Dr. N Blog

Headline: The conundrum of intimacy

As a gynecologist, I am uniquely suited to listen to women of all ages. I am a board-certified gynecologist providing the full spectrum of gynecological outpatient and surgical services.

It is such a privilege to hear, on a daily basis, the concerns that many women share. What is striking is the lack of information available to men and women, as it relates to their bodies and intimacy.

The other night in my office, I was able to have an open house to talk about the dilemmas women have regarding their anatomy and sexual response.

While some of this is relational, some of it is physical. These women asked questions about anatomy, hormones and solutions. They each had unique problems and challenges. They all felt confused as to what direction to take.

It was stunning to see the relief when they realized they were not alone in the problem and that there were solutions.

Whatever the concern, we meet you there, from menopausal symptoms to pain — or life after cancer.

We are here to help you have the intimate life you want. We offer hormonal solutions, physical therapy, C02 laser treatments (Mona Lisa Touch) or dilator therapy.

We refer to counseling when necessary. We are patient and compassionate.

In the realm of intimate concerns, you are not alone and there are solutions. Give us a call.

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Archetypes, the female patient – Azah, a muslim student

The concept of an archetype is that there is a standard and recurring depiction in the human condition, in this case, the female patient. In the practice of gynecology there are recurring themes. There are patient types. While there is variety, it is the commonality that allows a provider to find a common solution.
I see this in women’s ages. There are unique situations that arise at certain ages much like Piaget’s developmental stages. I also see this in personality types and chief complaints. I am intrigued by this. I believe that in hearing other women’s stories, many women can find their solutions. I am going to experiment by telling stories to see what response I get from my readers.
Azah is a woman that came from the United Arab Emigrates to a small town in Oregon. She came to study. She is the eldest
female of a traditional Muslim family. She has two sisters. She loves her family and hopes to come back to her country
some day with her education to improve conditions in her home country. On arrival to her new small USA town of residence she finds an apartment and adapts quickly to the academic environment. She is a good student, studying engineering. There is not orientation to American culture. Women are free to wear whatever they want and they go out alone at night. They are alone with men. They assert themselves as freely as the men. The cultural G forces are palpable to Azah. Did her family fail to prepare her? Did the University overlook the need for an orientation? She is not prepared for so much cultural change and is defenseless to it. She falls in love with a mideastern man named Tahir from Oman. He is handsome, bright, gentle and loving.
He respects her as an equal. They become lovers. The time comes when it is time to return to her country. She is fraught with torment around her love for Tahir and her love for her family and country. She has promised her beloved family that she will return and lives in fear that they will discover her loss of her virginity to her beloved Tahir. She fears for her life, knowing that honor killings occur in her country. She is afraid to confide to her family about Tahir and her life in America.
She elects to prepare to return home by having surgical correction of her hymen to regain her ‘power’ and to protect her life. She secretly, with Tahir’s blessing, undergoes surgery and pays cash. She returns home not knowing if she will ever see Tahir again. She hopes someday they will marry but she needs to be prepared for the demands of her parents to marry the man of their choosing. She does not want to take away the option for an American education for her siblings. Azah returns to UAE to confide in her mother her hearts desire. The outcome, uncertain. Tahir plans to return to Oman and wait to hear from her. He is uncertain whether to share his heart with his parents. The loneliness of their experience is profound and so sad.
We are failing these young people when they land in America. We need to empower and prepare these men and women to follow a path that allows them to enjoy their experience and be true to themselves. Information is power. Azah is my archetype.

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Postmenopausal Vaginal Pain

Dear Readers, it has been awhile since I have posted a blog. WE ARE BUSY. This is a great testimonial to a style of practice that I believe in. Women want a private place to go to voice their concerns where they will be heard. They want a collaborative approach to health care where they are in partnership with their provider. This is what we are dong and WE are busy. That being said, it is time to visit with my audience again.
We are launching the MONA LISA Touch. It is an FDA approved, office based procedure that not painful that is an AMAZING
alternative to hormones for the treatment of vaginal atrophy. Yes, the vagina begins to atrophy when the estrogen stops being produced by the ovaries. This process begins in a woman’s 40’s and remains unless an intervention is carried out. For some this is not a problem, for some it is disabling. Until recently the mainstay of treatment has been estrogen treatment either for the whole body or vaginally. Some women don’t want to do that including many of my breast cancer survivors.
There is now a way that through a laser treatment of the vagina, making small millimeter injuries with the laser, that the vagina, in the healing process is able to ‘rejuvenate’ itself to be back to its youthful state. It has been documented through biopsies and testimonials of women saying “it feels amazing again”, ” I don’t have pain anymore”, ” I’d forgotten how fun sex can be”, “I’m not just showing up anymore, I’m actually enjoying it”. Ladies and Gentlemen, this is a “game changer” for the menopausal vagina. No, it is not covered by insurance (yet), but it is an investment in feeling better and having a happier and healthier sexual relationship. You can read more about it on utube under MonaLisa Touch testimonials or www.monalisatouch.com
Call the office for a 20 minute consult to see if you are a candidate. I will discuss any and all treatments available,
because that is what we do at DrNGyn.

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Hymenoplasty- The Reality

Dear Readers,
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.

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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

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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

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The Morcellator

Dear Readers,

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.



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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.

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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

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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

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