Dr. N Blog
Hymenoplasty- The Reality
I want to write about a visit that is not too uncommon in my practice. It is important and relevant in the world and yet we are not talking about it. It has to do with the incredible power the hymen has over some cultures.
I saw a patient, lets say Julie. She was raised in Sudan by two working parents and for as long as she can remember, she was told to ‘protect’ her hymen by her mother. This was important for her future marriage and ability to have the family choose her a suitable husband. She never used tampons, she thought about it growing up with fear, thinking ‘what if it breaks?’, it was a mystery yet undeniably important. She loved and was loved by her parents very much. Fast forward to college where her parents want her to have the best education possible. She comes to an American University. Succeeds in her chosen major of engineering. She is different from the American women but is able to find her way. She has what she calls ‘an accident’ with her hymen. She had intercourse. It was a moment when she let down her guard and gave into normal human desire. Her life is now in turmoil because her plans are to return to her country for an arranged marriage which is the custom in her country. She cannot tell her family or her friends. She is isolated and afraid. She lives in the fear that if in the course of her marriage plans, if she does not bleed on her wedding night, she might be discarded or killed. It would shame her family.
There is no room for this kind of ‘mistake’ in her family. If her future husband had such a mistake before marriage, no one would ever know expect him and maybe another lover. He will not be help accountable for such perfection. She describes these fears in my office with a desperate plea to make her anatomy whole again so that she may be able to find forgiveness with herself and her God. We talk about hymenoplasty. She listens to the Koran in the preop and postop. She has tears of joy at being able to consider going back to her life in Sudan and marrying the husband of her families’ choosing. She has less terror and shame.
Many women do not bleed the night they consummate their marriage, even if they are virginal. Such fear in young women is inhumane and so sad. While I support cultural norms I do not support not having a way of forgiveness for women that does not involve shame, terror or even death. Growing up involves making mistakes of many kinds. We are only human.
Here at Dr N Gyn we are trying to help women find their way in this complicated world.
Vaginal Rejuvenation, Dr N Gyn
Rejuvenate- To make something or someone feel or look young, healthy, or energetic again; to give new strength or energy to something.
It has been some time since I have entered a post. Busy taking care of women, listening to women, operating on women. I want to write about a topic that is becoming clearer and clearer to me as I have had to courage to advertise that I am willing to rejuvenate the female genital structures. Something that has been a part of the field of OB/Gyn for many years but we have not given it a name. We have hinted at it or had patients say, WOW doc, you really made things feel better down there! But as providers we have not said, come to me if you have this problem so I may help you. It has been wrapped in a veil of a medical problem as though we are in denial of IT. What I have found, is that there are many women who want, as the definition says, to make the vagina or labia feel more energetic again. To regain something that was lost during childbirth, aging or hormonal changes OR want help with something they were born with- and women are asking for help. The results are astounding. Women find a regained confidence and ease with their body. They are facing fears and walking through them They are talking about their sexuality in an open way. They are not ashamed about their wants and their needs. They seem to come in afraid to talk and by the time WE at Dr N Gyn are finished taking care of them, we are laughing together, sometimes crying together and we are coming out the other side of the amazing journey of vaginal rejuvenation. Making things feel more new and energetic. Dr N
The Clitoris, Dr N
I want to write about the poorly understood clitoris. I have been researching the subject of sexuality in order to write a book for women about women. The most differing topic is the understanding of the clitoris. I am going to start with some common findings that run through my reading and experience with patients. Many women and men do not know where it is. That is a sad thing. Nor do they understand the response of the clitoris which has many nerve endings on the glans , which is similar to the penis, and is exquisitely sensitive. It has a hood that it retracts under when it gets aroused so things aren’t too sensitive. The tip of the clitoris is connected to the shaft which feels like a cord and from the shaft there are crurae that extend downward as roots towards and surrounding the urethra ending at the urethral sponge which is under the urethra thought to be the area of the G spot. The extensions of the clitoris that for some women can elicit a vaginal orgasm. The clitoris comes in different sizes and locations from the urethral opening. It is the primary source of arousal for women that leads to orgasm but the surrounding erectile tissue contributes to arousal and sensitivity. Many women find it by mistake when they are young and if they don’t know where it is have a hard time telling their partner what to do or where to touch. There are an estimated 20% of women who have never had an orgasm and I believe much of this is due to a poor understanding of the female arousal system and sexual response. Do your research ladies. It is a wonderful adventure. Dr N
For those of you that have had an LSH Laparoscopic Supracervical Hysterectomy, you probably had a morcellator used on the tissue to get the uterus out. Currently in the news there is controversy surrounding the device, due to the use of the technology in a situation that spread a uterine cancer. For patients that have had that form of hysterectomy, there is not cause for concern because the specimens were all sent to pathology to rule out a cancer in the specimen. Discussions are currently being held as to how to make use of this technology safer. It is an excellent technique to remove larger specimens through smaller incisions. There may be a move to ‘morcellate’ in a closed system such as a bag to limit the spread of potentially unsuspected tissue types. I hope this excellent technology can be used in the future. Be assured that if it was used on you, your provider will have checked the pathology specimen to ensure that it was non cancerous tissue.
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