, and then they shut down, which can hurt relationships. I think that women going through menopause should definitely be able to depend on their health care provider to give them information and tools to overcome the challenges. It is different for everybody and, just as it is when you’re younger, it is very personal. A lot of women don’t know they have options and choices.

Women’s health and women’s sexual health isn’t behind the curtain anymore. It is being forced out on the table partially by the fact that our world is smaller and we know so much about girls as slaves, genital cutting, sexually transmitted diseases... everything is discussed and it will continue to be so discussed because these are facts. It’s an open discussion now, and the word vagina can be said. Women make up 50 percent of the population, and we are full citizens.

Younger women are leading the charge and they will not be denied. They have no fear. I think it’s fantastic, and it’s going to get better and better.

July 25, 2016

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Women’s Health: We Won’t Be Denied

You can't talk about women's empowerment without talking about health.My good friend and women’s health advocate Marta Hill Gray recently attended the first summit of The United State of Women, a gender equality movement with high-profile support from Michelle Obama, Warren Buffet, Oprah, Meryl Streep, Amy Poehler and other well-known celebrities. (To learn more, watch this two-minute film.) Naturally I was interested (and very curious) to hear all about this event, which was convened by the White House in Washington D.C. Here are highlights of my recent conversation with Marta:

I understand the topic of this summit was ‘Healthy Women, Healthy Families.’

Yes, you can’t talk about women’s empowerment in any fashion without talking about their health—it’s one and the same, and it hasn’t been given enough attention and respect. It was exciting to see 5,000 women who took time to fly from around the world for this event.

It was a tsunami of attention around women’s issues.

What was your main take-away?

There was a lot of sizzle with big-name celebrities… but more importantly, it really put a spotlight on younger women who are dedicating their lives to women’s issues

Millennials are really stepping up and very much engaged in ways we may not have been at that age. The younger women are leading the charge and they will not be denied. They have no fear. I just think it’s fantastic, and I think it’s going to get better and better.

What kinds of speakers did you encounter?

I saw some wonderful health care professionals who are working with underserved communities, helping women get the support and education they need, and helping them understand their rights are in terms of pregnancy, treatment options and even what insurance will (and will not) cover.

For example, The Women’s Law Center spends all of their time answering the phone and explaining to women what their rights are, like the right of all women to have breast reconstruction surgery after a mastectomy.

Those are the kinds of things that many of us take for granted, but not all women get the same information or the same treatment.

What surprised you?

I am seeing a real shift in the language and the public perception about women’s health. This isn’t just a women’s problem—it’s a problem for men, for boys, for sons. This impacts families and it impacts lives.

Why this special focus on women’s health?

Women's bodies need to be understood separatelyHere’s an epiphany: Women’s bodies are not like men’s bodies. They need to be respected and understood separately. Yet, women don’t know about their bodies, there is often shame about it and there many cultural nuances. The question is, ‘How can we support women who need this kind of care?’ 

But the good news is that things are changing. This summit was full of vibrant conversations instead of the shame of years ago.

I was encouraged by the young women. To them, it’s so important that there’s no thought of repercussions. It gave me great hope to see women who are so sharp and directed and capable.

My conversation with Marta went beyond the summit to the topic of women, aging, and sexuality. Watch for my next blog to learn more.

Don't Be a Stranger

I referred a few weeks ago to the controversy surrounding recommendations for the frequency of mammograms. A conversation over the weekend reminds me that there’s a similar fog surrounding the change in guidelines for Pap guidelines, introduced about two years ago and now working its way through health insurance policies.

We used to all take for granted that our annual Pap screen was the centerpiece of our annual physical exam. In fact, many women calling my office for appointments referred to the appointment that way: “my annual Pap test.” And the prevalence of annual Pap screenings did have an effect, lowering the cervical cancer rate in the U.S. by more than 50 percent over the past 30 years, according to the American Congress of Obstetricians and Gynecologists (ACOG).

Current guidelines call for Pap screening every three to five years, depending on your age and other health conditions—and there’s a lot of agreement about that from the American Cancer Society, ACOG, the American Society for Clinical Pathology, and, likely, your insurance company.

But! This doesn’t mean that there’s no need for an annual “well-woman” visit, including a pelvic exam. Exactly what happens at each annual visit should vary according to your age and your health history. What’s common, though, in addition to updating overall health statistics, is a thorough inspection of the vulva and vagina, including palpation of the area, including the lower abdomen, rectal, and bladder regions. We’re looking for any early indication of abnormality, but if your general health is such that you wouldn’t treat a condition if discovered, no further evaluation is necessary. A clinical breast exam is also part of the annual exam.

In addition to the “clinical” part of the exam, though, there are benefits that you can especially appreciate as you navigate perimenopause and menopause. First, your body is changing, so having an annual “date” to check in on your body helps you be aware of what’s happening. When you share your observations with your provider—which I hope you do—they’ll be part of your medical record, which gives you both a view of trends over time. With our busy lives (jobs, parents, kids, grandkids, volunteer projects), without a checkpoint, we can find we’re simply adapting to changes without even being conscious of them.

And the second benefit is that, with regular communication, your health care provider can be a genuine partner in keeping you healthy—physically, emotionally, and sexually. Seeing him or her at least once a year is part of that; the other part is setting the expectation that your appointment includes answering your questions—about everything from your tennis elbow to your vaginal dryness.

If you don’t find that expectation being met, get bossy. An annual exam—and, just as important, the conversation that goes along with it—is part of managing your own health. Having a health care provider with the time, expertise, and patience to answer your questions is not too much to ask. And when you’re comfortable with and confident about your health care provider, you won’t be a stranger.

A Little Olive Oil with Your Workout?

So my medical journals are telling me, AGAIN, that I need I need to eat better and keep moving. Gee, folks, thanks for the news!

But I rarely receive such specific advice as I have these past few weeks. They have handed me very, very clear directions: 

  • Eat a Mediterranean Diet including extra-virgin olive oil.
  • Exercise 300 minutes a week.

Wait… Really?

Specifically….  for menopausal women… my medical journals are suggesting we do this to avoid breast cancer.

Well! That’s pretty specific! And pretty awesome when scientists are paying special attention to my favorite people!

So let’s look at these studies suggesting ways we just might, through diet and exercise, provide our bodies an optimal environment for fighting off breast cancer. 

The PREDIMED study, published in JAMA, September, 2015, was conducted in Spain from 2003 to 2009, wherein more than 4,000 women at high cardiovascular risk, aged 60 to 80, were randomly placed on three diets: the Mediterranean diet, supplemented with extra-virgin olive oil (first cold-pressed), The Mediterranean Diet supplemented with mixed nuts, or a Low-Fat diet.

The results of this study have been coming out for some time, and have been fascinating. This latest release shows that those on the olive-oil-supplemented diet had a 68-percent lower risk of developing breast cancer than the other participants in the study. It’s one study, of course, and needs to be repeated, but it’s rather fascinating. Earlier outcomes of the PREDIMED study suggested the same diet resulted in a delay in cognitive decline for the same population. There will be more news from this cohort. We will stay tuned. 

By the way, when shopping for olive oil, it is best to stick with first-cold-pressed, extra-virgin olive oil for your good health. It costs a little more, but that’s the healthy choice that this study is based upon. Cheaper oils have been heat-treated or chemically treated, and are no longer a healthy choice for your body. 

The exercise link is a the Breast Cancer and Exercise Trial in Alberta, Canada, published in JAMA Oncology in 2015. The study followed 400 women. Half of them worked out for a half an hour a day, 5 days a week. The other half worked out for an hour a day, 5 days a week. They worked out at 65 to 75 percent heart rate for at least half of their workouts. All without changing their usual diets. The women were overweight, disease-free non-smokers, and they were followed for three years. Subcutaneous and abdominal fat and waist-to-hip ratio decreased significantly more in the high-exercise-volume group.

Since body fat increases postmenopausal breast cancer risk, this suggests this higher dose is a better dose of exercise for us to keep the weight off, the body fat down. Lower body fat is a better environment for lower breast cancer risk. 

So I’m going to take a brisk walk to the grocery store, buy two big bottles of my favorite extra-virgin oil, and do biceps curls with them on the way home. Or maybe I'll just stay a little longer on my treadmill and have a nice salad with dinner. 

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