5 facts about (peri)-menopause you didn’t know!

We aren’t taught much about what happens during menopause and the few years before.

 Read on for some things you didn’t know were related to the loss of estrogen that your ovaries used to make!

1.  Vaginal dryness may be due to menopause!

You may not realize that dryness is related to the loss of estrogen. You may not get aroused as easily during sex. You may not be able to reach orgasm; orgasms are not as strong, or it takes too long and too much work to get there. Sex may even become painful. No worries, low dose vaginal hormones help treat all of these, (and you are normal if this is happening to you)! Giving back the estrogen helps the vagina lubricate. It also makes the vagina stretchy, with good blood flow, and more nerves going to it, which makes sex feel better! The good news is that vaginal hormones don’t have the same risks that go along with other hormone use. They do not increase your risk of breast cancer, heart attack, or stroke.

 2.  Menopause makes it harder to lose weight.

It is not that you are lazy or crazy. During menopause women become more insulin resistant. This means your body needs to pump out more insulin to get the same amount of glucose into the cells. Insulin makes your body deposit fat, which is not good for your waistline. Menopause leads to fat deposition around your middle instead of your hips and bust. This “apple” shape, as opposed to the typical female “pear” shape, leads to an increased risk of cardiovascular diseases like heart attack or stroke. Diet and exercise are the first step to losing weight and making your body less resistant to insulin. Some women may need the help of some of the medicines that are available to help you lose weight.

3.     Anxiety, depression and mood swings may worsen around the time of menopause.

Typically, hormone levels become erratic before periods stop. Women may feel like they are on a roller coaster ride of emotions. Also, this is the time the kids leave the home and women may be dealing with an empty nest or a lost identity. They may also be taking care of aging parents or have financial stressors. There are plenty of ways to manage anxiety, stress, or depression. Some are with appropriately chosen medicines, other times yoga or soothing apps like CALM may be all you need.

4.  Word finding difficulties, forgetfulness happens.

This can be incredibly scary for menopausal women. You can’t seem to remember why you walked into the kitchen or what task you were supposed to complete today. The good news is that brain exercise helps. Learn a new language or learn how to play an instrument. Exercise and diet also keep the brain “fresh”. Be sure to eat a healthy diet, including omega 3 fatty acids which are found in oily fish like salmon or tuna. A healthy lifestyle lowers your risk of Alzheimer’s Disease and delays the progression of Parkinson’s Disease.

5.  Low libido.

Menopause is not all about estrogen. By the time women stop having periods, their testosterone is much lower than it was in their 20s and 30s and this may lead to low or loss of sex drive. Loss of sex drive may significantly impact a women’s relationship, and couples that don’t have sex tend to grow apart. There are plenty of hormonal and non-hormonal ways to improve your sex drive.

Make sure you find a practitioner who is well versed in menopause and sexual health.

Dr. Becky Lynn is a gynecologist, menopause and sexual health specialist in St. Louis, MO.  She is licensed to practice medicine in Missouri, Tennessee and Illinois.  She she sees patients in her St. Louis office and offers telehealth consults to Illinois and Tennessee.  Call today to schedule your appointment.  (314) 934-0551 or click click here to schedule.

Vaginismus: When Your Vagina Won't Cooperate

Is your vagina uncooperative when it comes to sex?  Are you unable to have penetration or it feels like there is a brick wall in there?  You might have vaginismus.  Dr. Becky Lynn, Director of Evora Center for Menopause and Sexual Health, speaks with Megan Normille, PT and Program Director at SSM Health Physical Therapy, on the topic of Vaginismus. Vaginismus is an involuntary tight contraction of muscles around the opening of the vagina that makes putting anything in the vagina painful.

 Dr. Lynn: Hello, I’m Dr. Becky Lynn. I am a board-certified gynecologist, menopause and sexual health expert at The Evora Women’s Health.  We treat women with problems like painful sex, low libido and orgasm difficulties. We also offer a full scope plan for treating your menopausal symptoms, all of them, not just hot flashes.  Today, we are going to talk about a condition known as vaginismus, which can lead to painful sex or prevent women from having sex at all. I want to introduce you to Megan.

 Megan: Hello, I am a physical therapist with SSM health Physical Therapy and my specialty is pelvic floor dysfunction in women. I am excited to talk about vaginismus because we see so many women with this terrible problem.

 Dr. Lynn: Let’s start with what is vaginismus and what is happening anatomically. The vagina is a long hollow tube that is surrounded by muscles. Vaginismus occurs when there is involuntary contraction of the muscles that surround the vagina. Many women with vaginismus can't have penetration at all because the muscles are so contracted. I often hear my patients say "he is hitting a wall" or “he can't get in”. Many times they have seen several providers in the past and they’ve been told, “oh just relax, drink a glass of wine.” I cringe when I hear this because wine is not going to fix the problem.  Physical therapy is the first step in treating vaginismus, although not the only step.  Megan, how do you go about treating vaginismus with physical therapy?

 Megan: We start with education about the condition. We need to make sure our patients understand that it's not in their head and it's not, like you said, a conscious decision. It usually is something that has been going on for a long time. Recognizing and appreciating the frustration that women feel, and understanding that this is not something women should just power through either, goes a long way in helping our patients.

 When I work with patients, I respect what the body is going through and how the patient is feeling. We start all of the physical therapy externally.  We need to get the muscles to let go first, then we can work on stretching the muscle. We work on different ways to get the muscles to release. Sometimes that’s through diaphragmatic or belly breathing.  Sometimes it is through visualization, where we use a mirror to look at those muscles. I do a lot of education about getting comfortable with the vagina, vulva and the surrounding muscles. We talk about where those muscles are and what their functions are.

 Dr. Lynn: Will you tell us a little more about the function of the muscles?

 Megan- Basically the muscles have three primary functions. One is the “sphincter” function. The sphincters open and close and they help with bowel and bladder functions. The muscles also play a role in normal sexual functioning.  The third function is to support, to hold everything in from the bottom and that includes the internal organs and pelvic organs like the uterus and bladder. We tend to think that the muscles are either relaxed or contracted, that there is an on or off switch.  But that is not the case.  We teach our patients to try to turn down the contraction a bit so they can allow and enjoy sex.

 Dr. Lynn: One way I describe the pelvic floor muscles to my patients is to think of a human skeleton and picture the pelvis. I describe the pelvic floor musculature as a hammock that supports everything, so your organs don’t fall out the bottom when you’re standing up.You mention “diaphragmatic breathing”. What does that mean?

 Megan: Diaphragmatic breathing, also known as belly breathing, is one of my favorite techniques to teach my patients. Diaphragmatic breathing is when you breathe very deeply, high up in the ribcage. When you inhale, the diaphragm, the layer of muscle that sits right underneath the lungs, comes down to give your lungs room to expand. Then the pelvic floor comes down and relaxes just because you are breathing deeply. They work in concert.  When we take short shallow breathes, the diaphragm and pelvic floor muscles stay fixed and they can’t relax. If we can get somebody doing diaphragmatic breathing, then the pelvic floor is automatically going to be moving and relaxed. When the person inhales, the belly fills with air and then when the person exhales their belly is going to go back down.  Many times we will place hands on the belly while the patient is laying down on their back. They are in a comfortable position working on belly breathing that way.

 Dr. Lynn:  Sometimes when my patient can't get to pelvic floor physical therapy, I will recommend yoga because they teach belly breathing which relaxes the pelvic floor musculature. Yoga also strengthens your core and improves flexibility throughout the pelvis.  You also mentioned visualization as a way to treat vaginismus.  Can you tell me about that?

 Megan: Sometimes we do visualization, which is having the patient look at the tissue. This is done using the mirror. The vulva (outside of the vagina) is an area of the body we can’t see very easily and if it's been something that's painful, it's sort of scary to look at. When we google what it is or looks like, we really don’t know what "normal" is. In my practice, when I tell someone to “just relax” the muscles, it is difficult for patients to do. It is like telling someone to walk and then it makes walking more difficult.  When we say make the muscles “mushy” or “soft” or “let go” while looking at the tissue, they can understand relaxation better.

 Dr. Lynn: Do you ever use biofeedback?

 Megan: Yes, we do. In biofeedback we use stickers that go on the outside (nothing is inserted), that measure if a muscle is contracting or not.  Then we can show patients what it feels like when the muscles are contracted and what it feels like when they are relaxed.  

 Dr. Lynn How about dilator use?

 Megan: I have a love-hate relationship with dilators. I think they can be very helpful but patients need to learn how to use them or they won’t help and might make things worse. 

 Dr. Lynn: I agree. I never hand somebody a dilator and say go home and use this.

 Megan: When the muscles are still contracted, it's can be painful to insert the dilator. We want the dilator use to be pain-free. Before using a dilator, we need to get the 3 layers of muscles relaxed. We need to get the outer layers “mushy” or “let go” first, before we work on the inner layer. If those outer layers are still contracted and painful, dilator use won’t be successful in the way we want it to be.  Dilators can be very helpful, but it's usually later on in the treatment.

 Dr. Lynn:  I recommend thinking of dilators as “desentiziers”. Once my patients can relax the pelvic floor musculature, then I recommend that they try to insert the smallest dilator and gradually move up. I explain it by saying that using the dilator tells the brain that you can have something in the vagina and it not be painful. The other thing I've noticed with my patients is that it gives them confidence to try and have sex because they know they are able to have something in the vagina without pain.  If a large dilator can sit in the vagina and the patient is pain free, then they are more likely to go give penetration a try.

 Megan: With intercourse, there is a lot of movement too. We use dilators to work up to rotations and some slight in and out movements. This can bridge the gap between physical therapy and actual intercourse. I will even have the partner of the patient insert the dilator if they feel comfortable. This helps patients get them used to somebody else touching them.

 Dr. Lynn:  Right, I definitely think it's different when somebody else is touching you because you lose control, and I think that can make people very anxious. Once you lose control it becomes that much harder to do your deep breaths. I often recommend that when the woman does decide to have intercourse, that she be the one in control. She should be the one to guide the penis into the vagina, because it takes away the anxiety of being out of control and that makes a big difference.

 Megan: I talk a lot about boundaries. The patient may say to her partner "we are going to work on touching and desensitizing the external tissue", nothing further. That's the boundary that she has set. Then there's a mutual expectation of it not progressing further. Having those boundaries from the beginning can be very helpful.

 Dr. Lynn: I always learn so much when I talk to you because we approach the problem from such different angles.

 Megan: I’m curious what you tell patients about the time frame? I get asked a lot “how long is this going to take?”

 Dr. Lynn: This is a very long process and I think it's really important to set that expectation.  Having treated vaginismus over the long term for many years, I explain to patients that we take baby steps and it's not going to go away overnight. We make a little progress, then most people back up a little bit, and then a little progress forward again. Maybe they hit a stumbling block. It is baby steps forward and then a couple of steps back. But eventually, many women get past the vaginismus and are able to have pleasurable sex without pain. Many go on to get pregnant and have babies!

 Megan: We always do a little cheer when that happens so we can celebrate success with our patients. But you are right, it definitely can get better and can be successful and a good positive experience. As for the time frame, I try to be clear upfront that it is different for everybody. There are so many factors that play into it.

 Dr. Lynn: One thing that I want to say about vaginismus is that it is really important that you see a sexual medicine specialist or a pelvic pain specialist when you get the diagnosis because vaginismus can be due to several other medical conditions. It can be due to endometriosis, interstitial cystitis, irritable bowel syndrome, a history of sexual abuse or trauma, back and hip pain, and/or a lack of hormones. If you have vaginismus and let's say you found that diagnosis on the internet, and you go to pelvic floor physical therapy and nobody is treating the endometriosis or the irritable bowel, then pelvic floor physical therapy alone won’t cure the vaginismus. Only treating all of the contributing factors will. It is very important that you see someone who has knowledge in vaginismus and pelvic pain.

 Megan: I agree.  Many practitioners don’t have the expertise and that's when we hear "have a glass of wine" and other comments I like to think are well intentioned, but are not very helpful.

 Dr. Lynn: Patients get told it’s all in their head. Patients are relieved to know there's a reason they have this.

 Megan: Just the words, “you are not alone” can ease patients fears. Because of HIPAA we don't introduce patients to each other but there are so many patients out there with the same diagnosis. It's not as unusual as you would think.

 Dr. Lynn: Is there anything else you would like to add?

 Megan: I think that is about it.

 Becky- Alright, thank you for tuning in and we will see you soon! 

See this conversation on YouTube: https://www.youtube.com/watch?v=JZG9YD8-6is

 Dr. Becky Lynn is a national and international speaker, gynecologist and menopause and sexual medicine specialist.  She has been featured in Best Doctors in St. Louis, Martha Stewart Living and Self Magazine.  If you would like to make an appointment to see Dr. Lynn, call 314 934 0551 or go to her website.  Evorawomen.com.  You can even schedule a 15 minute visit just to get to know Dr. Lynn and see if she is the right fit for you.  If you have any questions, please email us at info@evorawomen.com. She is licensed to practice medicine in Missouri, Tennessee and Illinois.  She she sees patients in her St. Louis office and offers telehealth consults to Illinois and Tennessee.  Call today to schedule your appointment.  (314) 934-0551 or click click here to schedule.

Menopause: 4 things you can do when “down there” feels like sandpaper

Sandpaper. That is what my patients tell me about how their vagina feels during sex after menopause.  There’s good news though--you don’t have to live that way.  There are several things you can do to reinvigorate “down there”.

 What is menopause?

 When your ovaries stop releasing eggs each month, you have entered menopause.  Without the ovulatory cycle, your ovaries are not making estrogen and progesterone like they used to.  Testosterone is also decreasing.  These hormones play a large role in sexual function.

 Vaginal changes after menopause

 We call the changes to the vagina vaginal atrophy which is part of the genitourinary syndrome of menopause (which includes changes to the urinary tract).   Vaginal atrophy doesn’t usually appear until about 5 years after the last menstrual period.  Many women don’t realize that vaginal dryness is due to menopause.  They feel like something is wrong with them when sex hurts. Many times, their partner is concerned because they don’t appear to be lubricated or aroused and the couple is unaware that this is a normal change of menopause.

 Lack of estrogen causes some major changes to the vagina.  Before menopause, estrogen  makes the vaginal walls thick, moist and stretchy.  There is good blood flow to the vagina and plenty of nerves (just ask anyone who has had a baby!).  There are small folds (rugae) in the vagina that allow the vagina to stretch so a penis can fit into it or a baby can come out of it.  All of this leads to pleasurable sex. But after menopause, the vaginal walls become thin and dry.  They lose their rugae, stretchiness and they don’t naturally lubricate during sex.  This loss of elasticity combined with lack of natural lubrication can lead to painful sex.

 4 things you can do about vaginal dryness.

Lubricate:  There are several types of vaginal lubricants: water based, silicone based and natural oils like olive oil.  If you are menopausal and have vaginal dryness, throw away the water based lubes. Although they sound “natural”, water based lubes pull moisture from the vaginal tissues and make dryness worse. Pick a silicone based lube like Uberlube or Wet Platinum.  Water based lubes do not affect the integrity of a condom but some silicone based lubes do.  If you are using condoms, the silicone based Uberlube is a good choice because it does not affect the condom.  Put some on the outside of the vagina, which is called the vulva, and before sex, put some on your partner too.  This will help things glide a lot more smoothly.  

Moisturize

Just like you put lotion on your hands, you can also moisturize the vagina.  There are a variety of products on the market for this, like Lubrigyn or Hyalo Gyn.  I tend to recommend coconut oil (solid) or wait for it. . . .Crisco.  You can use as little or as much as you want.  You can put some on the vulva morning and night, or every time you pee.  You can even freeze chunks in an ice cube tray and then insert them into the vagina with your finger.  This does not increase your risk of infection.  

 Low dose vaginal hormones

 Low dose vaginal hormones replace what the vagina is lacking during menopause- estrogen.  Before you say no to hormones, remember that low dose vaginal hormones do NOT increase your risk of breast cancer, blood clot, heart attack or stroke.  Vaginal hormones restore the elasticity to the vagina, allowing it to stretch without pain and return its ability to lubricate itself again. Sex becomes pleasurable again as there is more blood flowing to the vagina allowing for more sensation and engorgement. 

 Vaginal laser

There are some several studies evaluating vaginal laser for the treatment of genitourinary syndrome of menopause.  Thus far, they show some promising results.  Vaginal laser breaks down old collagen and your body replaces it with new healthy collagen and elastin. After laser, the tissue appears more like premenopausal tissue with more superficial cells and women report less dryness and less pain. 

Go ahead, reinvigorate the vagina! No need to have painful sex when there are so many treatment options.  You will be so pleased with your results!

DOES THIS SOUND FAMILIAR? CLICK HERE FOR MORE INFORMATION

Dr. Becky Lynn is a gynecologist, menopause and sexual health specialist in St. Louis, MO.  She is licensed to practice medicine in Missouri, Tennessee and Illinois.  She she sees patients in her St. Louis office and offers telehealth consults to Illinois and Tennessee.  Call today to schedule your appointment.  (314) 934-0551 or click click here to schedule.

How having breast cancer affects your intimate life

Breast Cancer- that thing that turned your world upside down, breast cancer survivor.  You never thought it would be you.  No family history, you eat right, you exercise, but somehow you found a lump that turned out to be cancer. And you are young! Cancer is for old people.  But no, now you embark on the road to recovery, see the oncologist, the breast surgeon, the plastic surgeon, the radiation oncologist so you can fight this disease. You get your care and it’s done. Time to get your life back.

But no one told you what was going to happen to your intimate life!

 Did you know your breast would look funny or that you would lose sensation in your chest?  Your nipples would be gone? Did they tell you what lack of estrogen does to the vagina?  Did anyone mention that sex was going to become excruciatingly painful or you would never want to do it again? No, no and no. Because, as they should be, everyone is working on making the cancer go away for good. At the end of the day, you still have to lead your life. But should you even worry about intimacy when you should feel lucky to be alive?

 The answer is YES! Intimacy matters!  Sex Matters!

 Finding your new sexy

 Sex is going to be different now.  One of the most common issues in women with breast cancer is vaginal dryness that causes painful sex.

 Vaginal dryness

 If your breast cancer is estrogen and/or progesterone receptor positive, then the treatment to prevent it from coming back is to prevent estrogen from working or to get rid of as much estrogen as possible so there isn’t any left to stimulate a breast cancer cell to grow.  Vaginal dryness is the most common side effect of low estrogen levels. Lack of estrogen changes the vagina.  When your body is making estrogen, the vaginal tissue is thick and moist and it stretches.  It has proteins like collagen and elastin that help it stretch so a baby can fit out of it or a penis can fit into it.  It also has special cells that make moisture when you get aroused or excited.  When there is estrogen around there is a lot of blood flowing to the vagina and this makes a difference in sensation, how good sex feels. When there is minimal estrogen, the vaginal tissue gets thin and dry.  It loses its collagen and elastin so it doesn’t stretch when you try to put something in it.  This can cause a lot of pain, especially on initial penetration.  Also, there isn’t as much blood flowing to the vagina so some women say there is a lack of sensation.  

 What to do about vaginal dryness

 First of all, throw away your water based lubricants.  Some of you may have already purchased a lubricant and yes this is the first step.  Put some in your hand, put it on the outside of the vagina which is called the vulva and put some on your partner’s parts, penis or otherwise.  Invest in some silicone based lube or olive oil.  (unless you are using condoms, then you have to stick with the water based).  Water based lubes pull the moisture out of the vagina and make dryness worse. Avoid any lubes with flavors or tingly sensations.  I recommend the silicone based lubes Uberlube or Wet Platinum. 

 You can also moisturize the vagina.  Just like you use hand lotion for dry skin, you can use a vaginal moisturizer for the vagina.  There are many available on the market, but my recommendation is plain and simple, coconut oil or solid vegetable oil (Crisco).  You can use as much or as little as you prefer.  There is no right or wrong way to do this.  If you use too much, you will feel greasy or messy.  If you use too little, you won’t notice any difference at all.  Put it where you feel dry on the vulva or in the vagina.

 Lubes and moisturizers do a fantastic job at decreasing friction during sex.  They don’t do much for increasing the stretchiness of the vagina or bringing more blood flow to it.  Only low dose vaginal hormones do that.  But you thought hormones were out of the question, right?  Well, there are several national organizations like the North American Menopause Society who have evaluated the medical research about this and come up with some recommendations.  If lubes, moisturizers and other nonhormonal treatments have not worked, women with breast cancer can discuss the risks and benefits of using low dose vaginal estrogens or intravaginal DHEA (a different hormone) with their providers.  Treatment should be individualized, taking into consideration quality of life, risk of the cancer coming back and how bad your symptoms are.  Yes, you can consider the use of vaginal hormones in consultation with your cancer doctor after a thorough discussion of risks and benefits.

 Quality of life matters, relationships matter, human touch and intimacy matter.  So bring it up with your doctor.  Talk about it with your partner.  Don’t just accept sex as a thing of the past.  Find the right provider who can help you.  You need honest and accurate answers. 

 Don’t just survive. . . . . THRIVE!

 Coming soon, a discussion of low libido in breast cancer patients and survivors.  Stay tuned!

 I am a Sexual Medicine Gynecologist

Dr. Becky Lynn is a gynecologist, menopause and sexual health specialist in St. Louis, MO.  She is licensed to practice medicine in Missouri, Tennessee and Illinois.  She she sees patients in her St. Louis office and offers telehealth consults to Illinois and Tennessee.  Call today to schedule your appointment.  (314) 934-0551 or click here to schedule.

Schedule an appointment with Dr. Lynn

Check out my website for more information. 

 evorawomen.com

 Or call 314 934 0551 to make your appointment today!

Why can't I climax anymore?

Why can’t I climax anymore?

“I just have to work sooooo hard to reach orgasm nowadays”, said my patient.  My husband thinks it is him and it’s not.  “I just don’t know what is wrong with me”. I hear this from my menopausal patients day in and day out.  They feel bad, they are worried something is wrong with them, it is causing concern in the relationship.

You can blame menopause.

Difficulty reaching orgasm or inability to orgasm is super common during menopause.  During menopause your ovaries pretty much stop making estrogen and by this time they aren’t making much testosterone either.  Both the vagina and the clitoris need these hormones to function normally.  So, reaching orgasm requires a lot more work, for some women. Some women then decide to forgo that elusive orgasm (or they fake it). “oh, don’t worry about taking care of me” my patient says to her partner.  “You can get me next time”.

The problem with this scenario is that for the woman, the sex isn’t always that great when she doesn’t get that pleasure release of orgasm.  When a woman reaches orgasm, she gets a flood of dopamine in her brain.  Dopamine is that feel good hormone, it is the one that is released if you do heroin or cocaine that keeps you coming back for more.  (NO, don’t do heroin or cocaine).  After orgasm, your body releases oxytocin, the cuddle hormone, that makes you want to curl up next to your partner.   A good orgasm is an important part of good sex.  When sex starts to become not so good, sex drive decreases too.  In order to want to have sex, it has to be sex worth wanting.

We just don’t learn about this stuff!!

 Did anyone tell you this was going to happen during menopause?  Heck, no!! Women’s sexual pleasure is a bit hush in our culture.  Well, it shouldn’t be.  All women should know that there is treatment for difficulty with orgasm due to lack of necessary hormones. Low dose vaginal hormones can be used and these do NOT increase your risk of breast cancer, stroke, heart attack or blood clot.  I repeat, no increased risk when used vaginally.  Low dose vaginal hormones bring the healthy blood flow back to the vagina.  They allow the vagina to make the cells that make moisture and they allow the vagina to be stretchy again, so sex is much less likely to hurt- another menopausal trouble, to be discussed in another blog. 

I have to mention that there are a variety of other things that can affect a woman’s ability to orgasm and the list is long.  If you are having trouble, see your doctor.  No let me change that,  see your sexual medicine doctor!

Dr. Becky Lynn is a gynecologist, menopause and sexual health specialist in St. Louis, MO.  She is licensed in Missouri, Tennessee and Illinois.  Call today to schedule your appointment.  (314) 934-0551 or Click here to schedule an appointment.. If you are not located in Missouri, Tennessee or Illinois, Dr. Lynn offers an E Health. Click here to learn more about E Health and meet with Dr. Lynn today!

Click here to read more.

 Check out our website today for more information. 

 Evorabydrbeckylynn.com