How to lose weight during menopause! Meet Katie Heaney, RD.

 Link: https://www.youtube.com/watch?v=9s9UNax-QQ0

 Dr. Lynn: Hello, I’m Dr. Becky Lynn. I am here with Katie Heaney, RD. I’m a gynecologist, and a menopause and sexual health specialist.

 Katie: I am Katie Heaney. I’m a registered dietitian working with Dr. Lynn. I specialize in weight management, obesity interventions, nutrition for the whole family, and some sports nutrition.

 Dr. Lynn: Well, fantastic! One of the reasons I wanted to bring Katie here today is because I see so many menopausal women who tell me that when they go through menopause, their metabolism slows down, and they’re gaining weight. They tell me that they watch what they eat, they make healthy choices, they exercise, and they just can’t lose weight.

 Katie: This can be really frustrating because menopause is a big transition in life. I see many menopausal women struggling with those last 15 pounds! As women journey through the lifecycle, their bodies naturally shift in response to hormonal changes that usher them out of the fertile phase of life.  Menopause is frequently accompanied by weight gain, muscle loss, and lack of energy, making it challenging to achieve a healthy weight.  Many women who have gone through menopause or are going through menopause come to us to help them with weight loss and muscle gain. 

 When people see me and want to make healthy changes and lose weight, I start by getting as much information as I can about their current eating habits. I discuss what healthy weight loss looks like and realistic timelines.  There is so much that goes into healthy eating and weight loss.  It isn’t just about calories in and calories out. I do a deep dive into what they’re eating, when they are eating it, do they exercise, and if they are getting enough sleep. Sleep is so important. It is one of the first things we talk about. We are more likely to make unhealthy choices when we are sleep deprived.

 Dr. Lynn: During the years before your periods stop (the perimenopause) and then for a few years after they stop, many women have night sweats and they can’t sleep at all or have awakenings in the middle of the night. This is not good for those carbohydrate cravings!

Stress

 Katie: Stress plays a role too. Having a lot of stress in your life affects how hungry you feel.

 Dr. Lynn:  Stress hormones like cortisol increase, which leads to insulin increase which makes you deposit fat and crave carbohydrates.   So, how would you define healthy weight loss?

Defining Healthy Weight Loss

 Katie: It depends on where we start. Generally, we say half a pound to a pound a week of weight loss. It is a bit controversial with dieticians – like counting calories or not. I like to discuss mindful intuitive eating. We try to figure out how to be mindful of caloric intake. I also calculate women’s resting metabolic rate and their activity level in order to calculate how much or how little they need to take in to lose weight.  Research show that the average weight gain during menopause is a little more than 1 pound per year.  With reduced calorie needs as women age, weight gain is expected if they don’t eat healthfully and increase physical activity.  Lifestyle factors are extremely important to consider when talking about weight gain. 

Measuring Resting Metabolic Rate

 Dr. Lynn: How do you measure the resting metabolic rate?

 Katie: I use an equation called the Mifflin-St Jeor equation. It is based on an algorithm that uses your age, gender, activity level, and height and weight (of course). It is an estimate, but you can also use a special kind of breathing machine. You breathe into it and based off of your oxygen level and carbon dioxide level, it measures how much energy you use at rest just to run your body.  This is your basal metabolic rate.  It is very useful information.

 Dr. Lynn: It gives you the calories you burn each day?

 Katie: Resting metabolic rate is the total number of calories burned when your body is at rest. From there we use the activity level to calculate how many calories you need for healthy weight loss, because the breathing machine only gives us the calories you would need at rest. Also, I have clients that will take multiple measurements over time, because as you lose weight, there is less of you to feed, so your resting metabolic rate decreases. The way you can increase or maintain your resting metabolic weight is to build muscle as you lose weight. I am not a personal trainer or a physical therapist, but I encourage 2-3 days a week of weight training and building muscle because that can really help boost your metabolic rate. Your metabolic rate tends to go down as we age and as women go through menopause.

 Dr. Lynn: So it is funny that you say that because (and I am not a dietitian), but I always think that when you’re trying to lose weight, you need to do aerobic exercise, get your heart rate up and burn calories. And so, I have said in the past, if you have limited time, concentrate on the aerobic exercise. I have changed my tune on exercise over the years. Now I see the value in strength training, especially for menopausal women because menopausal women lose muscle mass when they lose the hormones their ovaries used to make.

 Katie: Resistance training is great for muscle building!

Resistance Training and Aerobic Calorie Burning

 Dr. Lynn: What would be the optimal mix of resistance training and aerobic calorie burning?

 Katie: That is a really good question. I don’t think it’s either or; it is hopefully both. I would start with looking at what you are willing to do. Many times I have clients say, “yeah I’m just not going to lift weights, but I would like to get my heart rate up and start exercising more.” I focus on where the client wants to start.  If I say to someone, “do all of this,” it can get overwhelming, and they may not start at all.

 I just had a client the other day say “I’ll do ten minutes a week and that is all I will do”.  I have another client who is already doing three days a week of Krav Maga, high intensity interval training, and she said, “I’ll go up to four days a week!” So, it just depends on the person, but ideally the recommendation for adults, is 30 minutes a day, or 210 minutes per week. It can be 30 minutes a day or it can be three 1-hour long sessions a week. I try to choose something that works for each person.  If it were up to me, I would say the 30 minutes a day, because then maybe we can incorporate two days a week of strength training for 20 minutes.

Logging Your Data

 Dr. Lynn: Okay, so you talk about sleep habits, you talk about exercise, but then do you have them write down what they eat?

 Katie: Every client is different. Generally, when they come in, I want to know what they’re eating. Some of them come in with a notebook, and many, many, many clients come in using  My Fitness Pal. I think you’re familiar with it?

 Dr. Lynn: Yes!  My Fitness Pal synchs up with our electronic medical record.   

 Katie: Some people come in and they have it all recorded, so we can go through that. Typically, I get a verbal intake of what you are eating on a typical weekday, and I usually get a couple samples of meals and schedules. For the weekend, schedules change. So, I also get a weekend day. From there, we talk about eating habits. For example, “do you skip meals? Do you eat when you’re stressed, bored, angry…” Emotional eating is common.

 Dr. Lynn [humorously]: That’s me!

Emotional Eating

 Katie:  We have to eat all the time and we are always thinking about food. So, there is a lot of eating that goes with emotions. I also ask about binge eating habits or eating disorders, and I usually refer to a specialized therapist for those.

 Dr. Lynn: Yes 

Katie: I am not a therapist. I sometimes introduce cognitive behavioral therapy(CBT) in sessions as a behavior change technique, but I usually refer to a trained counselor or therapist for more detailed training on CBT.   

Katie: I also talk about hunger with my clients. For instance, I go through the hunger scale. I usually compare fuel for my body to gas for a car, so when the gas is empty, the car stops. When you’re really, really hungry, your body doesn’t work as well as it should. Your brain doesn’t work as well as it could.” I always say 10 is like Thanksgiving Day, when you eat so much, and you can barely move. Ideally, we want to stay between a 4 and a 6, so you don’t allow your body to get too hungry and you stop when you’re at a 6 versus eating until you’re stuffed. Achieving a healthy weight is about eating enough, but not too much. I talk a lot about what people are eating, but I also talk about how much.

Portion Control

Dr. Lynn: Portion control basically. We all know that we have large portions. If you go to a restaurant, there are sometimes a thousand calories in one meal, if not more. I feel like we are used to large portions, so a smaller portion seems too small. If you read labels and look at serving sizes, a serving might be much smaller than the amount you would normally eat.

 Katie: It can be shocking to show what a healthy portion of rice is… it’s half a cup!

 Dr. Lynn: Right, it looks like three bites!

 Katie: Yes! After we calculate your calorie needs, I create a meal plan together with your idea of what that looks like. That way it fits with your lifestyle and habits. I also talk about having all the food groups in a meal, having a healthy amount of carbohydrate, fat, and protein. I focus quite a bit on protein. I try to create meal suggestions that incorporate all the different food groups, like starch (especially whole grains), vegetable, fruit, fat, and a meat or protein.

Katie: Protein is really important in achieving a healthy weight and having energy. If you’re incorporating exercise you have to have enough protein to maintain your muscles, but not too much. I focus a lot on portion size and a tool I have been using lately, which is pretty basic but helps you visualize, is divide your plate into fours.

 Dr. Lynn: I think I’ve seen that before.

 Katie: It is through choosemyplate.gov, which is an updated food pyramid.

 Dr. Lynn: mm-hmm!

Katie: I recommend that women practice mindful eating, control portions, and focus on nutrient-dense foods such as fruits and vegetables.

Fruits and Vegetables

Dr. Lynn: Right. I have a question about that. I tend to eat a lot of fruit, but not as many vegetables. So, if you say 8-10 servings of fruits and vegetables a day and nine of those ten are fruits, am I still missing something? Should I try to balance it out a little bit?

Katie: 2-3 of those servings should be vegetable. You don’t have to go up to 7 vegetable servings tomorrow but try to find some recipes. I see many clients who just don’t like vegetables because the only way they’ve eaten them is boiled or steamed.  I talk a lot about roasted vegetables. They are so much better! If you roast brussel sprouts, asparagus, cauliflower, or broccoli, they don’t quite taste like French fries, but they have a nice crispy texture. Or some people like vegetable soup. Vegetable soup can be store bought or made. If bought, then it isn’t labor-intensive and you still get your vegetable servings.

 Dr. Lynn: We all probably need to eat more vegetables…. Me especially.

 Katie: Amen! I agree!

 Dr. Lynn:  Thank you so much Katie for helping our patients the way you do.  I am lucky to be working with you!

Dr. Becky Kaufman Lynn is a gynecologist and the founder of the Evora Women’s Health. She is a North American Menopause Society Certified Physician who has been treating menopausal women for over 20 years. Her practice is located in Chesterfield just outside of St. Louis, Missouri. Dr. Lynn offers a comprehensive midlife health program including helping women lose those pesky last 15 pounds! Go to evorawomen.com for more information about her practice or to schedule an appointment or send us an email at info@evorawomen.com

Katie Heaney is a registered dietician working with Dr. Lynn at the Evora Center for Menopause and Sexual Health. She holds an undergraduate in Nutrition and Dietetics. She completed her dietetic internship at Yale-New Haven Hospital and then obtained a Certificate of Training in Obesity Interventions for Adults. She is a member of the Academy of Nutrition and Dietetics and the national and local chapter of the Academy of Nutrition and Dietetics. Click here to schedule an appointment with Katie.

Why can't I lose those last 15 pounds after menopause?

Why are the last 15 pounds so difficult to lose after menopause? 

Menopause can be miserable.  The hot flashes, the night sweats, the mood swings.  Of all the menopausal symptoms, for some people the WEIGHT GAIN is the worst! Not only do menopausal women gain weight, they gain around the middle instead of in the bust, bum or hips.  Women who used to have a pear shape, now have an apple shape and apple shaped women have a higher risk of cardiovascular disease and diabetes than their pear counterparts.

Can I blame my hormones?

It happens partly because at menopause our ovaries stop making estrogen, the “female” hormone.  No worries, your fat cells make estrogen too, but not in the amounts that your ovaries did when they were working. When there is less estrogen around, you deposit fat more like men do, the proverbial beer belly.  By the time you have gone through menopause your testosterone is also pretty low.  Testosterone levels peak in your late 20s and early 30s. After that they start to decline ultimately leading to more fat and less lean body mass (muscle).  Testosterone helps build muscle mass, and muscle burns more calories than fat even when you are just sitting around.  Declining levels of estrogen and testosterone around the time of menopause play a role in making it hard to lose those last 15 pounds.

Insulin plays a role too.

Weight gain is not only about your reproductive hormones.  During menopause, women are more likely to have an increase in insulin resistance.  This means it takes more insulin to get glucose into our cells.  Our pancreas starts making extra insulin and insulin helps our body deposit fat.  The more fat we have, the more insulin resistant we may become, which leads us to become more overweight or even obese.  It can be a vicious cycle, and it is a difficult cycle to break. 

Your genes aren’t helping you.

Furthermore, our body is evolutionarily programmed to keep weight on.  Every time we restrict calories and lose weight, our body becomes more efficient at putting it back on.  When we lose weight, the amount of energy it takes just to live decreases. This is part of the reason why many women, despite eating low numbers of daily calories, still can’t lose the last 15! When you are losing weight by restricting your intake, your body also responds by increasing a hormone called ghrelin.  Ghrelin makes you feel hungry.  Studies show that if you have lost weight in the past and gained it back, your ghrelin levels will be higher than they were if you had never lost weight, making you feel even more hungry!

7 things you can do about it.

1.      Eat a healthy diet.

Eat whole foods, with adequate protein, and minimal amounts of processed foods.  The amount of protein you need depends on your size and your exercise level. Protein also helps keep your insulin levels in check.  If you eat a high carbohydrate meal, your insulin will rise much more than if you eat a protein + carbohydrate meal or a protein rich meal.

2.     Exercise!

Exercise decreases insulin resistance and helps to build muscle mass. Building muscle mass raises your resting metabolic rate(RMR). RMR is the amount of calories you burn just being alive. When you restrict your calories, your RMR decreases which slows down weight loss or stops it altogether. Building muscle mass through exercise can increase your RMR. At Evora, we measure your RMR scientifically with a specialized device called the Breezing Pro that calculates your exact RMR. This helps us develop a personalized weight loss plan just for you.

Exercise is hands down the best thing you can do for your body - not just for your weight. Exercise burns calories, builds muscle mass, keeps your bones strong, improves your moods, increases your metabolic rate, decreases brain fog and decreases your risk of a host of medical problems - including decreasing your risk of breast cancer! No excuses here - you have to exercise.  If you hate exercising, try making it social.  Find something you like to do with a friend - even a Zoom friend.

3.     Consider your triggers. 

Are you an emotional eater?  Does stress make you head to the kitchen?  Sit down and make a list of situations that lead you to overeat.  Then think of ways to avoid or change the situations.  Learn to overcome thoughts that give you permission to overeat like, “I had a tough day at work, so I deserve to eat this box of cookies” or “I can’t lose weight anyway, I might as well not even try”.  Consider seeing a behavioral therapist who can teach you strategies to manage triggers and negative thoughts.

4.     Set small goals. 

If you decide you are going to eat 500 calories a day the next six months, you may be setting yourself up to fail.  Try shooting for 1200-1500 calories a day for a week.  Then the goal seems reachable and reasonable in your mind.  You are much more likely to set yourself up for success.  Consider seeing a registered dietician for help with creating a well-balanced low-calorie program.

5.     See a registered dietician. 

Women often ask which diet is the best diet.  The answer is the diet that you can stick to.  There are many choices, from the Mediterranean diet to the Keto diet to intermittent fasting.  They have all proven to help people lose weight, but if you can’t live without bread in your diet, maybe the Keto diet is not the one for you.  A dietician can help you formulate a well-balanced program that you can follow.

6.     Consider weight loss medicines. 

Weight loss medicines like phentermine or naltrexone/buproprion are not for everyone but for some women they work very well.  Depending on how much weight you have to lose, and what other medical problems you have, sometimes these medicines can help you control your cravings or give you a jump start to losing weight. 

7.     Consider using hormones. 

Hormones are not specifically indicated for weight loss, but we know your hormonal milieu plays a role in weight management.  Estrogen can help improve how your body responds to insulin. Testosterone helps to build muscle mass and muscle burns more calories than fat.  Like any medicine, they have many benefits, but they also have risks and side effects. Before starting anything, talk to your provider. Find a provider who is well-versed and up to date with the recommendations and research.

Go to the North American Menopause Society (NAMS) website for more science backed information on hormone therapy or to find a NAMS certified menopause provider.

 Dr. Becky Kaufman Lynn is a gynecologist and the founder of the Evora Women’s Health. She is a North American Menopause Society Certified Physician who has been treating menopausal women for over 20 years. Her practice is located in St. Louis, Missouri. Dr. Lynn offers a comprehensive midlife health program including helping women lose those pesky last 15 pounds! Go to evorawomen.com for more information about her practice or to schedule an appointment or send us an email at info@evorawomen.com

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.

Testosterone for Women: Miracle Drug or Bogus Science?

Testosterone.  That lovely hormone of desire, of sex, of muscles and power and strength.    We think of manly men with hairy chests when we think of testosterone. But did you know women have testosterone too?  They even make more testosterone than they do estrogen. Testosterone is one thing that controls sex drive in women and does a whole host of other things.  It starts to decline in your late 20s. This can contribute to low libido in women. So should testosterone be replaced? I hope to answer this question for you with answers based on scientific studies- not bogus internet marketing claims.  Let’s get started.

Does testosterone make for better sex?

If you are a midlife woman, peri or postmenopausal, then in some instances the answer is yes!  Testosterone has been shown to definitively improve several aspects of sexual functioning. Testosterone improves sex drive, arousal, helps you have more and better orgasms, and increases pleasure and responsiveness.  Who wouldn’t want all this at a time when your sex life tends to get a little dull and unsatisfying and in some women, a whole lot of work as well. When a midlife woman is suffering from low sex drive, testosterone can be used to improve it.  This is a big deal for many women because low sex drive is uber common in midlife women and many are very distressed by it. Low drive can add a lot of stress to a relationship. 

What are the benefits of testosterone?

Apart from improving your sex life, some data shows that testosterone may also help build muscle mass, improve fatigue and help with weight loss.  The data isn’t definitive though and it isn’t recommended to use testosterone for these reasons.  

What are the risks of testosterone?

There are no medicines without risks or side effects so don’t believe anyone who tells you a medicine has no risks.  Testosterone is a hormone. It gets converted to estrogen in the body. Like estrogen, it increases your risk of blood clot.  The medical term for a blood clot is deep venous thrombosis (DVT). DVTs can be quite dangerous because the clot can break away from the blood vessel and travel to your lungs and prevent you from getting oxygen.  Good news though, if you don’t have a clotting disorder, are a normal weight, don’t smoke and don’t have certain other medical conditions, your risk of having a blood clot is very low. It is much lower than when a woman is pregnant or on birth control pills.  

What about bioidentical hormones?  Do they have risks?  

Even “natural” things have risks, so don’t be fooled by the term bioidentical.  Bioidentical means that whatever you are getting has the same chemical structure as the hormones that your own ovaries used to make or are currently making. Compounded “bioidenticals” are no safer than standard prescription hormones and on the flip side, there are prescription hormones that are bioidentical.  Stick with the prescription ones. The companies that make them have to prove to the FDA that they are effective and safe. Compounding pharmacies don’t. 

What are the side effects?

When appropriately replaced, some women on testosterone will develop acne or a little bit of facial hair.  If the testosterone level in the blood gets into the male range, way too high, there can be some significant and permanent side effects like a lot of facial and body hair, deep voice, male pattern balding, and an enlarged clitoris. Your prescribing physician should be checking your blood levels to make sure you stay in the correct range.  Most women do not have these side effects.  

How should testosterone be given?

Testosterone should be given in a topical form, either a gel or a cream that gets absorbed through the skin daily.  I prescribe testosterone as a topical cream for my patients. Women put some of the cream on their calf. This mode of delivery gives a very steady blood level of testosterone and if there is a bit of local hair growth, you can just shave it off.  I don’t like the intramuscular injections of testosterone because they give you a very high dose right after you inject, then your body metabolizes it and the level goes down until your next dose when you get a whopper dose again. This creates a lot of ups and downs in your hormone levels.  Not my favorite.  

What about hormone pellets?

I don’t recommend certain hormone pellets-namely BioTe. Some of these tend to give women very high levels of hormones.  I have seen numerous women with the same blood levels of testosterone as a man would have.  At these levels, women grow beards, have deepening of the voice, male pattern balding and the clitoris grows.  These changes can be permanent. 

Also, pellets have not been studied in women in peer reviewed published medical studies.  They haven’t been proven to be any better, safer or more “natural” than anything that has been studied.  The North American Menopause Society and the American College of Obstetrics and Gynecology specifically do not recommend treatment with pellets because their safety has not been proven.  For BioTe, go to their website and check out the disclaimer at the bottom of the website. It says these are not intended to treat or cure anything! 

I will say women come to me feeling fantabulous on their testosterone pellets.  They have amazing libido! That is because they have as much if not more testosterone floating around in their blood as their male partners and maybe as much facial hair too.  Just keep in mind the permanent changes pellets may cause.

What's the best way to find out if testosterone is a good option for me?

If you are in your 40s or 50s, peri or postmenopausal, testosterone may be a good choice for you to boost your libido, barring certain medical conditions.  Make sure to see a provider with experience in treating sexual conditions. A sexual medicine specialist will also look for other factors that may be contributing to your low libido like a not-so-nice partner, depression or certain medications. Testosterone is not going to improve your libido if your partner is a jerk.  

TO SEE IF TESTOSTERONE IS RIGHT FOR YOU CLICK HERE

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.