Letters! We Get Letters!

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?”

Full stop.

DUH.

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!

January 22, 2016

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pelvic floor ›   women's sexual health ›  


Pleased to Meet Missy

When I first talked to Missy Lavender, I really had no idea if I would ever catch my breath. What knocked the breath out of me? Pick one: The sheer force of her charm, the drama of her comeback story, the strength of her will, the depth of her love, the remarkable cheer and impishness of her presence—even over the telephone. Or just the fact that we are on the same path, working on the same problem, with exactly the same drive… to make sure that women everywhere get to enjoy good pelvic health, for life. 

With Missy, it’s been no holds barred. And so I jumped at the chance to join her advisory board, and I’m happy to be exploring what we might accomplish together. So, this post will be an introduction to Missy and her mission, because we really want you to know all about her and the BelowYourBelt.org, the organization she founded as her response to, as she would say, “things going sideways” in her pelvic life. That’s kind of putting it mildly. 

But this Kellogg Business School MBA lost a lot after childbirth left her in pelvic trauma, with a babe in arms, and struggling, despite all of her many resources, to get the help she needed to recover her urinary and sexual function post childbirth. She made up her mind that the difficulty she had finding solutions to pelvic problems would never have to happen for other women. 

With the kind of energy no new mother in her 40s usually has, she jettisoned her former career in investor relations, and established the Woman’s Health Foundation with the goals of improving women’s pelvic health and wellness, driving research, developing and offering education and fitness programs, fostering conversations, creating communities for women, and serving as a national resource on pelvic wellness issues. 

And if that sounds like a lot to pull off, just know that now, in their twelfth year, they are doing it. All of it. And doing it really well, too, from their offices in Chicago, with their amazing and dedicated team, and largely because Missy herself is a force of nature. 

We struggled and huffed and puffed, but eventually caught up with Missy, for a moment, over the holidays, for cup of tea and a chat about this path she has been on. She was preparing for yet another pelvic surgery to manage the aftermath of that difficult childbirth, a situation she will share completely with her readers in the blog she writes on the Foundation’s website, where you can keep up with all of the projects they are managing, and all of the many good souls making their work possible.

Some of the people you get to meet are her favorites, the “Grumpy Patients” and mine, the “Grumpy Patients.” Here’s Missy:

I’m a grumpy patient. Grumpy patients are a blessing! Grumpy patients have made all the difference. The proactive patients are the ones who change the world. But you ladies already know that at MiddlesexMD. Your readers are all the grumpy patients already. Seekers, I suppose.
     We all need to be turning around and talking to our female relatives who are not online, our sisters and mothers and daughters. What keeps me up at night is knowing that so many of us are out of touch with our pelvic lives. As a culture, we don’t understand our lives below the belts at all. Culturally, we aren’t raised to pay any attention to it.
     As women we should really be owning this wonderful center of our bodies, the center of our divine feminine, our procreative center, our digestive center, our urogenital center, we should understand it all, how it works, where everything is and how it functions. We should start understanding it all, in all of its dimensions, from a very early age, so we can see it all in our mind’s eye, and remain mindful and in tune with our pelvic health and well-being so that we can stay on top of problems and learn to get help quickly when things start to go wrong. Never ever just sit back and live with pain and dysfunction the way our mothers and grandmothers did. In silence, imagining this is a woman’s lot in life!
     In generations past, even now! Once a woman got past her late 30s, more than half of us, for most of us, things start to go wrong below the belt, any of a number of issues, pelvic organ prolapse, endometriosis, twisted tubes, cysts, simple fungal infections—oh, you name it—and there was very little help or information available. And societal silence!
     And then what happens? The last thing we feel like doing is having sex. Consciously or unconsciously partners, just get shut out. My hypothesis, and I’m setting out to prove it, is that more than half of marriages end because of problems below the belt, and pain and shame that is not shared or managed. 
     My goal is a world in which women don’t have to stumble around. There really is so much help. There are so many therapists and doctors. It doesn’t have to cost you. There is so much that can be done that is not invasive these days. So much we can do for our own pelvic health. The point is, we have to all keep asking until we get the right answers. And we just have to make it easy to have these conversations. Take the hush-hush out of it.
     Our work has been focused on helping provide pelvic health education and outreach for every stage of a woman’s life. And encouraging sharing the transitions, woman to woman, so we know what to expect. Right now we have to fix the silence up and down the generations. We have to help our children and our mothers and grandmothers because the silence has been too big of a problem for too long. 
Women just don’t have to live with discomfort and dysfunction below the belt. We don’t have to. There are so many therapies that are non surgical, and so many barely invasive surgical procedures. And so many surgeries that will simply give you your whole life back. It’s worthwhile to know all of your options. 

So that’s a bit of Missy. The whole Missy is transforming. Her books (including this one for daughters and granddaughters) are charming and so worth having in your home and giving to the women you love. I’m giving them to the women I love. We’re looking into offering them through our site.

Meanwhile, do check out BelowYourBelt.org, throwing light on pelvic health in all its complexity and beauty. Demystifying it and keeping it all working for us, happily and comfortably for life

November 30, 2015

2 comments

addyi ›   desire ›   hsdd ›   women's sexual health ›  


A Watershed Moment for Women's Sexual Health

It may surprise you to hear a practicing doctor readily admit that there are vast fields of uncharted forest in human medicine.

I knew that when I began my studies, and now, many years later, I still find the constant learning that the discoveries my scientific sisters and brothers bring to my field my greatest hope and challenge. And sometimes it’s a source of frustration too, but today I’m focused on hope.

For quite a few weeks now I’ve been able to offer my patients something new. Addyi, the trade name for Flibanserin, the much talked-about prescription drug designed to treat Hypoactive Sexual Desire Disorder (HSDD), a disorder that I’m all too familiar with in my practice, a heartbreaking condition faced by so many of my patients and their loved ones.

But back to the question of advancements in medicine. When I think of this moment. I think of a parade of watershed moments in medicine. I know it may not seem like this to many people on the surface of it, but the approval of this drug, to doctors who serve women with sexual disorders, is HUGE. In my field it’s up there with, say, the dawn of anti-septic operating procedures. Think: we’ve only been washing our hands carefully before surgery since the 1860s. In the scheme of things, not that long ago! Or another watershed moment for women, the publication of Our Bodies, Ourselves by the Boston Women’s Health Collective in 1973, a book that changed everything, utterly. Or the Public Health Service Act of 1975, which made gender inequality in medical education illegal for the first time and propped open the doors for my own education… Finally.

And when I think of my ability to write Addyi prescriptions for my patients, that’s mainly what I think. I think…Finally! As hard as it was to get this one single drug for female sexual dysfunction (compared with 26 for men?) approved, and with all of the weight of its warnings and the hoops of physician training and the cost of it — despite the weight of all of that, through all of that — the FDA heard us. THEY HEARD US. 

And that is the win. 

So. Addyi is my new septic procedure. The one that will start saving lives immediately, one way or another. I can’t tell you what it means to me to have at least one arrow in my quiver for the women, LOTS of women, suffering, in my practice, because they WANT to want to feel the fullness of their sexual selves come alive. A basic human right, says the World Health Organization. A basic human right. 

(By the way, did you know that Joseph Lister, the inventor of septic operating procedures was ridiculed widely and run out of this country, had to work extra hard and fought a difficult uphill battle to convince people that, really, anti-septic procedures in surgery would save lives? True story… If people had only believed him right away…. )

The outcome of the past few years is a watershed, a turning point because through the process of approval, the FDA has gotten the message: They now completely understand that this previously misunderstood disease — or the complex of Female Sexual Dysfunction, is very real. These women are suffering. So are their partners. They deserve focus, research, discovery, and treatment. And judging by the most recent news that the FDA has recognized Female Sexual Dysfunction as one of the 20 key unmet medical needs in the United States, they will be getting it. 

HUGE.

Meantime, Addyi will help some of these women. Maybe your sisters or daughters. Some with Hypoactive Sexual Desire Disorder will improve with this treatment. At least they will know within a month or two of trying, and for those suffering, the option is available to them right now. 

These women will need to talk to their doctors about Addyi. Women who don't think they need it can help their sisters by asking their doctors about it, showing that it matters. Doctors will need to complete a short online training course to familiarize themselves with the new drug. It’s very short, and found right here. The sooner doctors get their training in, the sooner they can start prescribing the drug, the sooner women can at least try it, to see if it will work for them. I started prescribing in October, so expect to hear in December, after the recommended two months, whether it’s been beneficial.

If it works, happier lives. Fuller, happier lives. The medicine will keep getting better. Have hope!

To Squish or Not To Squish

The American Cancer Society has released new guidelines for Mammogram Screenings. We know you’ve likely read a lot about it. I thought I’d hand it over to our old friend and writer Julie, a longtime MiddlesexMD blogging pal, who has breasts of her own and some thoughts to share on what to do when new guidelines hit the airwaves.

Guideline Headlines!!! Okay girls! Grab them and run! But which way! When? Where? But wait!!! No!

No! These guidelines are saying to maybe squish less often? For some of us? Really? To not start so soon? Who are these people?

I’m confused.

With the latest release of Breast Cancer screening guidelines from the American Cancer Society, it’s easy to feel a little—entangled—in questions of when and whether to handle our screenings. And no wonder. The discussions are very much in the air, and the experts are agreeing to disagree. Very politely.

It wasn’t the intention of the committee to create this confusion, of course.

They truly wanted to offer up more leeway in guidelines, particularly for women with average risk of developing breast cancer—and that’s most of us. But leeway is very hard for most of us to interpret. Most of us just want very clear direction. We want safety and assurance. We want to avoid unnecessary exposure to radiation and unnecessary medical procedures. That’s not too much to ask, is it? 

Well, we can’t have absolute assurances from medical guidelines. It would be so nice if we could. We can only get the best advice from smart committees working from what data they have to keep the greatest number of us safe most of the time.

So the new guidelines ease up on the youngest women, aged 40-45, saying they don’t need to start screening if they have average to low risk of breast cancer. Of course we women in menopause are already screening our breasts, have already been at it for years by now. Now we are wondering what to tell our daughters. And we will be getting different advice from at least three of the six breast-cancer-guideline-writing organizations in the US alone. 

In fact all of those concurrent guidelines exist out there already, in our doctors’ heads. And online. And in our restless heads and hearts. So what do we do with all of this various information?

First… We breathe.

Then…  We remember, that we are each in charge of our own bodies. Guidelines are there just as a framework of reference. In practice, we each are working on our particular realities, which must be dealt with in the particular, with a plan that takes in all of the unique, unusual, specific aspects of our own bodies, or our daughter’s, their daughter’s.

So, I’ll take me, for example.

Those guidelines would suggest, since my breasts have been around for 55 years (well, one of them. The other seems much, much older), and in my family there is no history of breast cancer at all, and I have no current cancer markers, good and good. But… I’ve had so many surgeries and lung problems my chest as been radiated enough in my lifetime to light up Tokyo on a moonless night, which is not so good, and I’ve had to have a few lumps biopsied here and there, which have markers they like to peek at now and again, so….. Yeah I’m signed up for annual scans. Am I worried? Not really. But I’m committed. My sister, with the same family history, may logically choose to scan less often. Because she’s been much healthier throughout her life.  

A young relative in my family? Just turned 40. Did she need to go for her first exam? Not really, but she and her friends made a party of it at the local breast exam clinic. Wine and bites and breast squashing in paper robes. She could have put it off another 5 years, but she prefers to get this ball rolling. Preference plays a roll here. She is being cautious. 

You see how this rolls. Family history + conference with your physician over your own medical history + your own ideas and feelings about medical tests at this time in your life, taken together with a careful review of the recommendations = your best plan for screening. That plan for screening? It changes year over year as you age. That’s how you do this. Review your plan each year for you. Discuss it with the women in your family. And your friends. Like. Discuss it. Out loud. Over coffee or tea.  Like, “What’s your breast scan plan, Mom?” 

Like that.

It’s not rude. 

No. It’s not.

Happy deciding, everyone.

Q: Can I be tearing during intercourse?

It sounds like what you're experiencing is "bridging." There's a "bridge" of tissue at the base of the opening of the vagina. When stretched, it will occasionally separate or tear. As we lose estrogen through menopause, those tissues lose elasticity; there's also narrowing of the opening of the vagina.

A very successful solution is a "perineoplasty," a surgical modification of that tissue. Like a small episiotomy (sometimes done in labor to ease childbirth), it involves a small incision and repair to relieve pressure. In this case, the repair is made from front to back rather than from side to side.

This procedure is done in the office, under a local anesthetic, with just a few absorbing stitches. In my experience, it's very successful and much appreciated by women. Keeping things comfortable will often require some combination of localized estrogen, vaginal moisturizer, and a lubricant with intercourse.

November 10, 2015

0 comments

sexual health ›   women's sexual health ›  


Happy Vessels for Happy Organs

We have a new product in the house, and our team is pretty excited about it. I’m asking some of my patients to work with it as well as trying it myself, and I’m hoping to see exactly the same success with us as the manufacturer has been seeing in their studies. The studies you can see here, in the Journal of Sexual Medicine.

This product, called Stronvivo, is a supplement for women and men. 

And, before you worry about a doctor pushing Supplements, please hold on a minute. Good science backs this supplement up.

Stronvivo contains a stack of amino acids and minerals that are all essential to human life, but particularly helpful for supporting endothelial health—that is, strong blood vessels. These are amino acids and minerals that at our age we might not be easily getting or producing through our diets, metabolisms, or normal organ function.

And what are healthy blood vessels good for? They are great for the happy working of sexual organs. They are what make those organs go. Hers and his and theirs.

But, bonus! These same elements in these supplements are great for helping support the circulation of sexual hormones! Win-win! And especially a win for women who, because of cancer risk or preference, want to support what hormonal production their bodies can manage post-menopause without the aid of hormone replacement. This is a great offering for me as a physician. I love having a non-hormonal alternative I can present to my post-menopausal patients, and their partners!

And it plays out in the research of this formulation. The company tested their Informed-Choice, all-natural, US-manufactured product with women and men over 40 who have arousal issues. The results showed clinical improvement of the health of the endothelium, stimulation of nitric oxide production, reduction of platelet aggregation and adhesion, improved circulation, improved hormone production in the test subjects.

Clinical evaluations used the FSFI (Female Sexual Function Index), the PHQ-9 (Patient Health Questionnaire), the IIEF (International Index of Erectile Function, and the ADAM (Androgen Deficiency in the Aging Male) to measure female and male patients over 90 days. The women showed improvement in desire, arousal, lubrication, orgasm, satisfaction, and pain. The men improved in androgen levels and overall satisfaction.

And both women and men had improvement in mood, with less depression.

To understand the full potential, 90 days’ use is recommended for women; men may see full benefit after as little as 30 days.

Personally, I like the idea of a nutritional supplement that couples take together. It represents a kind of shared commitment to lovemaking and holding on to one another. 

Also, from a purely medical point of view, keeping the smaller blood vessels of our sexual organs happy will keep your larger vessels happy. And that will keep your whole body working better through time. 

And that makes this doctor very happy. If we’ve convinced you to give Stronvivo a try, you can order it here.

The Things Up With Which We Put

We have recently learned that women will live with incontinence 7 (seven) times longer than men will before seeking help for it. 

Wow.

I am the help, so I had to put this to my friends to help me understand why this would happen, because, well, frankly, I try so hard to be easy to talk with, and so do my colleagues, especially my colleagues and all their care teams in urogenital care.

So why, oh why would it take so long for anyone to come to us with such a difficult problem? No news could be more worrying.

As it turns out, it’s one of those problems many of us imagine is untreatable, undiscussable, more embarrassing because we imagine a leaking bladder makes us somehow… less. I just read the word on an incontinence forum: Unwantable. It broke my heart.

Then it sort of made me mad. Because nothing could be further from the truth! If a leaky bladder made us unwantable, most of us would be unwanted! Because here’s the truth! Humans Leak! I’m a doctor! I know this for a fact. We leak all over, all the time! 

But particularly menopausal women leak. I hardly need to mention that, do I? Sneeze, leak. Laugh, leak. Giggle fit, leak. Dream about peeing, major leak.  

Fully a third of us will experience some form of incontinence in our lifetimes. That’s way too many unwanted people, isn't it? So of course that's not right. Incontinence is just human. And it's got lots of causes. And it's treatable. 

Today’s truth is, there are so many varied and layered causes, treatments and options for managing incontinence that we understand now so much better than before, it's as if we have dozens of baseball bats we can grab hold of to smash that tired old stigma to bits.

But we have to do this out loud, and together, and among all of our friends and acquaintances. Let no one you know not help with the stigma smashing! It especially makes sense for us to pay attention to continence issues, and the great people who are helping us understand it and learn to manage it before it manages us. We look forward to sharing more on this and related topics from our friends at the Below Your Belt, where resources are available for women of every age on all aspects of pelvic health.

Too, this month the National Association for Continence (NAFC) is gearing up with free classes all over the United States, and then continuing all year long with Twitter chats on bladder health to help you learn what you need to know to Stay Strong.

Their message: Kegels are important, yes. But we must learn to do them correctly. And they are not the only way to strengthen your pelvic basket. These coaches will teach us to get to know our whole anatomy and strengthen our entire pelvic arena by teaming up with physical therapists and pelvic floor experts across the country to help all of us learn and gain control that we may have lost or may have never had to begin with.

Knowledge is power. Partnering with a provider you trust can get you that knowledge quickly. Check out Below Your Belt and the NAFC website, where you can find classes, coaches, products, a forum to speak openly and honestly with other people who are experiencing exactly what you are, descriptions of different kinds of incontinence and lots of treatment options. It’s a whole new world for us. We don’t have to just live with any of it any more. 

Clinical Pearls for Sexual Health and Happiness

I’ve got much to catch up on, study up on, and share with you from my trip to the North American Menopause Society (NAMS) annual meeting a couple of weeks ago. It was a whirlwind of great talks, and such a marvelous time to catch up with colleagues who are doing wonderful work. 

One of my all-time favorite people, Dr. Susan Kellogg-Spadt, who’s been a medical advisor here at MiddlesexMD, spoke at the conference! She was fantastic, of course.

She’s a nationally recognized expert in pelvic and vulvar pain and the Director of Female Medicine at the Bryn Mawr office of Academic Urology at the Center for Pelvic Medicine, in Rosemont, Pennsylvania. She treats patients throughout the United States as a vulvar specialist, sexual dysfunction clinician and therapist.

At her NAMS talk, Susan talked specifically about the sexual needs of menopausal women, and in some detail. We gain so much from having her in our field! But without further, um… gushing? Here are Susan’s top clinical pearls for our sexual health and happiness:

Add moisture daily. If we use a water-based, bioadhesive lubricant several times a week, regardless of sexual frequency, we can get a lot more comfort and satisfaction with sex and just make it easier to have an orgasm whenever we want to.

Nourish yourself. A Mediterranean diet has been shown to promote sexual function, (and, we just learned, perhaps lower breast cancer risk). And regular exercise improves mood and overall health, both of which contribute to better sex.

Talk it out. When we use “I” language to talk with our partners about sex honestly and in a non-accusatory way, we increase the chances of sexual success. Your NAMS doctor or therapist can help provide the vocabulary and communication tips.

Prioritize pleasure. Don’t wait for intimate time to just happen. Even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex. Putting it on your checklist may seem like a cold thing to do, but trust us, it gets hotter with practice.

Mindfulness matters. Reading or watching even the softest erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important. All mindfulness training can contribute to your ability to stay in the moment during your most intimate moments. 

Intensity, baby. After menopause, many women need more intense stimulation to reach orgasm. Consider introducing vibrators into sex play. The term, “Doctor’s orders!” can be very useful here. You have our permission to use it.

Do try. Just opening up and talking about sex problems, and finding what can still be sexual successes, shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship. Mutual affection, honest attempts at exploring what is possible, comfortable, what still feels good, does amazing things for a relationship. 

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