Posted on

The encouraging news that teen pregnancy rates have been on the decline comes to us from the Journal of Adolescent Health. The amount of medically accurate information available for teens has increased. The conversation about what constitutes safe sex as well as the fact that some teens are simply waiting until later in life to engage in sexual activity also plays a role.  The teens who are sexually active are getting better about using safe and effective contraceptive methods such as “the pill” to avoid pregnancy, as well as condoms to avoid sexual transmitted infections. Additionally, the stigma around talking about sexual activity has diminished, and the discussion of sex of all kinds has empowered teens to have more open discussions with their educators and partners.

National Survey of Family Health
Laura Lindberg, PhD and colleagues reviewed data between 2007 and 2012 from the National Survey of Family Health to see substantial declines in adolescent pregnancy and birth rates in the United States occurred between 2007 and 2012. They wanted to find out if sexual activity, contraceptive use, and contraceptive efficacy correlated to the declines in the pregnancy and birth rates during this time. It did.

The researchers found that the contraceptive behaviors of sexually active adolescents have driven the recent shifts in fertility outcomes. The increases in overall contraceptive use during sexual intercourse between the years 2007 to 2012 are part of a longer trend. Between 1995 and 2012, any method use at last sex among adolescent women increased from 66% to 86%, while use of multiple methods increased from 11% to 37% during this time.

Public policy and programs can play a critical role in supporting adolescent contraceptive use. Since contraceptive use is the critical driver of adolescent fertility, it is important to ensure adolescents’ access to comprehensive sexuality education that provides medically accurate information about contraception.

Our practice offers a variety of solutions to pregnancy prevention, which can be stopped or removed at the time our patients are ready to start a family. We support the entire lifecycle of women, and it all starts with a healthy young adulthood.

To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com

Posted on

Leading researchers are urging the medical community to rethink how they treat patients who experience severe menopausal symptoms. Mache Seibel, MD., former 20-year veteran of Harvard Medical School faculty, editor of My Menopause Magazine and Professor of OB/GYN, University of Massachusetts –was inspired by his wife’s experience, and took it upon himself to help her and countless others, manage this important phase of life. Dr. Seibel studied the hormones given to women to treat symptoms and revisited the research in the Women’s Health Initiative (WHI) from 2002. After an up-close look at the data, he realized that further educating people about the role of hormones in health was necessary.


Jane Doe Lost Her Mojo
Many women who are in the prime of their lives and height of careers struggle with the debilitating symptoms associated with menopause. Consider this scenario: A healthy woman, aged 51, is looking forward to engaging in a night of foreplay, fun and sex with her partner, but is unable to enjoy herself, because of the lack of natural moisture she’s had all of her life until now. The “dry sex” she now has leads to pain during intercourse–two common symptoms of menopause. Following an unsatisfying sexual experience, she eventually falls asleep, only to be awakened by hot flashes and night sweats, soaking her sheets. The next day she wakes up tired, frustrated, and in a mental fog, only to have this experience happen the next night, and the next, and the next, and again the week after that. Knowing that sexual desire for women starts in the brain, she became unsure about how to connect her desire for intimacy with her body’s sexual response the way she used to, and her overwhelming fatigue makes her wonder if it’s worth the effort. The good news is that the experience of the menopausal transition can be positive, given the appropriate treatment, which varies depending on the age and health-status of each woman.

Understanding Menopause
The process of menopause is like the process of puberty—but in reverse, says Dr. Seibel in his revolutionary book, “The Estrogen Window: The Breakthrough Guide to Being Healthy, Energized, and Hormonally Balanced–through Perimenopause, Menopause, and Beyond.” Although puberty is well understood, menopause, which effects every woman, is less so. Women may assume that the surge of estrogen during early menses will suddenly shut off like a spigot, but it is more subtle and takes longer than one might imagine, leaving in its wake, uncomfortable symptoms, which were broadly treated with hormones such as estrogen and synthetic progesterone (progestin) until the WHI study results were released in 2002.

The WHI hormone studies have increasingly come under fire for the way they were designed, most importantly the inclusion of women up to age 79 years. The results of these studies have reverberated through the medical community as the changes they caused may have been both too broadly applied and in some cases simply incorrect. The findings that hormone therapy was putting many women at risk for certain conditions such as breast cancer and cardiovascular conditions caused many women to go off their hormone-replacement therapy “cold turkey” without knowing how to address the consequences, and not fully understanding the risks versus rewards. For example, some of the patients in the WHI study were already at risk for cancer or cardiovascular disease because of life-long smoking, being overweight and the age at which they started hormone therapy. However, otherwise healthy women should be able to use these therapies to ward off the symptoms that affect sexual health and pleasure.

Opening the Estrogen Window
Dr. Seibel calls the estrogen window, the “decade-long time-frame between the ages of 50 and 60, or 10 years from the time of menopause,” which is defined as at least 12 consecutive months menstrual period-free.

His book outlines important recommendations that are not a one-size fits all approach. Here are several key takeaways for improving and maintaining sexual vitality:

Low estrogen levels at midlife are common causes for genitourinary syndrome of menopause that causes bladder leakage, vaginal dryness, and elasticity in vaginal tissue to change–leading to discomfort during sex (location 3014).

The estrogen window for vaginal estrogen always remains open; it never closes (location 836).

Estrogen alternatives exist for women with medical histories (e.g., breast or endometrial cancers, blood clots, liver disease, pregnancy, undiagnosed uterine bleeding) that make it inadvisable to take estrogen (location ,787 814).

This book is available online and at the website drmache.com/Estrogen-window-book. This website contains downloadable bonus material, including the Menopause Checklist, Sleep Diary, and much more. Armed with this information, a visit to your gynecologist can lead to better overall health and importantly, a continuation of a satisfying sex life, well into advanced age.

To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com.

Posted on

penis_0For those who read, Part 1, sorry to leave you hanging (pun intended) last week. 

This time, yes, I am talking about penis size. For men, it is often all about size, thus the term “penis envy”. But for women, the penis is perceived as just another masculine feature, like muscles, a flat stomach, or being tall. If women do have a focus on a particular physical part of the male anatomy, it’s most likely to be the buttocks, a subject I will save for another time. (See, for reference: A Billion Wicked Thoughts: What the World’s Largest Experiment Reveals about Human Desire by Ogi Ogas and Sai Gaddam; Putnum Group, 2011)

The availability of abundant, free Internet sexual content portraying men with huge penises as “the norm” has created a bit of a one-eyed monster, if you will. I have now seen a significant number of female patients who have completely unrealistic expectations for the penis size of their partners, not to mention, a skewed idea of how long their partners should be intimate without breaking a sweat or ejaculating. Some women have actually done the unspeakable, telling their partners, ”Your penis is so small!” Ouch! Talk about hitting below the belt.

Pornography, which is the portrayal of sexual subject matter for the purpose of sexual arousal, has created such common, unrealistic expectations (beyond penis size) that it has actually spawned an excellent TED talk, as well as a “realistic porn” site: Make Love Not Porn.

So, if you imagine, even for one minute, that a Genoa-salami-sized-penis is “normal,” here are the actual facts: The range of erect penis length for most men is 5 – 6.5 inches. The circumference of the average man’s erect penis is 4 – 5 inches. This means the corresponding erect penis diameter is 1.27 – 1.6 inches. This size information has been confirmed multiple times among different ethnic groups and populations with only minimal variation (www.kinseyinstitute.org/resources/bib-penis.html or https://en.wikipedia.org/wiki/Human_penis_size).  While these sizes “are only numbers,” and as they say “a picture is worth a thousand words,” there is actually some good pictorial information that can provide meaningful visual perspective.

So, while fantasy is fine and actually very healthy, the reality of having sex with Jonah Falcon, the man with the world’s largest penis (a giant, freakish, colossus of 13.5 inches in length), could be completely terrifying! The takeaway here, Ladies and Gentlemen, is to be careful what you wish for, because you might not know what to do with it should you get it.

Interested in women’s sexual health? Contact us for an appointment.

Posted on

glansNo, this post isn’t about penises or vibrators. (Why do our minds always go there!) I’ll reserve that subject for Part 2. This is about the clitoris. Yes, the clitoris, “a small erectile female organ located within the anterior junction of the labia minora that develops from the same embryonic mass of tissue as the penis and is responsive to sexual stimulation” (according to Merriam-Webster on-line dictionary). While seldom the subject of much scientific research, a recent publication* investigated the relationship between clitoral size and sexual function (including the extensive internal portion – “out of sight, out of mind” you might say).

In a small convenience sample of women having a pelvic MRI for other reasons (such as fibroid tumors), these researchers compared clitoral size and each woman’s sexual function as measured by several validated scales. Paradoxically, women with the smallest clitorises (yes, that’s the correct pleural of clitoris), specifically the clitoral body and crus (see diagram below), had the best sexual function. Those women with a smaller clitoris tended to have better desire, arousal, lubrication, and orgasm. The authors of the study suggest that a greater density of nerves, basically squeezing the same number of nerves into a smaller space, is what leads to better function.

There are several limitations to this study, so take these findings with a grain of salt. The relatively few women who participated were having their MRIs done for other medical reasons besides participation in this sexual function study. Therefore, the findings may not actually be generalizable to all women, especially “normal” women without another existing medical condition. But, this study does give a whole new potential meaning to the oft-quoted “good things come in small packages” idea.  And that’s c.o.m.e., not c.u.m! Really, does your mind always go there?

Interested in women’s sexual health? Contact us for an appointment.

 

* Vaccaro CM, Fellner AN, Pauls RN. Female sexual function and the clitoral complex using pelvic MRI assessment. European Journal of Obstetrics & Gynecology and Reproductive Biology 180: 180–185, 2014.

 

Posted on

Vulvovaginal Atrophy

vulvovaginalVulvovaginal atrophy (VVA) is a common condition associated with the decreased estrogenization of the vaginal tissues. It occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body’s estrogen production declines.

The inevitable estrogen deficiency that accompanies reproductive aging and menopause results in universal changes in the vaginal ecosystem associated with a variety of vulvovaginal and urogenital complaints. At some point in their lives, the majority of women will experience these symptoms, collectively termed the genitourinary syndrome of menopause (GSM), a term which has recently replaced vulvovaginal atrophy (VVA) in the accepted nomenclature. VVA or GSM symptoms usually develop gradually and become most bothersome as women transition to the mid-to-late 50’s. These symptoms typically follow the vasomotor symptoms of menopause, such as hot flashes and night sweats. Unlike VMS, which usually subside after several years, the symptoms of GSM (see below) persist and increase in both frequency and intensity as women age.

With estrogen deficiency, the epithelium (aka the surface cells) of the vagina and vulva thins and loses its rugal folds. Those folds are really important. Think of the difference between a pair of pants with elastic, or a skirt with pleats vs one without. Imagine how you would feel trying to put them on if you’ve gained 20 pounds. Which pants would you like to squeeze into? With menopause and increasing VVA or GSM, the elasticity provided by those rugal folds diminishes, and susceptibility to injury, even with minor trauma, can ensue. Estrogen deficiency also leads to diminished vaginal glycogen and decreased acidity of the vaginal secretions (increased pH), thereby reducing the vagina’s natural defense against local pathogens (i.e. yeast and coliforms [the most common bacteria of fecal material]). The close proximity of the lower urinary tract to fecal contamination is associated with an increased risk for acute and recurrent urethritis and cystitis (bladder infections).

When a woman doesn’t have intercourse or other vaginal sexual activity on a regular basis following menopause, her vagina may also become shorter and narrower. Continuing to have regular vaginal sexual activity through menopause helps keep the vaginal tissues thick and moist and maintains the vagina’s length and width. This can help keep sexual activity pleasurable. This has euphemistically been referred to as “use it or lose it”.

If you do experience vulvovaginal symptoms (dryness, irritation, burning, itchiness, pain) do not automatically assume that reduced estrogen levels are the reason for these symptoms. Because vaginal discomfort can arise from many different sources, persistent symptoms should be brought to the attention of your healthcare provider for evaluation.

 

Interested in women’s sexual health? Contact us for an appointment.

Posted on

Is the FDA Approval of the “Pink Pill” a Probable Outcome?

18jdwo1qlvkujjpgA failure to approve flibanserin would set a dangerous precedent. Why? Because the pharmaceutical company did everything the FDA asked it to do, and the results came out statistically significantly better than placebo—which was the desired endpoint. If the FDA were to deny approval of the drug, it would be saying, in effect, that it can change its mind in the middle of the argument.

In reality, the FDA is likely to say yes to approval, but with restrictions, as that is what its advisory committee recommended. What those restrictions will be remains to be determined, but they are likely to resemble those of other drugs in the class, such as selective serotonin reuptake inhibitors (SSRIs), including a warning to be careful using flibanserin with alcohol until the drug’s effects are clear.

 

Interested in women’s sexual health? Contact us for an appointment.

Posted on

Opposition to the “Pink Pill” –  New View Campaign Has an Old View (Part 1 of a 4-Part Series)

During the public hearing portion of the advisory committee meeting, most of the testimony came from women seeking approval of the drug. However, there were some naysayers. Their arguments against approval boiled down to 4 perspectives. In my opinion, the arguments against the drug miss the mark.

The view is presented that development of flibanserin represents “medicalization” of a disorder that can be treated effectively with psychotherapy and education. This perspective is best embodied by an organization called the New View Campaign.

Refuting this perspective, however, is research in animal models that clearly demonstrates that HSDD (or its equivalent in animals) is the result of an imbalance between dopamine and norepinephrine on the positive end and serotonin on the negative end. These findings are supported by functional magnetic resonance imaging (MRI) and positron emission tomography (PET) scans of the brains of women with HSDD who are shown erotic stimuli. The scans demonstrate that their brains respond differently from those of normal women. So if it’s all about education and counseling, why are the brains of women with HSDD functioning differently?

I would argue that, if depression and HSDD are both abnormalities of the serotonergic system (flibanserin is essentially an SSRI), then how can depression be a biologically based disorder but HSDD can’t? In my opinion, the New View Campaign isn’t new at all.

Continue reading “Opposition to the “Pink Pill””

Posted on

The “Pink Pill”-Who Is It For?

Pink PillsThe “pink pill”, flibanserin, was developed for premenopausal women. Although preliminary data on flibanserin use among postmenopausal women are available, the drug was studied primarily in premenopausal women with Hypoactive Sexual Desire Disorder (HSDD), the indication sought at this time.

In the premenopausal population, problems such as pain with intercourse or hyperestrogenism aren’t typically present, simplifying the identification of HSDD. In clinical trials of the drug, HSDD was secondary, generalized, and acquired—that is, it followed a period of normal sexual function. And it didn’t come and go but was present regardless of location and circumstance.

Study participants had had a normal sex drive before their desire “turned off,” an occurrence they found distressing.

Clinicians, myself included, have been frustrated by our inability to prescribe an effective treatment for this common problem. The recent recommendation of an FDA Advisory panel to approve flibanserin for the treatment off HSDD in premenopausal women brings us a step closer to having additional options for treatment.
(Excerpted from an editorial by Dr. James Simon published in OBG Management, July 2015)

 

Interested in women’s sexual health? Contact us for an appointment.

Posted on

Women’s Sexual Health- Is There A Remedy For Hypoactive Sexual Desire Disorder (HSDD)?

woman-506120_640Women’s sexual health took a step forward last month when an advisory panel to the US Food and Drug Administration (FDA) recommended approval of the drug, flibanserin, for the treatment of hypoactive sexual desire disorder (HSDD) in premenopausal women. The approval came with some reservations regarding safety (use with certain medications and alcohol). And it’s worthwhile to note that the FDA had on hand its own Drug Safety and Risk Management Committee during deliberations. However, assuming the agency follows the recommendations of the Bone, Reproductive, and Urologic Drugs Advisory Committee, women will soon have available the first agent for sexual dysfunction—aside from a medication for intercourse-associated pain—developed specifically for them.

The wait may be over.

(Excerpted from an editorial by Dr. James Simon published in OBG Management, July 2015) Women’s sexual health

 

Interested in women’s sexual health? Contact us for an appointment.

Posted on

Hypoactive Sexual Desire Disorder (HSDD) is described as having the following characteristics:

  • persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activitypillows-820149_640
  • marked distress or interpersonal difficulty in response to this deficiency
  • lack of another explanation known to affect sexual function.

In other words, a person once had a healthy desire for sex which they have lost, and there is no other explanation for that loss of interest or desire. In addition, the loss of this desire is noted by the person and the change is causing distress, relationship difficulty or both. (Source: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition)

In clinical practice, HSDD is easily identified using the Decreased Sexual Desire Screener (DSDS), a simple screening test that asks 4 yes/no questions:

  1. In the past, was your level of sexual desire or interest good and satisfying to you?
  2.  Has there been a decrease in your level of sexual desire or interest?
  3.  Are you bothered by your decreased level of sexual desire or interest?
  4. Would you like your level of sexual desire or interest to increase?

A “yes” response to each of these questions is required. In addition, a fifth question asks whether a number of conditions, drugs, or circumstances might be responsible for the decreased desire or interest:

  • an operation, depression, injuries, or other medical condition
  • medications, drugs, or alcohol you are currently taking
  • pregnancy, recent childbirth, or menopausal symptoms
  • other sexual issues you may be having (pain, decreased arousal or orgasm)
  • your partner’s sexual problems
  • dissatisfaction with your relationship or partner
  • stress or fatigue.

Only when all of these items are excluded as possibilities can a diagnosis of HSDD be made. (Source: OBG Management, July 2015, sidebar)

 

Interested in women’s sexual health? Contact us for an appointment.

Recent Posts

Categories

Archives