Dr. N Blog
Menopause- Puberty in Reverse
Dear Readers, I am struck with what little information women are given about menopause. When patients come in they are uncertain what to expect and whether or not to treat it. It makes me think about puberty. This unusual time in a girl’s and boy’s life when their body starts to change. It is unspoken but understood, in a way. Not talked about much and somewhat weathered alone. It is, however finite, and well defined. Most everyone goes through the same symptoms, with some variety, and then at some point it is over- complete. One would think that menopause, the turning off of ovaries, would also be well defined, and finite. That there may be a predictable turns of events and then a point is reached when it is, over…. or beginning depending on your perspective. In my clinical practice, this is not the case. I have listened to thousands and thousands of versions of menopause. There are approximately 34 symptoms that can manifest, or not. In my experience there are about 4 different large classifications of this process. Some women don’t even notice. Some enter the menopausal state, average age 48-51 and with their symptoms, without treatment, keep these symptoms for the REST OF THEIR LIFE. Some women enter a window of symptoms for 3-5 years and then return to a manageable baseline and some, after 3-5 years return to a plateau that is different and tolerable, or not. It is complicated and confusing, even for physicians. The information out there is contradictory at times, even in the ‘evidence based literature’. Women are wandering in the dark and need guidance. I would suggest, better teaching needs to occur in medical training. A more uniform approach needs to be established rather than “what do you want to do?” And we need to offer medical advice that is realistic and factual. I regularly see patients that get differing opinions from different specialists. If we can’t agree as clinicians, how are we suppose to help the patients navigate these very complicated waters. Yes, there are many factors, family history, lifestyle, co-morbidities, and personal preference. We need to work out a more improved management for a complicated condition during these “Golden Years”. We are worth it.
Compassion to others Compassion to Self- Body Dysmorphic Disorder
Dear Dr N, I do not like my body. I am healthy, I can do what I want to do but just can’t seem to stop being so critical of myself. This may not be gynecology but I would like to see what you think? I don’t need surgery or anything, I just need to turn my brain off!!! NB
Dear N- What a sweet note. Believe me, you are not alone, there are many people, not just women who have that constant self critical voice that often relates to our physical appearance. There is a diagnosis called Body Dysmorphic Disorder BDD that affects approximately 1% of the population (although I think it is higher, just not self reported). It is a diagnosis that was added to the Diagnostic and Statistical Manual of Mental Disorders in 1987 although it was first described in 1886 by a different name. The ‘disorder’ in its most severe form can lead to severe social isolation, depression, love avoidance or suicide. In milder forms, it is a tiring voice that is not often revealed to others. There is a difference between specific abnormalities that can be corrected that will lead to improved self acceptance and those aspects of an individual that make them uniquely them that may not fit into societo-media norms. It is important to differentiate between the two. For patients that have BDD that are constantly having plastic surgery to improve how they feel, these patients need help. This can be psychotherapy, medication, addressing abuse issues or cognitive-behavioral therapy. It is important to consider one’s motives and intentions before exploring surgical interventions to change their appearance. We all have a great deal to learn about compassion to self and others. As we criticize ourselves so too, do we judge others.
The softening of the critical voice to self and others makes this journey much easier. It becomes easier to love and be loved- which is one of the great ‘importants’ of life. By telling on ourselves, we get help in the journey.
Thanks for writing, Dr N
Pain with Sex, age 70- The Female Patient
I saw a patient today that is 72 and CANNOT have intercourse with her husband of over 40 years. They have had an active and satisfying sex life but things have reached a point where she hurts too much to enjoy it, cannot achieve orgasm and he is upset about not being able to enjoy a connection they once had. She had a female genital tract cancer over 20 years ago and was told she could not take hormones. She was given some cream a couple of times a week by her family doctor and no counseling, teaching or encouragement. It didn’t help but she wasn’t sure what to do. They have tried lubricants, the medicine didn’t work and she finally said, ‘go find it somewhere else’ it just hurts too much. She came to my office to see what could be done. I was so sorry to hear that it had gone on so long. Our medical system needs to allow the time not to trivialize patient’s quality of life and allow providers to ‘talk’ about issues that patients are brave enough to bring up. They will often only bring it up once, especially embarrassing topics that are difficult to discuss. We need time to listen to patients and address their concerns in real , solution oriented ways. This patient, after so many years can use vaginal estrogen cream. Even if she could not, there are options with dilators and anesthetic topical agents to allow the increase in the caliber of the vagina. With estrogen cream, this will allow a more accommodating vaginal canal more quickly. I am starting a treatment plan that assesses her theraputic response and supports her along the way. We have ordered some dilators for her and plan to help her and her husband learn how to use them. There is a physical therapist I work with that can help them if necessary. I want to help her re-kindle her physical connection with her husband, and I believe this is entirely possible. I hope providers would help patients with sexuality concerns in real, practical ways or refer if they are not comfortable treating these disorders. This patient left with hope and feeling heard. She was grateful. Female sexual response can continue into your 70′s if you want it to. The anatomy and neurons will allow it with some help. The physical connection can continue. Dr N
Ovarian Conversation by Dr N
Dear Dr N, I am scheduled for a hysterectomy for endometriosis and I am 35 years old. I do not want to have pain anymore. Should I have my ovaries out too? signed puzzled
Dear Puzzled- This is a great question! On one hand I am certain that you want to feel better with less pain and suffering from the disease of endometriosis. I am certain you and your clinician have tried many forms of conservative therapy if you have arrived at a hysterectomy. It used to be that if you were having surgery to manage pain, and wanted it to be definitive, we were taught to remove the ovaries and replace the hormones. There are many new studies now in support of conserving the ovaries, which has always been my preference. Early menopause increases the risk of osteoporosis. It also increases the risk of ‘all-cause’ mortality, meaning that it may shorten your life span if women’s ovaries are removed before 45 and hormones are not replaced. There are also a small, but not significant number of women that just don’t feel right after having their ovaries removed either with menopausal symptoms or an affect on cognition and libido despite our efforts to given them their hormones back. In my opinion, it is better to be conservative to start and see if it will manage the pain well enough. Do not add surgical menopause to the problem and then if the pain persists, your surgeon can always go back laparoscopically and remove the ovaries.If they are removed, be sure and have hormonal supplementation for at least 10 years. Your body needs it. There are studies that support the removal of the fallopian tubes to lower the risk of ovarian cancer at the time of hysterectomy. I DO support this. In short, I believe in ovarian conservation while you are still using them unless you are close to menopause 48-51.
By all means talk to your provider, you two have all the facts. Good Luck. Dr N
What a “Mesh” by Dr N
There are commercials out there that warn patients about Mesh. This has become a new four letter word in medicine. I am saddened that advertisements can have a deleterious effect on patients’ well being. If I am watching television for enjoyment and I see an ad that frightens me about my own medical condition, this is wrong. If it makes patients feel fear or doubt, the commercial is doing harm. This should not be allowed. Yes, there have been some poor outcomes in some patients with some devices. That can be said about most surgical devices. Not everyone has the outcome they desire and at times there are complications. It is a complicated decision making process that leads a physician to choose a certain line of therapy and surgical intervention. Physicians are trained to ‘do no harm’ and make the best decisions they can make for a given patient.
The MESH problem arose because it was used in the vagina to correct complicated prolapse patients and a higher than expected amount of erosion, in the vagina occurred with some devices. I never used the devices that were recalled. Erosion at times, led some patients that have pain or problems with intercourse. I do not want to minimize the problems that have arisen. Some of the products have been removed from the market to allow further study in this area. That does not mean that ALL MESH is bad in ALL areas of the body and should never be used. Patients are now afraid of the word and if used by board certified, good providers and surgeons- patients will often say NO I don’t want that before they even listen to what is being recommended and why. Informed consent is very important but the harm that this form of advertising is wrong and places and undue amount of fear and anxiety where it is not needed. It belongs in the consultation between the physician and the patient. It belongs in informative publications that are based on fact not advertising. It needs to be part of an informed consultation where all the facts are presented or even during a second opinion, which I encourage. There is mesh used in blood vessels, under the bladder, to support the abdominal wall, in neurosurgery and other specialities and it helps a lot of people, a lot of the time. Complications happen. But lets give and get good information in a compassionate, understandable format. Not television commercials. And for that matter, I think medical information on the internet needs to be regulated so people do not get hurt. That is another topic. But yes, it’s a MESH and I hope patients will not let commercials affect their peace of mind. Talk to your doctor and get good evidence based information. Please do not let fear guide you. Dr N
IUD is Alive and Well
I would like to comment in the diverse use of the progesterone/based IUD- Mirena. It is Levonorgestrel releasing that primarily confines itself to the uterus with systemic release. It is beginning to be more than a contraceptive. In our recent “green” journal there were articles addressing some other indications. The key topics that were brought up were- it is safe to use in the teen population, it is safe to use in women that have not had children, it is used to manage very heavy periods, it might be effective in preventing uterine cancer or polyps in high risk patients and the risks are minimal. It’s use has increased from 1.3% in 2002 to close to 9% in 2009 of all contraceptive users. I believe that number will increase as it has become more affordable. Women of all ages are using it and once they experience the freedom of little or no bleeding, they want to do it again. The insertion is done in the office, by a trained provider, and should take less then 10 minutes.
It is an option that I believe more providers need to talk about. Not only for contraception but for other gyn disorders as well. Dr N
Female Embarassment by Dr N
I want to write about many women that I provide care for that see me because of EMBARRASSMENT. The majority of consultations for labiaplasty reveal that they have been self conscious about their body for years, sometimes decades. They describe too much skin that makes it hard to clean or difficult to wipe. They describe pulling or trapping of the skin with exercise or intercourse. They talk about being shy about changing in front of other people or with their partner. The majority of women come to this belief on their own. It is not media driven or a message given them by others. I would like to explain to those, that don’t understand, including some physicans and medical boards, or partner, or parents….. that we need to support the right of these women to choose something different that will allow them to feel better about themselves. It is a ‘truth’ that they come to on their own, for themselves. It is enormously rewarding to lift the burden from these women that they have carried for so many years. They are so happy once it is done. I agree, it is not for all women. I do embrace all of our differences. But for those that are embarassed and it persists into young adulthood and it affects their daily lives, we NEED to offer a safe, effective surgical solution that improves their self esteem and makes self care and self expression easier for them. It is not about wanting us all look the same. It is about helping a woman feel good about herself and encourage HER right of self expression, without judgement. I individualize the surgical approach to what they want. The repair leaves a look that is natural and does not leave any scars into the future. It is a healing journey that I am proud to be a part of. Women can have children after the procedure, sexuality is unaltered and the burden is lifted. Dr N
Be Real Dr N Gyn
Dear Dr N, Thanks for your office, your staff and your ability to talk about anything. Its real and it is appreciated. signed D.M
Dear D.- Going to the doctor can be uncomfortable at best. It is a choice to be vulnerable and talk to someone who knows more about your health due to their knowledge base. I went into the practice of medicine to be a source of knowledge for patients. I feel a responsibility to help give them the I have an information let them make their own decisions. The comfort starts in the waiting room. Small, personal can feel more private. We handle all information with integrity. My staff is approachable and helps you feel comfortable. We try to balance enough time to listen and still accomplish enough efficiency to run a small business. It is about balance. If we need more time, I will ask you to come back. I want you to feel empowered with knowledge.
We CAN talk about anything. You need a place to go where you can ask real question and get real answers. Thanks for the feed-back. Pass it on. Dr N
Nexplanon, Implant Contraception
Dear Dr N- My daughter has a scholarship for college, but she can’t get pregnant or she loses it. How do I, as a parent, help her with this as she goes to college? signed worried parent
Dear Worried- Your daughter is venturing into a great adventure. You want her to be careful and protect the great fortune she has with her scholarship. SHE has to commit to being careful as well. If she is sexually active a great option for her is to have an implantable contraception that does not require compliance. It is in the inside of the arm, and requires no remembering. It lasts 3 years and has few side effects. There is also an injection every 3 months, the Nuvaring that is in the vagina and is changed every month or a DAILY pill. I think the Nexplanon implant is a great option, little considered, simply because people do not know about it. Easy clinic insertion. No remembering. I wish your daughter well. It is progesterone only and only side effect can be spotting. Call your gynecologist and get her protected. Dr N
Anxiety by Dr N
I am going to post tonight and talk about Anxiety. There is a tremendous amount of worry and stress in the world. Patients come in and talk about their hormones, and while hormones contribute to a worsening of symptoms……. de novo or new SEVERE anxiety is not hormones only.
I can feel the anxiety when I walk in a patients exam room. There are many variations to this including tears that are being held back, pressure of speech, perseverating on fears, thoughts, ideas without rationale basis. I have had patients say “I am not a worrier” but “I go to an emergency room at least every 6 months with my heart racing and they can never find a cause”. I have patients state “I just need something to help me sleep” because they cannot stop thinking about their day or focusing on the next day. I have people say “I get up to see if my children are breathing” or “I think spiders are going to crawl up my sheet if they touch the floor” or “I can’t stop thinking that this pain is cancer” . But, when I ask, are you anxious or worried? They say no….. and they are the most resistant to therapy or medications because they are “concerned” about how the medication might make them feel or the long term effects of the medication. THIS IS ANXIETY. I listen and treat is every day. I feel like patients need therapy, psychiatrists- an avenue to talk about it. Primary care physicians often just hand out a prescription because they don’t want to talk about it. Psychiatrists are far and few, not covered by insurance and ALSO hand out prescriptions without talking about the fears. Anxiety can be chemical but frequently, it has a root. Learned behavior, trauma, phobias, depression , unhealthy home or work environments, body image, fear of death, spiritual crisis…. the list goes on. If someone would pay me to help patients with anxiety, if I could bill for the time- or physicians could take the time to talk to patients to guide, educate or help them- they wouldn’t be so quick to hand a prescription to them. I feel we have a society that medicates the problem rather than listens, guides, counsels. Sometimes people just need a sounding board from a compassionate listener and a counselor to help them find a way through their fears. I will treat with hormones at times, sometimes I listen, sometimes I make suggestions but the resources I have, as a provider are nil. Just wanted to talk about it. Dr N