Sunday, May 26, 2019

Vaginal mummification - there is help!

True confession - I never watched Sex in the City - mainly because at the time I was a poor starving just out of residency doctor who couldn't afford cable TV and also because I'm a gynecologist and didn't think sex made for TV could top what I was already learning from my patients.

Boy, was I wrong.

I recently saw a patient who was brought in by her husband because she is becoming more 'forgetful' and while that is their number one concern, each time she comes in she laments about how she 'is dead from the waist down' and how she is 'drier than the desert down there'.

I don't have a picture of a desert, therefore the mummy image.

Our last conversation went something like this:

"I'm concerned about my poor husband" (patting him on the knee), "I never feel like having sex. Is there something to be done? It is very painful and I feel bad because when we do have sex it gets so bad I am telling him to just hurry up and get it over with. And I never have an orgasm anymore so what's the point?"

Me - "I agree with you. Isn't that what makes you want to have sex in the first place? If you can't have an orgasm then what's the point?"

At this juncture her husband interjected, "You ladies are cracking me up." as he shifted uncomfortably in his seat.

So we talked about some options (which I will get to later) but it got me thinking later - what other  reasonable options will help her?

Then I watched Sex in the City and realized that maybe seeing a TV show about sex would help her discover things about sex that she hasn't tried or learned about yet. Maybe Sex in the City is another option for her. I saw things I never saw before and let me warn you - you can't un-see that stuff!

One episode was all about vibrators! But I digress.

SITC is definitely pornographic - like pornography with classy storylines and characters you can befriend and learn from (and develop shoe envy). And for some people, seeing other people having sex can increase the desire to have a satisfying sex life. So for this patient, once she can 'feel down there' again, she may also need some visual aid to get the fires burning (so to speak). Until then, it may just cause frustration!

So ladies, if you find yourself 'never wanting to do it' or going 'dead down there', let's chat.

First, have your doctor check your anatomy. If you aren't getting adequate hormone support then your vagina and vulva (skin and 'lips' around the vagina and clitoris) will begin to lose connective tissue and thickness, resulting in a pale shadow of it's former self.

This translates to dryness and pain with intercourse.

As a Functional Medicine doctor, I also check hormone levels and try to find out if there are other hormones involved (i.e. stress hormones) which can alter normal hormone metabolism. Traditional Obgyns don't check hormone levels because they are usually not familiar with how to translate the levels into physiology, so find an integrative, Functional Medicine or naturopathic doctor who is familiar with bioidentical hormone therapy and start there.

Estradiol is the main hormone that keeps the urogenital area (vagina and vulva) maintained with blood supply and growth factors that keep the architecture of the area from collapsing and that translates to a thicker vaginal wall, 'fluffy' but not flabby vulva and a clitoris that has enough nerve and blood flow to be stimulated by touch. Estriol (another estrogen) has been found to also encourage blood flow and tissue thickness in the vaginal area.

So the first thing I offered her (after checking her hormone levels) was a vaginal cream or suppository compounded with bioidentical estriol (safer than estradiol).

I also offered her 'scream cream'. There are several different variations but each formulation is designed to increase blood flow and heighten sensitivity. It is applied to the clitoris just before sex.

If these don't work for her she may consider a procedure to rejuvenate the vagina and clitoris. There are two currently that involve a medical device, the Mona Lisa (laser) and the ThermiVa (radiofrequency heat). These are done in your doctor's office or outpatient procedure room and may need to be done multiple times to get results. The underlying issue (loss of collagen support and blood supply) will revert back to it's shrunken state if the procedure isn't repeated at regular intervals - usually every 12-18 months - so it is not a permanent fix.

Another procedure that can help is an injection with platelet rich plasma (PRP). This technology was developed for thoroughbred race horses to repair joint injuries but has expanded to be used by professional athletes and now can be found in many clinics (including the one where I currently work). The platelets bring in growth factors and stimulate collagen formation and repair wherever the injection is placed.

So the clitoris and upper vagina can be numbed and PRP (harvested from your own blood) can be injected to increase sensation and orgasmic quality is improved (or regained if it was lost). I recommend some hormone treatment prior to this procedure if there is currently no ability to orgasm.

In fact, tailored hormone support will help maintain the area along with any other therapy that works for you. That requires checking levels and rechecking while you are on therapy.

I've had patients come in and demand testosterone, saying that they have a friend, cousin or sister who got some and got her freak back on. I say that if your doctor gives you testosterone and doesn't check levels then find yourself another doctor.

I've had patients who thought they needed testosterone to solve all their sex and libido issues and they had high levels of testosterone without any being added so more is definitely not better! So if you decide to use hormones, make sure you are only adding hormones that you lack.

So to sum up:
1. Check hormone levels
2. Topical hormones in the vagina
3. Stimulant creams to the clitoris
4. Medical procedures
5. Ongoing hormone support (appropriate to your needs)
6. Maybe a little SITC - you know, as a visual aid, if you like that sort of thing. Or a vibrator.

And remember - 'if you don't use it, you lose it' applies to the vagina.

Keep it juicy.
Dr. M

Sunday, May 5, 2019

Strong Bones - do you have to drink milk?

May is National Osteoporosis Month. So let's talk about bones again.

I get a lot of questions from patients about preventing osteoporosis so I'll cover that today. The word osteoporosis means porous bone. All bone is porous but strong bones are much less porous then weaker osteoporotic bones.

This image is showing enlarged spaces between bone structure that weakens the bone progressively until it is easily broken. This is important because as we age we naturally lose more bone mass and this can increase our risk of hip fracture (or other fracture) with a fall.

Menopausal women are especially at risk as their estrogen levels fall with age and their rate of calcium absorption goes down. When your body doesn't get enough calcium in the diet it breaks your bones down to get some because calcium is essential to your metabolism!

It has been reported that the one year mortality rate (rate of death from an injury at one year after the injury) from a hip fracture is somewhere between 14-58%. So you definitely want to protect your bones and decrease your chances of a fracture from a fall!

So how can we best protect our bones? For women that means considering estrogen replacement as we go into menopause. I found one resource from the National Institutes for Health written in the mid-90s that recommended 1000mg of calcium a day for menopausal women on estrogen and 1500mg a day for menopausal women not on estrogen. I think that's huge! This recommendation just shows how important adequate estrogen is to bone health.

Of course, if you can't take estrogen for whatever reason you can still protect your bones. The first place to focus is on foods that contain calcium. I will add a caveat before I get into the specifics. Calcium absorption is very low when conditions for absorption are not ideal. Here and here are some of the factors that can hinder absorption. Some of the nutrients that need to be adequate for better absorption include vitamin D3, vitamin K2 and magnesium. Vitamin C is also critical to absorption.

So when you look up calcium rich foods dairy is usually mentioned as if it is the only option - in fact, the National Osteoporosis Foundation - advertising National Osteoporosis Month - has a video on their website that draws a huge picture of a glass of milk and a piece of cheese and other options are minimized. So what's a dairy intolerant person to do?


1. Seeds - make chia pudding (chocolate chia pudding in the photo) or sprinkle chia seeds into smoothies. Sprinkle sunflower seeds or pumpkin seeds onto salads.

2. Beans and lentils - sprinkle black beans on a Taco Salad or make black bean salsa by mixing canned (organic!) black beans into either prepared or homemade salsa. Make dal with lentils or add cooked lentils to your hummus recipe to add extra calcium.

3. Almonds or almond butter - add 2 tablespoons to a smoothie recipe and get a little protein, fat and calcium boost.

4. Soy - choose organic, non-GMO soy beans or tofu and enjoy edamame or a good tofu stir-fry.

5. Leafy greens - choose low oxalate kinds for best absorption but most leafy greens provide good amounts of calcium. Make a chopped salad or a soup with added greens. I even add chopped greens to my spaghetti sauce.

6. Broccoli rabe - I just had a bunch of this Thursday night since it is in season and I was fortunate enough to get a bunch from a local grower. I just steamed it and ate it but I also have a good recipe for Ginger Sesame Soy Rabe with asian noodles that amps up the calcium content.

7. Oranges - I'm allergic to orange peel but if you peel it and break it into wedges I'll enjoy it with you!

8. Dried fruit - especially dried figs - enjoys whole or chop into smoothies. Other dried fruits with calcium include raisins, prunes, apricots and dates.

9. Okra! I love it roasted in a pan, drizzled with olive oil, but you can smother it or add it to soup or a pot of beans (double bone whammy).

10. Fortified non-dairy milk - check your non-dairy almond or other milk and see if they've added calcium.

So the bottom line is this - dairy does have a lot of calcium but the absorption of calcium from plant sources is higher. If you tolerate dairy don't rely only on diary as your source of calcium. If you do consume dairy make sure it is grass-fed organic dairy so you don't expose yourself to pesticides, antibiotics, hormones and other substances in industrial-based cow dairy products.

What about supplements? There are lots of options to make sure you get adequate calcium and other essential nutrients for bone health.

See a Functional Medicine provider like myself to make sure you have adequate levels of the nutrients (like K2 and vitamin D3 and vitamin C) needed to absorb and use calcium from your diet. You can also discuss with your provider when to test for bone density, what to do about osteopenia and whether supplementation with calcium is right for you.

Chocolate Chia pudding:

Mix together 2 tablespoons of organic cacao powder and 3/4 c. warmed hemp, almond or soy milk to dissolve the cacao. While whisking add in 3 tablespoons agave or maple syrup. I also added a packet of powdered monk fruit. Add in 1 tsp organic vanilla extract and a pinch of salt. Once it is well mixed pour in 1/4 cup of chia seeds and whisk. It should begin to thicken after about a minute. Pour into ramekins and place in fridge for 4 hours or overnight. Enjoy. Makes 2 small ramekins - may double if needed to make 4 servings.

This is nice sprinkled with cacao nibs or wild blueberries and a dash of cinnamon. Have it as a light dessert after your fajita feast today! Happy Cinco de Mayo!