A Valentine's Day Gift She Will Really Love

by Lauren Streicher, MD

Now, I have written about vaginal dryness before, and talked about lubes, moisturizers, and estrogens. But what I haven’t talked about is that it isn’t necessarily the woman who should be supplying it. Guys, it’s time to GO SHOPPING.

The key to being the most popular guy on the block – or at least in your house – is simple. Give her a gift of being prepared with the slippery stuff instead of waiting for her to get it. Will she be upset? Are you kidding? She will be ecstatic that you have taken matters into your own hands, and you still find her so sexy that you are dying to make mad passionate love to her. You don’t need to have a discussion or get her permission. I’m giving you permission.

The world of lubes is confusing and there are a lot of products out there. You will see shelves of vaginal lubricants that warm up, light up, and come with a theme song. Your first impulse will be to grab the bottle at the very end of the aisle, while stocking up on shampoo and deodorant to hide the fact that vaginal lubricant is the only thing on your list. But take some time with your decision, because this is an important one.

I am a fan of silicone lubricants since they tend to be the most slippery, longest lasting and least irritating. Silicone lubes are a little pricier than water based lubes, but well worth it. Just as your wife prefers designer fragrances over the $4 perfumes from the corner drugstore, she’ll recognize a good lube. You get what you pay for. Wrap it up with a beautiful bow, throw in some chocolate, and maybe a gorgeous nightgown.

Don’t wait until you are in the middle of having sandpaper sex to whip out the lube. Store it in a handy place, like under the bed. You don’t want to have to go on the hunt. As soon as you get an erection, apply the lube all over your penis (it will feel good!). Bonus: She will be happy to help. Use your fingers to apply the lube to the outside of her vagina. No need to put it inside (your penis will take care of that).

You will be amazed at the difference. Not only did you make things more slippery, but she will be in awe that you thought of it, supplied it, and knew what to do with it. Nothing makes a woman hotter than being with a sweet, sensitive man who can ensure that sex is pleasurable instead of painful. That kind of confidence and consideration will translate to a better sex life – and a better relationship.

This is one holiday secret that is too good to keep to yourself. Spread the word to your guy friends. Their wives and girlfriends will thank you. One word of caution – this may not be the gift that she wants to announce the next day at work when her friend's ask, "What did you get for V-Day?"  – so you may still need to spring for a little jewelry  and of course, a copy of Sex Rx: Hormones, Health and Your Best Sex Ever to read together. 

 

Extreme Makeover: Vagina Edition

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Throughout history, women have adorned or altered their appearance to appear more attractive and desirable The genitals are no exception to this rule of adornment. Hair removal, piercings, tattoos, and yes, even surgery are all things that many women choose to do in the interest of making their private parts more attractive.

But it’s one thing to glue a few crystals on your mons or dye your pubic hair pink for kicks. It’s quite another thing to undergo plastic surgery to change the appearance of your genitals.

Along with the “less is more” pubic hair trend comes the ability to clearly see what things look like, and as with every other part of the body, women tend to be really critical of their appearance.  I’ve even had a few patients who were so self-conscious about the appearance of their labia that they avoided sexual intimacy altogether and requested  a trim even when reassured that their labia were perfectly normal.

Beyond appearance, many women do have lengthy labia that simply are uncomfortable or "get in the way" . lengthy labia can also obstruct the flow of urine, a situation known as urinary splaying. .

  I never realized just how many women were dissatisfied  with their labia  until I mentioned it in my book, The Essential Guide to Hysterectomy. Suddenly, women were coming out of the woodwork telling me that they wanted to have their labia shortened but they had never before asked because they were too embarrassed. While some women are motivated by being tired of cleaning urine off the toilet seat, others requested a labioplasty because they experience discomfort and irritation during sexual or athletic activities. And then there are those that simply don’t like the way their labia look.

Women who requested labioplasty in one study gave the following motivations for desiring surgery:

           Aesthetic dissatisfaction 87 % 

           Discomfort in clothing 64%

           Discomfort in playing sports 26%

           Uncomfortable sex 43 %

 

Another disturbing trend is the increasing number of teenagers requesting labial reduction surgery. In  May  2016, The American College of Obstetricians and Gynecologists (ACOG)  released  the following  position statement:

"When adolescents seek medical treatment, the first step is often education and reassurance regarding normal variation in anatomy, growth, and development. Nonsurgical comfort and cosmetic measures may be offered, including supportive garments, personal hygiene measures (such as use of emollients), arrangement of the labia minora during exercise, and use of form fitting clothing. If emotional discomfort or symptoms persist, then surgical correction can be considered."

 In other words, labial surgery should be a last resort. The very last resort.  So, whether  you a teen or an adult, when opting for surgery, it’s important to keep in mind that there is always the risk of complication. And, like any cosmetic procedure, sometimes the result isn’t exactly what you had in mind, Unlike the minimalist pubic hair style which is all the rage today, there is no going back from surgery. My advice, love your labia as they are and only go for the 'designer vagina" if discomfort, not appearance is the issue. 

Use It or Lose It: Fact or Fiction About Vaginal Lubrication?

If you’ve read enough of my past blogs, you’d think the whole world is experiencing dry, painful intercourse — and that without the benefit of a great lube, a local vaginal estrogen, ospemifene (a non-estrogen oral medication), or a CO2 laser treatment, women are doomed to a destiny of sandpaper sex or no sex. But that’s not the case.

Before menopause, the majority of women don’t require anything other than the occasional lubricant. Post-menopause, only about half of women have lubrication trouble.

So what separates the two groups: Good genes, good diet, or good luck?

When it comes to vaginal elasticity and lubrication, a number of factors besides estrogen and age have a role. Certain medications have a negative impact, for example, and women who’ve never had a vaginal delivery are more likely to have vaginal tissue that becomes dry. Other contributors to a lack of lubrication are inadequate blood flow to the vaginal walls due to the normal aging process, a medical problem such as diabetes, and cancer treatment.

Another factor beside age, medical problems, and luck is the value of regular use.

Vaginal Lubrication and Regular Intercourse

Regular stimulation of vaginal tissue helps maintain blood flow, which in turn increases lubrication and elasticity. And that’s where “use it or lose it” comes into play.

Women who have had a long sexual hiatus are more likely to experience vaginal dryness than women who are regularly having intercourse.

So what’s a woman to do when she’s between partners, or has a partner who’s out of business, to keep her tissue from drying up?

In many cases, the changes destined to occur from lack of use are preventable. You may have to get creative and be consistent about stimulating blood flow. Regularly inserting a dildo or a vibrator should help maintain vaginal lubrication and elasticity. And just like going to the gym, you will probably enjoy it once you get started!

Of course, if your vaginal tissue is already very thin and dry, a little repair work may be in order in the form of a prescription product like vaginal estrogen. One of the most common questions I get when I prescribe a local vaginal estrogen is, “How long will this treatment be necessary?”

In general, my answer is “forever,” because once the treatment is discontinued, the vagina will become thin and dry again. But in my experience, for many women who have had a long hiatus, a local vaginal estrogen repairs the situation and they maintain vaginal elasticity by regular stimulation — they don’t need to continue using a prescription.

So if you have no pain, but alas, no partner, stimulate with a device to keep things good to go. Use it or lose it.

Eliminating Sandpaper Sex with Laser Treatments

Not only can you laser your face smooth, laser your pubic hair away, and laser off regrettable tattoos — now you can also laser your vagina

Not only can you laser your face smooth, laser your pubic hair away, and laser off regrettable tattoos — now you can also laser your vagina

In spite of the many safe options to treat what I’ve dubbed sandpaper sex, only 7 percent of affected women use a prescription product that goes beyond what a lubricant or a long-acting moisturizer can do to alleviate dry, painful intercourse.

There are a number of reasons that this number is so low:

  1. Many women are not distressed by the inability to have intercourse; they think it’s not important enough to treat.
  2. Some women don’t want , or can't afford,  to use a pharmaceutical product on a regular basis.
  3. Many women, despite reassurances, are concerned about side effects from local vaginal estrogen or Osphena tablets.
  4. Often, a woman’s physician advises against using local vaginal estrogen. 

If you fall into the first category, you probably stopped reading this article already. But the other categories are a different story, and those women either abandon sexual activity altogether or put up with the pain. In fact, in a of sexual behavior in more than 3,000 postmenopausal women, 73 percent admitted they silently endured painful intercourse to please their partner.

But there’s a new solution for women who prefer not to use estrogen or have been advised to avoid it: vaginal laser treatments, a new non-estrogen option to treat vaginal dryness and thinning.   You read that right. Not only can you laser your face smooth, laser your pubic hair away, and laser off regrettable tattoos — now you can also laser your vagina.

How Laser Treatment for Vaginal Dryness Works

The Mona Lisa Touch is an FDA-approved medical carbon dioxide (CO2) laser that delivers controlled energy to both the surface and the deeper layers of vaginal tissue to stimulate your cells to make more collagen. The result is restoration of lubrication and elasticity that had vanished as a consequence of menopause, surgery or cancer treatments.

The laser treatment involves three five-minute sessions performed in a doctor’s office, spaced six weeks apart. No anesthesia is required, and most women report feeling only gentle vibration while a slender laser probe is in the vagina.

Women in a recently presented clinical trial reported that after the treatment, they had significantly less dryness, pain, and irritation, along with a dramatic improvement in sexual pleasure.

So what are the downsides of vaginal laser treatment? Really only two things.

First, there have been no long-term studies on the procedure, though it’s unlikely to have long-term adverse effects. And second, it’s hard to say how long the results will last. After the initial three treatments, the manufacturer recommends one treatment every year to maintain the results.  Vaginal laser treatment has been used both here and in Europe in over 25,000 women. In clinical studies, the overwhelming majority of women are pleased with the results.

The main problem is that medical CO2 laser treatments for vaginal dryness are expensive and not covered by insurance: Three treatments are in the neighborhood of $3,000. If the results last for years, clearly the procedure is worth it, but you still have to come up with the cash. One woman told me the choice was between pleasurable sex for a year, or a vacation in Florida for a week. She chose sex for a year.

Whether you choose a local vaginal estrogen, Osphena (ospemifene) tablets, or vaginal laser treatment, there is no reason to grit your teeth and endure painful sex — or avoid sex altogether. Mona Lisa should not be the only one smiling.

Click here for more information about this treatment

 

Blood Clots, Birth Control and Being Aware

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Whether it is arsenic in your apple juice, or blood clots from taking birth control pills, it is always disconcerting to hear that something you thought was safe may in fact be risky. The drospirenone clot issue first came to light in May 2011 when two studies suggested that drospirenone, one of the hormones in Yaz, Yasmine, BeYaz and generic equivalents, might increase the risk of a life-threatening venous thromboembolism, a clot that forms in blood vessels and then breaks off and travels to other parts of the circulatory system, potentially causing a stroke or heart attack. Many other studies did not show such an association, which is why the FDA decided to review all the data and determine if there was reason for concern.

An FDA committee met and decided that drospirenone may have a slight increase in risk over other pills, but the data was not conclusive enough to tell women to stop taking drospirenone products or to pull them off the market.

All hormonal contraceptives with estrogen will increase the risk of blood clots, particularly in women who are smokers or who are obese. Additional risk factors include a genetic predisposition to blood clots, recent surgery, cancer and/or prolonged immobilization. Fortunately, blood clots in young women are very rare, which is why knowing the actual numbers helps to keep things in perspective.

  • The likelihood of a blood clot if not on birth control pills is two to three for every 10,000 women
  • The likelihood of a blood clot when taking birth control pills is three to nine for every 10,000 women
  • The likelihood of a blood clot during pregnancy is 5-20 for every 10,000 women
  • The likelihood of a blood clot post partum is 40-65 for every 10,000 women

Clearly, anyone can develop a blood clot, but it is far more likely during pregnancy or after delivery than while taking contraception. Also, most clots occur in the first few months of pill use, so women who have been on pills for years are at significantly lower risk.

Ultimately, the FDA concluded that the benefits outweigh the risk and since the data is not conclusive, the FDA is not currently recommending that women stop taking drospirenone products. The only outcome of the meeting is that, in a move similar to the European counterpart to the FDA, product inserts will now reflect the concern.

The BRCA Gene and Cancer: Do You Really Want to Know?

by Lauren Streicher, MD

I’ve had to tell a lot of women that they have ovarian cancer throughout my career. It’s not easy. I also routinely tell women they are BRCA-positive.  Trust me, it is much less difficult to talk about strategies to decrease or eliminate the risk of cancer than to tell someone they already have it.

Half a million women in the United States have the BRCA gene mutation, but only 4% are aware of it. In other words, 96% of woman that are at very high risk for developing breast or ovarian cancer don’t even know it.

Women with a BRCA mutation have up to an 87% risk of developing breast cancer. These breast cancers occur at a much younger age, often before women are advised to get mammograms. The only way to significantly reduce one’s risk in this case is to prophylactically remove the breasts, and many BRCA carriers choose mastectomy and reconstruction. Others opt for close surveillance with mammography and MRIs starting at age 25.

Women with a BRCA mutation also have a 44% risk of developing ovarian cancer as opposed to the 1.4% risk found in the general population. The best way to significantly decrease one’s chance is to surgically remove ovaries before cancer cells start to grow. Many women choose not to do that, or want to wait until they have completed their families. In those cases, there are a number of risk-reducing strategies.

Taking birth control pills for 5 years or longer reduces the risk of developing ovarian cancer by as much as 60%. It’s a mystery to me why pharmaceutical companies, who have made millions by advertising that birth control pills reduce acne, don’t advertise that!

It appears that the fallopian tubes are often the source for ovarian cancer cells, which is why tubal ligation, or removal of tubes, reduces rates of ovarian cancer as much as 40%.

What About Ovarian Cancer Screening?
You may have heard of the benefits of a blood test to see if you have elevated levels of CA125, which is a substance that ovarian cancer cells shed. But, normal cells that become inflamed also make CA125. The majority of women with a slightly elevated CA125 do not have ovarian cancer but have a nonmalignant condition such as endometriosis or fibroids. In addition, CA125 levels don’t increase until the disease is well established: 50% of women with Stage 1 ovarian cancer have normal CA125 levels.

Routine screening in low-risk women has not resulted in favorable results – or every gynecologist would recommend it. Women who are BRCA-positive, on the other hand, should have a CA125 test every 6 to 12 months beginning at age 25, along with a transvaginal ultrasound.

A strong family history of cancer creates a lot of stress and anxiety. Contrary to what you might think, knowing your carrier status reduces stress. You can slay the monster you see coming, but not the monster that is invisible.

For more information, I recommend the following websites:

Bright Pink: An organization for young women who are at genetic risk for breast and ovarian cancer.

Facing Our Risk of Cancer Empowered: A nonprofit organization devoted to hereditary breast and ovarian cancer.

Originally published doctoroz.com 11/26/2012

Bare Necessities: What You Should Know Before Grooming Your Pubic Hair

By Lauren Streicher, MD

Changing trends in hairstyles are not limited to the hair on your head. As a gynecologist, I get a firsthand view of what’s trendy when it comes to pubic hair. Today, less is more, and many women that I see alter their pubic hair in some way, whether it’s just a trim or complete removal. But sparse pubic hair wasn’t always the style.

During the 15th century, abundant pubic hair was a sign of not only sexuality, but also good health. If someone had a Brazilian in 1450, it wasn’t an indication that they had just been to the beach, but that they had a sexually transmitted disease. Syphilis was the STD du jour, and the only treatment was mercury injections, which had the nasty side effect of making your hair fall out. All of it. If you were lucky enough to escape syphilis, you probably contracted pubic lice. And without the option of stocking up on anti-lice shampoo from the corner drugstore, you would simply shave everything off. Enter the merkin: pubic hair wigs that men and women pasted on to hide their vaginal baldness due to syphilis or lice. Today, some women remove hair for religious reasons, and many say that baldness increases sensation during sex. But most simply prefer the way it looks.

But, I’m a gynecologist, not a stylist, so I’m going to focus on the medical aspects. First, what’s the function of pubic hair? Before central heating, pubic hair kept the genitals warm. The obvious advantage of warm genitals is that people would be more likely to take their clothes off, and men would be more likely to maintain an erection. Evolutionarily, the other function of hair was to draw attention to the genitals. (Evidently, it is not just modern men who seem to need a map to ensure they are heading in the right direction.) Pubic hair also decreases friction during intercourse, and I’ve seen some pretty nasty “rug burn” from rubbing while bare.

But if you do choose to lose the pubes, there’s a multi-million dollar industry that has evolved surrounding pubic fashion, and there is no shortage of options. Waxing, shaving, electrolysis, clipping, chemical depilatories and laser removal are all at your disposal, but is there a best way? Keep in mind that, with the exception of clipping, some red bumps commonly result no matter what method is used, particularly in African American women. Professional waxing and electrolysis result in the least amount of irritation, allergies or complications, but can be expensive …  not to mention painful. Many women use a topical anesthetic (Emla cream, available by prescription) to reduce the agony.

But before choosing a permanent method of hair removal, such as electrolysis, keep in mind that next year, the bush may be in style again, and you may be forced to invest in a modern-day merkin.

 

Hysterectomy, Fibroids, and a Cancer Controversy

Up until 20 years ago, there was no efficient way to laparoscopically remove a uterus enlarged by fibroids. Most fibroids are far larger than the tiny abdominal incisions used to perform a laparoscopic hysterectomy (removal of the uterus) or myomectomy (removal of fibroids with preservation of the uterus). The breakthrough in technology that enabled the surgeon to use these minimally invasive techniques to remove any size fibroid or uterus through a tiny incision is a device known as a power morcellator.

A power morcellator is an instrument that cuts a large uterus or fibroid into smaller strips of tissue, which then can be easily removed through a half-inch incision. An accomplished surgeon can remove even a large fibroid in a matter of minutes.

In 2015 there concerns were raised aboutspreading the cells of an undetected uterine cancer in the event that what appear to be fibroids (non-cancerous tumors) are actually a type of cancer called leiomyosarcoma (li-o-my-o-sarcoma).

Different Types of Uterine Cancers

Most uterine cancers are endometrial cancers, not leiomyosarcomas, and this is almost always known prior to surgery. Since endometrial cancer is usually detected in an early stage, the cure rate is over 90 percent. If an undetected endometrial cancer is inadvertently morcellated, the outcome is no worse for the woman.

Leiomyosarcoma, on the other hand, is a very serious, rare form of uterine cancer.

While leiomyosarcoma can occur at any age, it most commonly occurs in women over the age of 50. Many, not all, cases are characterized by rapid tumor growth. A leiomyosarcoma can often be discovered by a biopsy prior to surgery, but not all are detected or predicted prior to removal. Morcellation does NOT cause the cancer. But IF an unknown leiomyosarcoma is present, the process of morcellation will spread cancer cells throughout the abdominal cavity. Hysteroscopic morcellation is not an issue since there is no spread of cells outside of the uterine cavity. If cancer cells are spread during the process of morcellation either by power morcellation or hand morcellation, the outcome may be worse.

Keep in mind, even if a traditional hysterectomy is performed, with no morcellation, this is a serious cancer and only 40 percent of women survive at the five-year mark.

The frequency of leiomyosarcoma in women having fibroid removal procedures is highly controversial and ranges have been reported from between 1 in 370 cases of fibroids and 1 in 12,000. Most experts believe that the 1 in 370 number is not correct. Here’s why:

Fibroids Are Common, Leiomyosarcomas Are Not

Fibroids are very common and are present in up to 80 percent of women. The majority of women with fibroids do not require, and do not have any treatment. Women who do need treatment often undergo uterus-sparing solutions such as myomectomy or fibroid embolization.

If one in 370 women with fibroids had a leiomyosarcoma, every gynecologist would see dozens of cases during their career! In fact, most gynecologists see only one or two. If the 1 in 370 number were accurate, then every woman with fibroids should have a hysterectomy!

Following the FDA warning about morcellation, JAMA published data from 41,777 women who underwent myomectomy (removal of fibroids) in order to determine the true incidence of leiomyosarcoma, and even more important, to determine who is at highest risk.

Of women who did NOT have morcellation, uterine cancer was detected in:

  • 0.05 percent of women under the age of 40
  • 0.62 percent of women age 50-59
  • 3.4 percent of women over age 60

Of women who did have morcellation, uterine cancer was detected in:

  • ZERO percent of women under the age of 40
  • 0.97 percent of women age 50-59
  • ZERO percent of women over age 60

This was reassuring and important news since without the option of morcellation, the majority of women who are now candidates for a laparoscopic or robotic assisted myomectomy or hysterectomy would require a large incision resulting in a longer recovery, more pain, slower return to normal activities, and higher risk of scar tissue.

Minimizing the Risk of Morcellation

This week, MedPage Today (a doctor's website) published an article confirming what experts such as myself have been saying all along. The risk of morcellation was overblown, the FDA warning inappropriate and fueled by a media campaign that was not scientifically accurate. This new information confirms that the answer is not to eliminate the option of morcellation, but instead to minimize the risk associated with morcellation. In addition, it is now clear that women are being harmed, not helped by the ban on morcellation given the higher complication rate of an open procedure.

So, here's how to reduce the already very small risk even further:

First of all, a uterine biopsy (a sample from the lining of the uterus) should always be performed pre-operatively. If there is a known or suspected cancer, morcellation should not be used.

A specimen “bag” can be used during morcellation to contain the uterine tissue and eliminate the risk of spread in the abdomen and pelvis. That’s right: If a surgeon inserts an unbreakable bag into the abdominal cavity and morcellates the tissue INSIDE the bag, there will be no spill of cells outside the bag. In the rare event of an undiagnosed cancer, there will be no spread. Many experts are already doing this, and as the technique becomes widely known, I suspect it will become the standard of care.

If you are over age 60, myomectomy is not appropriate and morcellation of fibroids should be avoided, or at minimum, performed in a bag.

Like every surgeon, I can guarantee you that my primary goal is for my patients to have the best outcome possible. As an informed consumer, you need to know the facts so you can have a conversation with your doctor. If you require fibroid removal or hysterectomy and are a candidate for a minimally invasive procedure, let your doctor know if you are comfortable with a morcellation procedure and, particularly if you are older, ask if a bag technique will be used. Understand that an open incision will not eliminate your risk, (and will increase surgical risk) but is always an option.

When I wrote The Essential Guide to Hysterectomy, it was with the premise that if women are given good, accurate information, they will make good, informed decisions.

Now you can.

Photo credit: Alamy

Sex After a Heart Attack – How to Make Sure You Come, Not Go

 

While heart disease is the No. 1 killer of women. It is also one of the top killers of sexual health for the many women that survive a heart attack.  While every situation is unique, the one thing that seems to be consistent is that, chances are, your doctor, no matter how otherwise fabulous, has not adequately addressed, or even mentioned the impact heart disease may have on your sex life.

Only 35% of women receive information about resuming sexual activity after myocardial infarction (MI) – heart attack – and that is only if they initiate the discussion, according to a 2013 University of Chicago study.

“Women would like to resume sex after a heart attack, but they would like to be better informed about what’s safe so they can have a more enjoyable sex life,” said Stacy Lindau, MD of the University of Chicago medicine and study co-author,

The fear factor is huge and not without some validity. After all, New York Governor Nelson Rockefeller died while having sex with his mistress. Pope Paul II died while allegedly being sodomized by a page. Even the mighty Attila the Hun fell victim to a heart attack that caused his early demise – on his wedding night no less.

And while people might kid about it being a great way to go, fear of heart attack during sex significantly reduces the amount of sexual activity of patients with known heart problems. In one study, 71% of women post MI avoided sexual activity specifically out of fear on the part of the patient or spouse.

Other than making your heart go “pitter-patter,”  what are the cardiac effects of sexual activity?

Volunteers having sex in a laboratory setting (that must have been interesting!) have a significant increase in pulse, blood pressure and respiratory rates. In other words, the heart works harder, pretty much along the same level as with a moderate workout.

What’s really interesting is when similar studies are conducted among married couples in their own bedrooms; heart rates don’t increase during sex! In fact, on average, married couples had a lower heat rate than recorded during normal daily activities. It’s actually somewhat depressing (and reassuring at the same time) that having sex with your spouse in your own bedroom requires only the same amount of exertion as a 2 to 4 mile per hour stroll on a level surface for a few minutes.

That is why studies show that sexual activity is rarely responsible for a heart attack. Risks are even smaller in men and women who are routinely sexually active, and have participated in a regular post-heart attack exercise program.

If you continue to avoid intimacy from a fear of dying or having a repeat heart attack, it may help to have an exercise stress test to assure you that your heart can take it. In general, most cardiologists say you are safe to have sex if you can climb up two flights of stairs without having chest pain or becoming out of breath.

Facing the fear factor

So if you have a heart condition or are post MI, make a specific appointment to talk to your doctor about the appropriate level of sexual activity. Often women will ask as the doctor is headed out the door and get a cursory answer. By letting your doctor know this is an important issue, and not something just tagged on to your heart attack check-up, you will get more information than if you ask on the fly.

But caution: Right after a heart attack is not the time to have an affair or join the mile-high club unless you are willing to suffer the fate of Nelson Rockefeller.

 

Vaginal Estrogen for Women with Breast Cancer?

 by Lauren Streicher, MD

For the woman who is newly contending with a diagnosis of breast cancer and dealing with the overwhelming stress of surgery, chemotherapy and radiation, sex is usually the last thing on her mind. The emphasis is, and should be, on treating the cancer. But after the physical scars have healed and hair has grown back, the consequences on a woman’s sexuality are often minimized. Sadly, many cancer survivors feel reluctant to complain about something as “trivial” as the loss of their sex life. It’s not unusual for a breast cancer survivor to attempt intercourse, only to find what was once satisfying and enjoyable is intolerable and upsetting, If she is brave enough to bring it up to her doctor, it’s typical to not get a lot of advice beyond “buy a lubricant” When that doesn’t work most women give up, assuming that vaginal estrogen, the most successful way to reverse vaginal dryness and intercourse, are just not an option.

Even if a doctor does give the go ahead, many women take one look at the package insert that practically has a skull and cross bones on it and decide it just isn’t worth the risk.

I published a study in 2013 in The Journal of Sexual Medicine showing a majority of gynecologists would themselves use vaginal estrogen even if they had breast cancer. It’s not that gynecologists are more willing than the general population to risk their lives in the name of having good sex, it’s that gynecologists know that the Black Box Warning that lists the dangers of using estrogen is not based on data that has anything to do with vaginal estrogen, much less women with breast cancer who use vaginal estrogen.

Today, the American College  of Obstetricians  and Gynecologists (ACOG) released a position statement very clearly stating that the use of estrogen in women with a history of an estrogen dependent breast cancer is safe and appropriate . ACOG  states, " Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms. "

Since there is   essentially no evidence that using a tiny amount of estrogen directly on vaginal tissues to increase lubrication and elasticity of tissue that has become thin and dry causes an increased risk of breast cancer recurrence, it is time for the  FDA to   remove the scary, inappropriate black box warnings. Clearly the miniscule amount of estrogen absorbed from the vaginal use of estrogen doesn’t even increase blood estrogen levels above the normal menopausal range andis not  risky.  And in fact, what little data there is regarding the use of vaginal estrogen in women with breast cancer is very reassuring. One study which was published in a medical journal (Climacteric 2003; 6:45-52) followed 1,472 breast cancer patients who routinely used vaginal estrogen and were found to have a LOWER recurrence rate than women who did not use vaginal estrogen.

Most  breast surgeons and oncologists are  now comfortable allowing women with breast cancer to use vaginal estrogen. Ultimately, you need to do what you are comfortable with, but if you do decide to use vaginal estrogen, it should ease your anxiety a lot knowing not only most gynecologists, but alsoACOG is now firmly on board. 

 

Oregon Gets it Right! The Case for Over the Counter Birth Control Pills

by Lauren Sreicher, MD

 

Mexico is known for beautiful beaches, great guacamole and, as any woman who’s forgotten to bring along that all-important pack of pills knows, over-the-counter hormonal contraception. That’s right. You can wander into any pharmacy in Mexico and pick up a pack of birth control pills without a prescription – a convenience that until now, with Oregon's new law, has not existed in the US.

 

A lot of people, including most gynecologists, agree with the  change. Even  the American College of Obstetricians and Gynecologists (ACOG)  released a position statement in 2012 recommending that oral contraceptive pills be sold over-the-counter.

The reasons for that endorsement are clear. According to the Guttmacher Institute, 50% of the pregnancies that occur in the United States each year are unplanned. By age 45, half of all American women will experience an unintended pregnancy. Every year, failed contraception, or no contraception, contributes to 3.2 million unintended pregnancies.

Barriers to obtaining contraception, such as the prescription requirement, contribute to our nation’s sky-high unintentional pregnancy rate. It is irrefutable that increasing  availability of pills will improve usage of contraception. Other studies have consistently proven that when barriers such as cost and access are eliminated, unplanned pregnancy rates plummet.

Getting a prescription is a huge burden to many women who have no regular physician, no insurance, and a job that doesn’t allow the luxury of taking an afternoon off to go to see a doctor. The college student without a gynecologist (and without a car) doesn’t have it any easier. Not to mention, many insurance companies only release one month of pills at a time. It’s understandable how a prescription can lapse.

Opponents to the OTC initiative say it is too dangerous. They express concern that high-risk women are likely to take birth control pills which will lead to in an increase in serious side effects such as blood clots and heart attacks. Please! Women deserve a little more credit. The average woman is more than capable of self-screening and determining if taking pills would be dangerous or inappropriate. No woman wants to have a stroke. If someone is 40, overweight, and a smoker, she is going to be informed that she is not a candidate for hormonal contraception just as a man with kidney failure is informed that over-the-counter painkillers are not safe. ACOG, known to be a medically conservative organization, strongly states that the benefits far outweigh the risks.

Truth be told, the same people that say pills shouldn’t be sold over-the-counter are often the same people that think insurance shouldn’t cover contraception in the first place. And that abstinence education actually works. Or that easy access to contraception will increase teenage sexual activity. In other words, their political agenda, not women’s health, is their priority.

Mexican women are more likely to stay on their pills and have no higher rates of complications than American women! In addition, evidence shows that even if the pill is available without a prescription, women will continue to show up for their annual checkups, Pap tests and STD screens.

Most women spend the majority of their reproductive years trying to avoid becoming pregnant. The solution to lowering the country’s high unintended pregnancy rate is not going to be completely solved by increasing access to contraception, but it’s a really good start and I’m all for it.

 

2015 in Women's Health: Improve your Libido, Manage your Menopause,.. Steam your Vagina?

 

 

One of the really fun things about being a "media doc" is that I get to  learn  and comment about newsworthy medical innovations, research and discoveries.  2015 has been incredibly busy and I appeared in over 200 articles, TV and radio segments.

I was interviewed by More, Prevention, Health, Cosmo, Oprah.com  The Huff Post andThe New York Times. I had a great time being Dirty Sexy Funny with Jenny McCarthy in addition to appearing on shows such as Good Morning America, ABC Nightly News, Fox and Friends, (playing the part of  the token  liberal Democrat) and of course frequently hanging out with my buddy Steve Harvey.

In 2015 I commented on what's new in the world of menopauseitchy vaginas, and if your tampon can kill you. You name it; I have been asked to provide an opinion, comment or explanation. I weighed in on  Sex after 40, sex after cancer, sex after diabetes and sex after pretty much every other medical condition . (OK, that's what I get for writing Sex Rx-Hormones, Health, and Your Best Sex Ever)

 

I did too many interviews to count about the FDA approval of flibanserin, AKA the"little pink pill". My favorite segment, hands down, was my CNN appearance with Richard Quest.


A major media highlight for me, of course, was when Prevention Magazine did a feature article that portrayed me as a super hero!

 

Not all of the medical items I am asked to speak to are generated from the medical or scientific literature. In fact, more often than not when I get a call from a TV show or magazine, it is to comment on something that is medical advice from a celebrity. Hence, my list of the top three"Who Knew?" medical" breakthrough's in 2015:

"Who Knew?"

 Eating Placenta is Good For You

This actually all started a few years ago when January Jones recommended eating dehydrated placenta capsules to prevent post partum exhaustion. Her rationale for this practice was“we're the only mammals who don't ingest our own placentas."

I thought the whole eating placenta thing was adequately debunked and done with until Kim Kardashian, (who is a celebrity for what talent?) publically recommended this practice stating that placenta capsules prevent post partum depression and help with weight loss in addition to keeping skin youthful and hair shiny.

FYI Kim, yes placenta is loaded with nutrients and hormones. Yes, animals eat their placenta.  (They also sever the umbilical cord with their teeth but that doesn't mean humans should as well). But when animals eat their placenta they don’t encapsulate it or dehydrate it,  a process which destroys all the nutrients and hormones.

 

"Who Knew?"

Women Should Wear a Corset to"Train" Your Waist

I know I shouldn't keep picking on Kim Kardashian, but it's hard not to. Sadly, it appears more women get medical advice from Kim Kardashian than from a doctor. Just saying. 

In addition to advising women to eat their placentas, "Dr. Kim” also instructs women to wear a tight corset to "train their waist" to get back in shape after pregnancy so they can look as fabulous as she does. While it probably doesn't do any harm other than being massively uncomfortable, it doesn't do anybody any good. Unless of course you are one of the entrepreneurs making millions off of this stupidity. 

"Who Knew?"

 Steaming Your Vagina has Health Benefits

The top 2015 women's medical health influencer, hands down, goes to Gwyneth Paltrow who encouraged all women to steam their vaginas. I was asked to do no less than 10 interviews on that topic including a segment on The Steve Harvey Show

In case you missed this cutting edge scientific breakthrough, I'll review.

Essentially women sit on a mini throne while steam infused with mugwort swirls around the vaginal opening to enter and permeate the uterine walls. It’s a practice that’s been utilized in Korea for hundreds of years and according to Ms. Paltrow, balances hormones, "cleans" the uterus and helps keep skin looking young and healthy.

My first thought when I heard about this was, "People really do that?" and "What's mugwort steam and why would someone want to put it on their vagina?"

In case you need to be talked out of heading to your nearest spa and plunking down $50 to have your vagina steamed, keep in mind that you can potentially do a lot of harm to sensitive tissues not to mention you don't want to have to explain to your doctor why you have blisters on your vulva. That aside, what is obvious to the 99% of the population that does not steam their vaginas, is that there is NO BENEFIT. It does NOT "clean out the bad bacteria", (the vagina is self cleaning)  permeate the uterine wall (phew!)  or balance your hormones. So steam the wrinkles out of your clothes and the soil out of your carpet, but for god’s sake, do not steam your vagina.

So here's to a happy, healthy and steam free 2016

 

 

What to Really Worry About on Your Holiday Flight

Nervous flyers (myself included) have a lot of things to worry about. Analyzing every funny noise in case it is an indication of imminent engine failure and being ready to assume crash position in case the pilot forgets how to land takes a lot of energy. And sadly, worrying about the threat of terrorists. A far more likely threat however is the possibility of developing a life-threatening deep vein thrombosis (DVT) as a direct result of prolonged sitting in a cramped position.

A deep vein thrombosis (DVT) is a blood clot that forms in a leg, thigh or pelvic vein. The danger of a DVT is that it can break off and travel to the lung, resulting in a pulmonary embolism, a serious and potentially fatal complication responsible for over 50,000 deaths in the United States each year.

Anyone can get a blood clot, but some people, especially those who develop multiple DVTs, are genetically predisposed to form blood clots more easily. And more than 80% of people that develop a DVT have at least one, and often more than one, risk factor.

Heredity aside, risk factors for DVT include age (over 50), cancer, smoking, recent surgery and obesity. In addition, excess estrogen increases the propensity to form blood clots, so pregnant women and women using hormonal contraception are also at risk. Sitting for long periods of time is problematic since immobility allows blood to pool in leg veins. It used to be that the usual person who developed a DVT was an overweight, smoking, cross-country truck driver, but the airline industry has changed that. There is even a medical term that refers to the disproportionate number of people that develop a DVT during long plane rides: "Economy class syndrome." Not every DVT causes symptoms, but if a clot restricts blood flow, there can be pain, swelling or redness in the leg. Severe chest pain, a rapid heartbeat or trouble breathing may indicate a clot has dislodged and moved to the lung.

Short of upgrading to first class, there are strategies to reduce risk. Be sure to change position frequently, don’t cross your legs, and stand up and walk around as often as possible. At a minimum, flex and extend your ankle and knees periodically. Climbing over your seat mate to get to the bathroom is also an excellent way to get the blood moving through your lower extremities.

Properly fitted below-the-knee thromboembolic compression stockings (available in pharmacies or online) are not exactly highly fashionable, but will dramatically reduce the risk of DVT. While taking a sleeping pill is an appealing option for the anxious flyer, spending the flight in a coma-like state increases the chance of immobility and is therefore associated with a higher rate of clot formation.

In a nutshell—keep warm, move about every hour or so, don’t smoke, wear loose clothing, and drink plenty of fluids other than caffeine or alcohol.

From one nervous flyer to another, safe travels and Happy Holidays!

 Originally Posted doctoroz.com 11/23/2010, modified Nov 21

 

Vitamin D- How Low Can You Go?

by Lauren Streicher, MD

Vitamin D: It’s the magical supplement pill you can purchase at your local pharmacy that prevents cancer, and reduces the risk of autoimmune diseases, chronic inflammation, multiple sclerosis, osteoporosis, heart disease, and even the flu. Or is it?

A quick Internet search would seem to confirm the many health benefits of vitamin D. But before you go out and purchase a lifetime supply, there are two things that you should know about this much-touted vitamin.

The first is that scientific research shows only one absolutely proven medical reason to take vitamin D: to facilitate the absorption of calcium that can decrease bone loss and reduce your risk of breaking a bone. Even if vitamin D doesn’t prevent cancer and chronic disease, prevention of osteoporosis is reason enough to want to maintain an adequate vitamin D level.

Which leads me to the second thing you should know about vitamin D: Experts are still debating the optimal vitamin D level to assure bone health, but also for other possible health benefits. Recommendations have ranged from the Institute of Medicine’s suggested 20 nanograms per milliliter (ng/mL), to the National Osteoporosis Foundation‘s 30 ng/mL, to the Vitamin D Council‘s 40-80 ng/mL.

Why You May Need That Vitamin D Supplement

It’s no surprise that a significant portion of the adult population has low, and sometimes really low, vitamin D levels. The winter months pretty much guarantee a deficit in many adults, since vitamin D is synthesized in the skin after exposure to sunlight.  Even if you live on the beach, getting plenty of sunshine — and therefore vitamin D — puts you at risk for melanoma, wrinkles, and sunspots. Skin problems like these make basking in the sun without a hat, sunglasses, and a high SPF sunscreen a forbidden treat. And there is not much vitamin D found naturally in food, so you can’t always improve your levels through diet.

There are other reasons that you may have low vitamin D levels. Decreased absorption of vitamin D due to gastrointestinal illness, surgery, and normal aging also can contribute to levels that are too low in your body to effectively protect your bones.

Researchers have also theorized about the connection between vitamin D levels and inflammation. But, as a July 2014 Inflammation Research review  states, “Evidence that vitamin D supplementation cures or prevents chronic disease is inconsistent.” What appears to be likely is that chronic inflammation is what leads to low vitamin D levels in the body.

Why You May Need Less Vitamin D Than You Think

The debate over vitamin D  is no small issue, since almost half of all women break a bone after menopause, and millions of women over the age of 50 are advised by their doctors to take a vitamin D supplement to get their levels up to “normal.”

A study published in the August 2015 issue of the Journal of the American Medical Association looked specifically at the serum (or  blood) levels of vitamin D needed to absorb calcium. In this randomized, double-blind clinical trial,  researchers at the University of Wisconsin at Madison gave230 postmenopausal women under the age of 75 one of the following:

  • Dailyand monthly doses of placebo pills
  • Daily 800 international units (IU) vitamin D3 with monthly placebo pills (low dose)
  • Daily placebo pills with twice monthly doses of50,000 IU vitamin D3 (high dose)

This trial lasted for four years, and the results revealed a couple of things:

First, calcium absorption increased 1 percent in the high-dose group, but decreased 2 percent and 1.3 percent  in the low-dose and placebo groups, respectively. So while supplementing with high levels of D increased calcium absorption, it wasn’t enough to deliver bone and muscle health benefits.

Second, the researchers found that the most-commonly cited recommendation, to maintain a level of at least 30 ng/mL, is not necessary for bone health.

This is a major paradigm shift, since most doctors (myself included) have routinely measured serum vitamin D levels and recommended a supplement to patients whose levels are lower than 30.

As the authors of the Wisconsin study concluded, “Study results do not justify the common and frequently touted practice of administering high- dose cholecalciferol (vitamin D3) to older adults to maintain serum [vitamin D] levels of 30 ng/mL or greater.” They suggest instead that a lower minimum level, 20 ng/mL, is adequate.

While the jury is still out on this one, it is something to consider. No, I haven’t stopped my daily vitamin D supplement (I live in cold, cloudy Chicago). But I’m certainly thinking about it.

Originally published 8/15/15

Remove Your Tubes to Prevent Ovarian Cancer?

by Lauren Streicher, MD

The fallopian tubes are the sperm’s highway to the egg. Unfortunately the fallopian tubes can also potentially be a source of cancer cells  and a  road for cancer cells to travel down leading to ovarian cancer. In fact, most ovarian cancer is now  believed to originate in the tube. 

While ovarian cancer is not the most common gynecologic cancer, it is the most lethal gynecologic cancer. Screening and early detection are limited and in the majority of cases, it is discovered only after it has spread. While 10-15% of ovarian cancers are genetic, most women that develop ovarian cancer have no family history and no risk factors.

Since screening doesn’t seem to be the answer, the best strategy is to try and not get it in the first place. And yes, there are things you can do that really make a difference.

Gynecologists have known for some time that taking hormonal contraception will lower the risk of ovarian cancer. You only need to take the pill for 5 years to reduce your risk by 20%. After 15 years of use,  the risk is cut in half. It’s always been a mystery to me why the pill companies go on and on about the pill getting rid of acne and PMS, but never bother to mention that taking birth control pills can prevent a life threatening cancer. Seems to me they would not only be doing a service to women, but would sell a lot more pills.

Another little known fact is that a tubal sterilization can reduce  ovarian cancer risk by as much as 34%!

But instead of just blocking the tube, what will happen if the tube is completely removed? In 2009 a paper was published in the International Journal of Gynecologic Cancer suggesting that the majority of ovarian cancers originate from the tube and that removal of the tube has a major impact on cancer frequency. As a result of that study, the Canadian government  issued an official recommendation that tubal removal should be performed instead of tubal ligation.

It’s not practical for everywoman to remove her tubes, but if you are not planning a future pregnancy and one of the following circumstances fits you, it’s something to consider:

  • If you are scheduled to have a hysterectomy and are not removing your ovaries, ask your doctor to remove your tubes along with your uterus.
  • If you are having a tubal ligation, ask your doctor to remove the entire tube rather than just destroying a portion of the tube.
  • If you are having pelvic surgery for any reason (ovarian cyst, fibroids, etc.), ask your doctor to remove your tubes even if your husband had a vasectomy and you don’t need the contraception.
  • If you have a BRCA mutation and are at very high risk for ovarian cancer, the recommendation is to remove the ovaries and tubes. If you are not ready to remove your ovaries, or choose not to, consider fallopian tube removal as a “next best” option. This is particularly important since many women with BRCA mutations are reluctant to take hormonal contraception due to their high risk of breast cancer.

What’s involved with fallopian tube removal? In the hands of an experienced laparoscopic surgeon the procedure takes less than 30 minutes and can be performed using a couple of tiny incisions (essentially one stitch). Most women go home an hour or so later and are back to normal activities in a day or two. If your surgeon is already “in there” doing something else, tube removal takes no more than an additional 10 minutes and there is no additional recovery time. There will be no change in menstruation or hormones since the fallopian tubes have no function other than getting an egg and sperm together. The bonus? If you still need contraception, you won’t anymore

Posted on doctoroz.com 10/25/2010 |

Buyer Beware: "Bioidentical" Hormone Myths

by Lauren Streicher, MD

Frequently, patients ask if I prescribe “bioidentical” hormones. It’s a good question, but unfortunately, the answer is not a quick one. Like many  phrases, “bioidentical” means different things to different people. Generally, however, most women inquiring about bioidentical hormones are referring to compounded hormones that are advertised as being safer and better than FDA-approved estrogen and progestogens distributed by commercial pharmaceutical companies.

The North  American Menopause Society (NAMS) recently conducted a survey of 3725 hormone users  to determine the extent and differences between commercial compounded hormone therapy and compounded hormone therapy. Roughly one of four women who use hormone therapy are using compounded hormone therapy however  most are unaware that compounded hormones have not been evaluated or approved by the FDA .  Most are unaware that compounded hormones have risks in addition to benefits. 

Many promoters of compounded hormones claim that their products reverse aging, enhance sex, prevent cancer and, unlike FDA-approved commercial hormones, have no risks or side effects. It all sounds pretty good. But like most things that sound too good to be true, it’s important to separate fact from the myths propagated by clever marketing. 

 

 

Myth #1: “Bioidentical Hormones Are Natural.”

The only thing that is natural is to drink the horse urine or eat the soy plant (both are used in the manufacturing of hormones). All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product, which can then be put into a cream, a spray, a patch or a pill.

Promoters of compounded plant-derived hormones use the terms “natural” and “bioidentical” because it is appealing to consumers and implies that it is not synthetic.

Myth #2: “Compounded Bioidentical Hormones Are Identical to the Hormones in Our Bodies.”

Plant-derived estrogen from soybeans is molecularly very similar, but not identical to human hormones. That’s why I prefer the term “bio-mimetic” to “bioidentical.”

Furthermore, what you get from the compounding pharmacy (where a compounding pharmacist custom mixes drugs to fit the unique needs of a patient) is not “more human-like” than what you get in an FDA-approved product. In fact, you are actually getting the IDENTICAL estradiol molecule whether you get your hormones from a compounding pharmacy or your mega-pharmacy.

How can that be? This is the interesting part. Compounding pharmacies don’t manufacture hormones – they just mix them. Manufacturing factories are the ones that extract estrogen from plants, synthesize it to a useable form, and then sell the same active ingredients to both commercial pharmaceutical companies and compounding pharmacies. It is then that the active ingredient is used to make lotions, pills, sprays or patches.

It’s basically all the same stuff. In fact, many compounding pharmacies mass produce hormone preparations that are copies of those produced commercially.

Myth #3: “Since Compounded Bioidentical Hormones Are Natural, They are Safer Than Other Hormones.”

First of all, “natural” does not equal “safer.” We can all name many things that are natural, but hardly safe. Arsenic comes to mind. But, in any case, I’ve already dispelled the “natural myth” (see Myth #1).

Let’s forget the word natural and ask if compounded hormones are safer than FDA-approved commercial hormones.

Since compounded alternatives to FDA-approved estrogen and progestogen formulations have the same active ingredient (see Myth #2), they obviously are going to have the same benefits, and the same safety concerns. But unlike commercial hormones, the distributors and promoters of compounded hormones deny these risks. And that’s really misleading. So, how do they get away with it?

Since the FDA does not regulate compounding pharmacies, they can make whatever claims they want. So, they tell women what they want to hear – namely that compounded bioidentical hormones have fewer risks, fewer side effects, and are more effective than standard hormones even though there is no scientific evidence to prove that claim.

While women generally distrust the pharmaceutical industry – which is legally obligated to back up their claims, does testing, and reports all safety risks and negative findings – the general population seems to have little problem placing their trust in companies that have no such efficacy or safety standards. This combined with aggressive advertising and marketing has resulted in women believing that compounded products are safer than standard products.

It’s pretty scary to think that millions of women are using prescription drugs that have never gone through a new drug approval process to substantiate safety, prove efficacy, and ensure quality.

Since it is the same active ingredient, what’s the problem? 

It’s the dosages and protocols, which are commonly recommended, that have never been shown to be safe, much less safer or more effective than conventional prescription hormone products. I just saw a woman who was essentially going bald because of sky high levels of testosterone in a pellet that was injected into her hip. Transdermal progestogens from a compounding pharmacy are particularly  dangerous since there is no evidence that they prevent the lining of the uterus from developing pre-cancerous or cancerous cells. And in fact, the survey  recently published by NAMS  showed  there were 4 cases of endometrial cancer in the group using compounded hormone therapy compared to zero cases of endometrial cancer in the group using commercial products.  No surprise since only oral progestogens have been proven to offer that protection.

So, back to the original question: Do I prescribe bioidentical hormones? I prescribe FDA-approved “bio-mimetic” plant-derived estrogen, produced and distributed by companies that are obligated to tell you not only the benefits, but potential risks as well.  I prescribe products made by companies that adhere to strict protocols to assure purity of the product  and consistency of dosage.   I  do use compounding pharmacies when I need a product that is not available commercially but   I then inform my patient  of all known risks and benefits.

 One last thing...an added bonus to commercially available products is that your insurance company will likely cover your prescription.. The non-FDA approved compounded versions will require you to open not only your trust, but also your checkbook. 

Edited Oct 22, 2015  Originally posted  on doctoroz.com 11/09/2011

Prepping for a Trip to the GYN

by Lauren Streicher, MD

 

At least once a day, a patient apologizes to me that she hasn’t shaved her legs or had a pedicure before climbing into the stirrups. In addition to being worried that I am going to find some dreaded disease, they think I am judging their hairy legs, unwaxed crotch or chipped toe polish. It reminds me that what is a very routine exam for me is anything but routine for the women who are experiencing it.

But unlike the dentist, where brushing and flossing is essential, women need not do anything to prepare for an exam with their gynecologist. Truly, my only expectation is basic hygiene – a shower or bath within 24 hours is always appreciated. In some cases, a woman’s efforts to “prepare” for an exam could actually diminish my ability to get accurate test results.

If a Pap test is on the agenda, it’s important that a woman hasn’t done anything to wash away or obscure the cervical cells that need to be screened for pre-cancerous changes. It is also impossible to evaluate an abnormal discharge or odor if the environment has been altered. That means no spermicide, no medications, no lubricants and no douching (you should never douche under any circumstance!) for 24 hours before your appointment.

And, ideally, no sex. Having intercourse without a condom the night before a Pap will not make a normal Pap smear abnormal, but it might obscure cervical cells so that it cannot be accurately read.

Should you cancel if you “forgot” the night before? Realistically, after waiting two months for an appointment, asking for the afternoon off work, or desperately needing a refill on your birth control pills, it may not be practical to take a pass but use a condom (even if you don't need to)  so the semen will not obscure cells. 

On the other hand, if you are coming in specifically to check out an abnormal discharge or odor, you should probably reschedule. It’s pretty much impossible to figure out what is going on if you had intercourse hours before your visit.

If you are coming in for another problem, say abnormal bleeding, an STD check or pelvic pain, it really doesn’t matter.

Is it ever a good thing to have sex before your appointment? Actually, yes. If someone tells me they bleed every time they have sex, it is helpful for me to see where it is coming from – the uterus, cervix, or vagina. (Just don’t “prepare” in my waiting room or bathroom.)

And no, I really don’t notice and don’t care if you have shaved your legs and gotten a pedicure. Tattoos … now that’s another story (and a topic for another blog).

2/4 2013 doctoroz.com

Everything You Always Wanted to Know About Addyi

by Lauren Streicher, MD

by Lauren Streicher, MD

Now that Flibanserin, or Addyi,  — the new drug to treat low libido, or hypoactive sexual desire disorder (HSDD)  is available,  reporters, patients, my friends, and especially my friends’ husbands have peppered me with questions about this so-called “Viagra for women” .

I have no professional experience with Addyi. I do not work for the drug’s manufacturer, Sprout, or have a financial relationship with them. All of my information is based on the results of clinical trials, which are published in the scientific literature and available on the FDA website.

In response to the 25 most-frequently-asked questions that I get, I’ve been telling people:

1. Who should take Addyi (flibanserin)?

This medication is intended for a woman who loves her partner, but whose libido switch is simply in the off, not on, position. Not every woman who has zero sexual desire wants to do something about it. Women with true hypoactive sexual desire disorder are highly motivated to flip their libido switch back on not only for their own pleasure, but often to save a marriage or relationship sabotaged by the absence of normal sexual relations.

2. What causes low sexual desire in women?

The biological cocktail for an intact libido includes not only hormones, but also neurotransmitters.  Dopamine, norepinephrine and serotonin determine how often people think about, and desire, sex. It’s the balance of those neurotransmitters that creates that “I want sex, I need sex, and I’m thinking about sex” feeling. But this balance also keeps desire under control, so you can stop making love long enough to go do all the other things you must. Women with hypoactive sexual desire disorder do not feel normal sexual desire even if they’re in loving relationships. So essentially, this condition is a biological problem.

3. How do I know if I have hypoactive sexual desire disorder?

It’s perfectly normal to not want to have sex with a partner who smells so bad that you don’t even want to share a room. It’s also normal to not desire sex if it’s excruciatingly painful, you just lost your job, or you haven’t slept in a week. If you’re in one of these situations, you don’t need to take a pill. You need to fix your vagina, fix your work situation, and fix your life.

The Decreased Sexual Desire Screener, a five-question, yes-or-no questionnaire  guides both physicians and patients to, or away from, a diagnosis of HSDD.

4. How common is loss of lust?

Of all sexual problems, loss of lust is by far the most common. Up to 1 in 10 adult women are affected by HSDD.

5. How does the new drug work?

Unlike Viagra (sildenafil), which increases blood flow to a man’s penis, Addyi works on a woman’s brain to balance neurotransmitters and restore normal sexual desire.

6. How many women have taken Addyi?

More than 11,000 women participated in the flibanserin clinical trials. In comparison, 3,000 men were in the clinical trials for Viagra. The FDA only requires that clinical trials to approve a new drug involve 1,000 people.

7. What ages were the women who tried the drug?

The trials included for FDA approval included women who had not yet entered menopause who reported that they’d been in loving relationships for a minimum of 10 years, and who’d had HSDD for at least four years.

8. Were all women in the new drug trials heterosexual?

Yes, but sexual function is sexual function. Whether a woman is heterosexual, homosexual, or self-sexual, the biology of sexual desire is the same. There is no reason to believe the response will be any different no matter who (or what) you have sex with.

9. What about women after menopause? Is flibanserin right for them?

The FDA only considered premenopausal women for approval of the drug. However, postmenopausal women with HSDD were included in the Snowdrop trial,  a study of over 900 women with low sexual desire after menopause the results of which were published in the June 2014 issue of Menopause. And it’s good news: The response to flibanserin was statistically significant compared with a placebo treatment.

Doctors will likely prescribe Addyi for postmenopausal women just as many other drugs proven to be effective are prescribed as off-label. If you are postmenopausal, ask your doctor about the pros and cons of taking Addyi.

10. I heard the FDA initially turned down this new “female Viagra.” That worries me.

It should actually reassure you that the FDA is careful and demands a lot of information before approving a drug. In the United States, it usually takes 12-15 years for a proposed drug to appear in your pharmacy. Only 1 in 5,000 new drugs makes the final cut. Along the way, it’s very common for the FDA to require additional studies.

In the case of Addyi, more than 60 studies were submitted to the FDA. One of the side effects in people who took Addyi in clinical trials was sleepiness. In response, the FDA required a driving test to assure that women taking Addyi at night were not drowsy or impaired the next morning. The result? The women who took Addyi actually drove better than the women who did not!

11. Didn’t Sprout, the drug maker, enlist a PR company and use social media to pressure the FDA?

Even the Score is a campaign founded to raise awareness of the need for gender equity in sexual health.  In addition to Sprout,  24 organizations and non-profits and 60,000 people, support the campaign. But Even the Score isn’t just about one drug: The campaign will continue to address the disparity between research in male and female sexual health. Yes, it was Even the Score that was responsible for the spoof on Viagra commercial.

Remember: For approval, the FDA requires that a drug must both meet an unmet need, and be deemed effective and safe. The FDA approved Addyi because the science is solid, and it demonstrated these criteria. The FDA reviews data, not Tweets.

12. How well does Addyi work?

Women who took flibanserin in clinical trials reported a 53 percent increase in their sexual desire as measured by the Female Sexual Function Index (FSFI). They also reported that their number of satisfying sexual events doubled, and their distress about sexual function decreased by 29 percent.

13. Were the improvements only “modest” for most women?

Modest was the goal. The idea is not to make women hypersexual, but rather to give them normal sexual desire.

Results are an average. They include both people who didn’t respond to the drug, because not everyone is going to benefit from the drug, and “high responders.” The high responders reported six to eight more satisfying sexual events each month, and a return of their sexual desire score to what’s considered normal. That’s meaningful!

14. So how likely is Addyi to work?

There was an average of 53 percent increase in sexual desire overall, but 55 percent of women were high responders and had an even greater response.

15. How soon will it work?

Flibanserin usually starts to show positive effects two to four weeks after a woman begins taking the drug. If you see no difference in two or three months, stop taking Addyi. It’s not going to help you.

16. Why take a pill? What’s wrong with talk therapy?

Sexual problems from interpersonal, psychological, or cultural/social issues are important, and a therapist or change of relationship is often the fix. But brain activity is different in women who have HSDD: No amount of talk therapy is going to correct a biological imbalance. On the other hand, if you hate your partner or you avoid sex because it hurts like hell, a bucket full of Addyi is not going to make a difference, either.

17. Can Addyi make a woman too sexual?

It’s interesting how, on one hand, people are concerned that it doesn’t work well enough, and on the other hand, people are worried that it will turn women into nymphomaniacs. The ideal is to be normal, not hypersexual. Addyi will not cause you to rip off your clothes during a business meeting and seduce your boss any more than an antidepressant will make you euphoric.

18. Does this drug pose a potential “date rape” risk?

No, this is a daily drug that does not start to work for a couple of weeks. Even if your partner sneaks a dose into your morning coffee every day for two weeks, it wouldn’t make you hypersexual or make you do things you did not want to do.

19. Is Addyi a hormone?

No. It’s a new drug that modulates (controls) neurotransmitters like dopamine, norepinephrine, and serotonin that affect women’s desire for sex.

20. I’ve heard about side effects. What are they?

Typically, the most common side effects of a sexual dysfunction drug are cardiovascular problems, visual changes, a drop in blood pressure, or an erection that lasts for more than four hours.

Whoops, that would be Viagra!

Back to Addyi: the most common side effects in the trials included fatigue, nausea, and sleepiness. No serious side effects were reported. The biggest complaint from participants was that when the trial was over, they couldn’t keep taking it. Every drug comes with some risks, though; men have long been able to choose whether to take a drug with known risks to enhance sexual desire.

21. Will Addyi cause weight gain?

No, it did not cause weight gain in the clinical trials.

22. What about interactions between alcohol and flibanserin?

Drinking was allowed in the studies for this new drug, and the women in the clinical trial who identified as “social drinkers” (58 percent of the participants) did not have any significant issues.

The FDA was particularly concerned about binge drinking, so they required an alcohol challenge test to reproduce what heavy drinkers would experience if they were on Addyi. Some of the participants in that study had a drop in blood pressure or passed out.

Interactions with alcohol need to be discussed just as they would with any drug that affects your central nervous system. All centrally-acting drugs (think antihistamines, antidepressants, and hundreds of other drugs) are known to interact with alcohol, and the FDA requires a similar warning for these.

23. I hear that only men were included in the alcohol study. What about women?

The social drinkers in the study were women. However, the “alcohol challenge study” required participants to drink a half-bottle of grain alcohol first thing in the morning. They couldn’t get enough women to agree to the study, so they got permission from the FDA to do the test with men.

24. So does that mean that if I take Addyi, I can never have a glass of wine?

 Remember that 58 percent of women in the clinical trial identified as “social drinkers” and did not have any significant issues. The FDA however is very concerned about a potential alcohol interaction and is requiring physicians to advise their patients to not drink if they take Addyi. Hopefully as more information and experience comes out they will back off on this warning.

25. When and where can I get flibanserin?

 Flibanserin is available now but you must make an appointment with a physician that is a certified prescriber and get it from a pharmacist that has also been certified. Interesting that the FDA does not require doctors and pharmacists to be certified to prescribe and dispense Viagra, anti-depressants, narcotics or hundreds of other drugs that have significantly greater risks and side effects. Some might call that sexist. Just saying.

EDH Aug 2015

When Period Pains Cramp Your Daughters Style

 

by Lauren Streicher, MD

While it may seem like your menstruating teen is being a drama queen, menstrual cramps can be really painful. Roughly 50% of teens suffer from menstrual cramps and in 15% the pain is severe enough to interfere with normal activities. Since the average girl today starts menstruating at age 10, an adolescent with difficult periods can expect a minimum of 240 days, or over 8 months, of pain before she even leaves her teens

While endometriosis or another gynecologic issue is possible, most teen cramps are not an indication of a serious problem. The culprit is usually increased production of prostaglandins, a hormone-like substance that can cause intense uterine contractions. Some teens also experience monthly diarrhea, nausea and vomiting.

While crawling into bed, lying in the fetal position and wishing for a hysterectomy is one strategy, there are other solutions. The heating pad, an old standby, is actually a good idea. A study released in 2004 confirmed that continuous low level heat on the lower abdomen combined with ibuprofen dramatically reduced, or even eliminated, menstrual pain. Thermacare Menstrual Patches or any disposable heatingpad thatadheres to the lower abdomen, can be worn discreetly under clothes, and emit continuous heat for 8 hours. Over the counter NSAIDS (non-steroidal anti-inflammatory drugs) such as ibuprofen or naproxen dramatically reduce the formation of prostaglandins and decrease cramping and bleeding. The key is to take them the day before menstruation starts and prostaglandin activity kicks in. That’s no problem if your daughter has regular periods, but if her cycles are unpredictable, the medication should be taken at the first sign of bleeding or discomfort.  Once the period is fully flowing and the cramps excruciating, it’s too late to get the maximum benefit.

Of course, there is no better way to eliminate menstrual cramps than by eliminating menstruation. Using hormonal contraception like birth control pills to eliminate or drastically shorten bleeding (even when contraception is not needed) can change the life of a teen who has a major meltdown every time she realizes her period is going to interfere with an important social or sporting event. Many parents are concerned that giving hormonal contraception to teens will negatively affect future fertility or increase the chance of developing cancer down the road.  Fortunately, all evidence indicates that this is not the case. As an extra bonus, eliminating menses not only gets rid of cramps, but also reduces hormonal headaches, anemia, ovarian cysts, PMS and endometriosis. And any mother of an adolescent girl during a pre-menstrual meltdown can attest that the reduction in PMS alone makes it worthwhile. Not to mention the hundreds of dollars you will save every year by not buying pads, tampons and pain medication. And being the parent of a cramp-free teen ... priceless.

10/27/2010 doctoroz.com