MiddlesexMD

Don’t Take Menopause Lying Down

I always enjoy hearing from visitors to our blog, and recently one sent me a poem she’d written, which I’m sharing (with her permission).

Menopause

What else do you lose,
You asked,
After I said
The clitorati shrinks.

Hair. It thins
Or makes a career move
To your upper lip.
The plump walls of your vajayjay
—oh, and everything else down there—

Contract and dry up. 
By, like, eighty percent.
What you lose in volume,
You gain in bladder infections.
So, you know.
Even trade.

Desire takes a swan dive
Off the cliff
While you’re not even looking.

Your waistline vanishes.
(Although my sister says
It might be hiding under your breasts,
Which have retired and moved south.)

Forget about creaming your jeans.
Oh, god—
Remember those days?
No?
Ah, right.
Memory goes, too.

You suddenly become invisible.
Unless, according to research,
you’re an orca.
Which, you know,
We’re not.

Naivete, too—
All those years
Of little deaths
Each one
Knocking you off your feet,
Washing over you,
Pulling you under,
Tossing you back 
Onto the sparkling sand
Gasping.

Is there anything it doesn’t take?
You asked.

Sarcasm
(Not that I’m bitter.)

The poem is both funny and true (even the part about 80 percent). During menopause, there are a lot of things we lose. But that doesn’t mean we have to just give up. My whole reason for starting MiddlesexMD was to provide information and offer products that help women enjoy sex after menopause. 

The clitoris does shrink. What can you do? Use it regularly to maintain blood flow to the area. Consider investing in a vibrator, if you don’t already own one. 

Your hair may thin, but the cause isn’t always menopause. Talk to your doctor. There may be something you can do about it. 

You can improve the suppleness of all your urogenital tissues with things like localized estrogen cream (talk to your doctor), vaginal moisturizers, and lubricants. Do your kegels!

What about desire? It depends—but there’s a lot you can try, including testosterone therapy, increasing intimacy in your relationship (which is different from but related to having intercourse), and increasing the mindshare that you devote to sex. 

Maybe orgasms aren’t effortless any more, but they can still be very good. Try these tips.

With a little work, you can still have an amazing sex life!

(Oh, and if you wonder what orcas are doing in the poem, read this.)

Eating Disorders in Midlife

We don’t typically think of perimenopausal women when we talk about eating disorders, but middle age can be a high-risk time for developing one. More than one in ten women over the age of 50 engage in eating disorder behaviors, according to ANAD (The National Association of Anorexia Nervosa and Associated Disorders).

There are a few similarities between adolescence and perimenopause that make it easier to understand why women in midlife may be susceptible. Both are stressful times of transition to a new stage of life that we may feel ambivalent about or afraid of.  In addition, a characteristic of both is that our bodies seem to have minds of their own and change in ways we may not like. That is related to a third and particularly interesting (to me) similarity: fluctuating hormones, especially estrogen.

Research shows that reproductive hormones play a role in the development of eating disorders in adolescence, and evidence suggests that the same may be true for women in perimenopause. The time around menopause is a unique “window of vulnerability” for getting an eating disorder.

Eating orders are complicated things and there is not one thing that causes them. I’ve often heard that genetics load the gun and the environment pulls the trigger. If you or other people in your family have had eating disorders in the past, you’re more susceptible. In midlife, things like the loss of  a spouse or feeling lonely or powerless, or poor self-esteem may trigger an eating disorder.

According to ANAD, the biggest sign to look for is a preoccupation with food, calories, and exercise. How much time do you spend thinking about food and calories? How much time do you spend exercising? Does it interfere with other activities?

If you think you might have an eating disorder, talk to your doctor or another health care professional. Eating disorders have the highest mortality rate of any mental illness. They can affect bone density, the kidneys and the heart—and middle age bodies are less resilient than young ones. As with other illnesses, the earlier you catch it and address it, the easier it is to treat.

Why do more women than men get Alzheimer’s?

It’s not fair, but it is true: Twice as many women as men get Alzheimer’s. No one is sure why, but there are some dots in research that could well be connected, according to Lisa Mosconi, the associate director of the Alzheimer’s Prevention Clinic at Weill Cornell Medical College.

Gender—even when differences in lifespan between men and women is taken into account—is one of those dots. Another dot is that removing the ovaries or the uterus, increases the risk of dementia in women. The third dot is that women possibly start getting the disease earlier than men, according to Mosconi’s research. “It looks like the disease starts when your brain is the most discombobulated it’s ever been past puberty,” she says. “[W]omen have more years to experience the disease not because they live longer, but because they start earlier.”

Furthermore, while estrogen production plunges in women during menopause, during “male menopause” (androgen) testosterone levels decline more slowly and gradually, just one percent each year.

Estrogen may be the key. As Mosconi wrote in an editorial in the New York Times, “The latest research indicates that estrogen serves to protect the female brain from aging. It stimulates neural activity and may help prevent the buildup of plaques that are connected to the onset of Alzheimer’s disease. When estrogen levels decline, the female brain becomes much more vulnerable.”

Many factors affect your risk for Alzheimer’s, including genetics and lifestyle, and more research needs to be done before anyone can say definitively whether estrogen replacement therapy is the answer to preventing Alzheimer’s.

In the meantime, do what you can to protect your cognition: exercise regularly, eat lots of fruits, vegetables, and salmon (which is high in omega-3-fatty acids), and stay mentally active.

Q: If I even get an orgasm, it’s weak. Any ideas?

There are many reasons women have a decline in the ability to orgasm. Most often it is aging and all that goes with it: the loss of hormones, changes in vasculature (blood vessels) to the area. This is a common and frustrating condition for women.

It sounds like you have addressed some of the hormone issues with Estrace vaginal cream. This loss can be related to other medications; there’s a long list of medications that interfere in sexual function. The primary offenders are mood meds, pain meds, and cardiovascular meds (again, this list is very long).

I have found systemic testosterone therapy to be effective for about 50 to 60 percent of my patients. This is considered off-label (not approved for women for this condition) use of testosterone, and not all providers are comfortable or familiar with using testosterone. Another option is Viagra, again, off-label; there are women who respond favorably to using this medication at low doses. Wellbutrin is an antidepressant that for some women (again, variable from woman to woman) will improve sexual response

Have you used a vibrator? A vibrator provides more direct clitoral stimulation, which is generally necessary for women to achieve orgasm. For many women this—and patience—is a very helpful tool.

Q: Is it too late for me to try hormone therapy?

You say you’re seven years into menopause. You’re no longer having hot flashes or night sweats, but you’re aware of heart palpitations, occasional insomnia, anxiety, irritability, weight gain, and mental fogginess. You’re wondering if it’s too late for you to try hormone therapy and whether it could help with the symptoms that are of concern for you.

First of all, congratulations on upping your exercise regimen! That can make a difference in a number of aspects of health--as well as your feelings of strength and vitality. Exercise tops the list as lifestyle changes that are beneficial for menopausal symptoms, so I applaud your efforts and encourage you to continue.

The symptoms you share are absolutely on the list of many women who transition through menopause, or are, in other words, “hormonally related.” There isn’t, generally speaking, a “too late” in the timing to consider hormone therapy (HT). The exception is for women who are more than ten years beyond menopause and have known cardiovascular disease. For this group of women, initiating hormone therapy too long after menopause may introduce some increased cardiovascular risk.

The response to HT for palpitations, insomnia, mood disruptions (and by the way, anxiety and irritability are the top two I hear), weight gain, and mental fog is somewhat variable. We would expect some degree of benefit, but whether all of these symptoms respond favorably is hard to say.

Yours is the precise situation where I advise women (assuming no contraindications) to consider a course of HT to see how you feel. It usually takes two to three months to get a sense of benefit; there may be a dose adjustment in that time.

For many women it is well worth the trial to see how you respond and how much better (or not) you feel. Good luck!

Q: What’s with this burning sensation?

You describe a burning sensation when you urinate, which occurs for several days after intercourse. You’re using a lubricant and have had the MonaLisa therapy treatments.

These symptoms you describe sound consistent with possible atrophic vaginitis, vulvodynia, or a UTI caused by intercourse. Many women are not finding complete resolution of their atrophy with the MonaLisa Touch therapy. It may be helpful to add a prescription therapy; there are many safe and effective options.

Vulvodynia is a condition of inflammation at the introitus (the entrance) of the vagina, causing burning pain with and after intercourse. For some women the action of intercourse actually causes a UTI, a bladder infection that may be causing those symptoms.

You’ll need a discussion and a careful exam and assessment with your health care provider. Once the cause is determined, you can pursue the appropriate solution.

Q: Can I feel again?

You say that genital sensation is diminished, and you’re hoping for a surgical “fix.” You also experience some dryness, and wonder whether that “fix” could also affect lubrication. You’re also weighing the potential benefits of hormones.  

There aren’t surgical options to restore genital sensation. The “vaginal rejuvenation” approaches have no clinical data yet to support their benefit. I was on a phone call just recently with about 15 providers from across the country, discussing the topic of “vagina rejuvenation.” There are now some very difficult complications that have come from some of these treatments. I would caution you on this; we just don’t have enough good information to say it is a safe and effective option. While I absolutely empathize with your desire for a quick and lasting “fix,” unfortunately that just isn’t likely given available options.

Hormone therapy absolutely improves loss of sensation. The genitals have more estrogen receptors than any other area of the body, which means that the impact of estrogen is greater in the genitals than in any other area of the body! Especially in menopause (or other times of low estrogen), hormones (including testosterone) are a big ingredient of sexual function.

Exercise is a critical component of overall wellness (see this blog post on the topic). Exercise improves energy and self-esteem, releases helpful hormones, and does more that translates into improved sexual health and function.

Loss of sensation is a natural part of aging, as well as of chronic diseases like heart disease or diabetes; it can be a side effect of medications. The changes that lead to the loss of sensation happen over years. That means for each individual, countering that loss is a bit more complex than a single simple answer that works for everyone. For many women, vibrators work wonderfully to heighten sensation. Trying a warming or arousal lubricant might be helpful now that your genital tissues are healthy.

I hope this is helpful.

Q: Will these menopause symptoms never stop?

You say you’ve been menopausal for 20 years, and on HRT for part of that time. You still have night sweats and hot flashes, nearly every day and night. You’re missing your sex drive. Your doctors have told you these symptoms may or may not stop.

I’m afraid I have to agree with your doctor: Over time, most women will have fewer and fewer bothersome symptoms of menopause, but for others the symptoms will be for life. We don’t have any way to predict for whom the symptoms will resolve or when that might happen.

While lifestyle—diet and exercise—matters, it isn’t the complete solution. Congratulations on losing weight and building an exercise habit! I suspect your symptoms would be worse if you hadn’t lost the weight or were not exercising.

While estrogen is the most effective treatment for hot flashes, some women will benefit from other treatment options such as certain antidepressants, gabapentin, clonidine, and the herbal product Relizen. You could speak with your provider about considering a non-estrogen option.

Good luck!

Q: Which moisturizer would be safe for me as a cancer survivor?

All of the vaginal lubricants and moisturizers we carry are safe for women who have had uterine or breast cancer. None of them contains soy.

Soy is converted to an estrogen-like substance in about 25 percent of women who ingest it, that is, about 25 percent of us have an enzyme in our GI tract that converts soy to an estrogen-like substance. It is only oral/ingested soy that may be a concern to you; the vagina doesn’t function in the same way.

Q: Can you suggest a product for hot flashes?

You say you’d been using Relizen, but tried another over-the-counter product that didn’t work as well. When you went back to Relizen, it wasn’t as effective. Relizen is actually my first recommendation for non-hormonal hot flash management; patients in my practice have had great success. I have had nearly no success with Amberen, the other product you tried. I’m not sure why Relizen wouldn’t work now when it previously had. Have you been on it for 12 weeks or longer? Sometimes it can take that long to have benefit.

There are dozens and dozens of herbal products that claim hot flash relief; virtually none of them have clinical data to support claims of benefit. I am not opposed to women using herbal products, they just can’t be depended upon to work very well. The most widely used non-hormonal treatment of hot flashes is Effexor (venlafaxine), a prescription antidepressant that for about half of women reduces hot flashes—but is has its own side-effect profile that needs to be considered. Talk to your health care provider about that as an option. Prozac, Lexapro and Paxil also may provide some benefit. I have had patients who have had quite good success with acupuncture as well.

Of course the most effective treatment of hot flashes is estrogen. And there is exciting research for non-estrogen options in treating hot flashes. They influence temperature regulation in the brain, but those are likely a few years before coming to market.