Patient: 52-year-old woman: Doctor: Hi Mrs. Evans. How are you? How’s the family? Patient: Good, my daughters are both out of the house Doctor: Wow, time really flies. [flips through her chart] Patient: Lucie’s away, in her second year of college. And Janice is in nursing school. Nearby, which I like. Doctor: That’s great. And your husband? Patient: Jim’s fine. Works too much. Can’t get him to slow down. You know how it is. I don’t want to be a nag about it but maybe I should be. Doctor: Yes, I understand. So how are you doing? You haven’t been here in, looks like three years. Patient: Yes, you know [apologetically] things get so crazy, hectic. Doctor: Yes, of course [with a big smile]. So do you have any complaints or problems I need to know about? Patient: Not really. I’ve been fine. Nothing you wouldn’t expect. Knock on wood [patient reaches over to tap the doctor’s desk]. Doctor: No pains anywhere? Like your joints or abdomen? [patient shakes her head “no”]. Bleeding [patient shakes her head “no”]. Problems with digestion? Or your feet swelling? Or trouble sleeping? That kind of thing. Patient: No, nothing. Doctor: [looking at her chart again] How about hot flushes or headaches? Patient: Sometimes, but I’m used to them. Most of my friends are through it already. Doctor: Transition to menopause is different for everyone. Patient: Seems like mine is taking forever. It’s getting on my nerves -- and my husband’s. Doctor: I see. Do you have any particular concerns? Patient: Well, I’m not especially interested in sex anymore. I just do it since I want to keep Jim from getting frustrated with me. Doctor: Is it actual loss of interest or something else? Patient: Like what? Doctor: You know other marital issues, like growing apart, a little boredom, maybe wanting a little more space? Patient: No [irritated], we’re happy. Doctor: Maybe empty nest issues? [Patient shakes her head] Do you find yourself blue more often? [Patient shakes head no again]. Patient: It just hurts, it’s unpleasant. Doctor: Sexual intercourse? Patient: Yes [emphatically]. Sometimes I even have bleeding afterwards. That frightens me. Doctor: It doesn’t need to be that way. After the pelvic exam, let’s talk about available medical management options. FADE OUT/FADE IN Doctor: As is common with menopause, your vaginal lining is thin, what we call friable, which means it can’t handle too much friction. Patient: Is there anything you can do about it? Doctor: Well there are a few options. The ones that many women initially use, and many find success with, are the over-the-counter lubricants or moisturizers. Have you tried any of these products yet? Patient: Yes, I have and it’s still pretty painful…and messy! And besides, with all of the back surgery from scoliosis I had when I was younger, using vaginal products is really tough for me. Just can’t seem to reach around too well...! Doctor: Well, there are also prescription treatments that may take away the pain with sexual activity. Patient: Do I have to insert them around the vaginal area like the lubricants I’ve used? Doctor: Well, some of them, like the vaginal estrogens need to be inserted. However estrogen also can be used systemically, that means taken as a pill or a skin patch if that is preferable to you. In fact, I see in your medical record that you took oral estrogen therapy when you first became menopausal three years ago for hot flashes. However, you stopped it after a few months--- “didn’t like the breast discomfort” my notes indicate. Patient: Yes, even with the lower estrogen dose, my breasts were always tender, as if I were premenstrual! Doctor: There is a new, FDA-approved oral therapy for pain with intercourse that will be available soon (I think maybe by this summer) that’s not an estrogen. You may want to consider it. The product is osphemifene [OS PEN I’ FEEN]. It acts like an estrogen in some tissues of the body, like the vaginal area, but in other areas it does not have any estrogen effect. Patient: If it rescues my sex life, I’m in! Patient: 64-year-old widow Doctor: Come on in Mrs. Johnson. Please sit down. So how are you doing? Patient: I guess, OK [a little down]. Doctor: It’s been difficult for you with your husband’s passing, I’m sure. Patient: Yes [sighs] that’s part of it. He was only 65, only a year older than me, and had a massive heart attack. I feel a little guilty-- that it’s my fault. Doctor: How so? Patient: We’d really gotten a little careless. Eating too much. Not exercising. I should have paid more attention for both of us. Doctor: Understood. But don’t be so hard on yourself. You did say “we.” It’s not that easy for any of us to do everything that we know we should be doing! Patient: [nodding in agreement] I’m not feeling totally responsible but I could’ve changed what we were cooking and eating, done more outdoor activities together, which when we were younger we always did do, especially when our sons were still at home. Doctor: It’s never too late. You could start an age-appropriate exercise regimen. Patient: That’s what I’d like to talk about actually. I’m not happy about my weight, especially around the middle. I’ve been reading on the Internet that belly fat is the worst in terms of causing heart attacks. [Doctor nods in agreement]. So I joined a nutritional slash diet program in town two months ago, and I’ve been trying to eat a little less and more healthily. Doctor: And how’s it going? Patient: I’ve lost about five or six pounds so far. Doctor: Excellent! Patient: But a few weeks ago, I seemed to be not losing anymore and my older son said I needed to do more exercise than just walking, something aerobic. Doctor: Probably that would help. And you have no medical reason why you shouldn’t be able to do that. Patient: Yes, so I did register for a program at the Y for seniors. Senior Spinning it’s called. Doctor: What does it actually consist of? Patient: We ride a stationary bike for 45 minutes in a group with an instructor. They play music. It’s fun. I like it. Kind of like dancing with a bicycle. Doctor: You feel good after it? Patient: Yes, very. What’s great is that you go at your own pace, so I can set the resistance at what’s most comfortable, and increase it as I build up my stamina. Doctor: That’s perfect. Patient: But there is one problem. I do it twice a week and I’d like to do it more. Doctor: There’s no reason medically why you can’t. Patient: Well, I seem to be getting a lot of irritation from the exercise in my vaginal area. After every session now, I notice a lot of vaginal discharge for the next day or two following the spinning, so I’m worried about doing more. The first time it happened, a few weeks ago, someone said that it could be that the exercise clothing was too tight, rubbing, so I bought a new outfit that the instructor recommended for full-figured women but that didn’t really solve it. I’m still getting the discharge. And even if I, instead of a shower, go home after class and soak in the tub, same problem. It’s even worse. Doctor: Post-menopausally, as I’m sure you’re well aware, your skin changes. Same is true in the vagina and the surrounding areas. So, we need to see how everything is down there and then come up with a plan, OK? FADE OUT/FADE IN Doctor: Well Mrs. Johnson, as I suspected, from you pelvic exam it appears that your basic problem is that you have atrophy of the tissue in your vaginal area. The skin there is getting thinner. This condition is very typical with menopause and with aging. Patient: So I don’t really have an infection? Doctor: Exactly. Your vaginal area is becoming inflamed because of the estrogen loss from menopause -- we call this atrophic vaginitis. The longer the time frame that you are menopausal, the more your vaginal tissue is without estrogen. As a result, the natural surface around and in the vagina becomes very thin and there’s very little natural lubrication. That’s the problem we have to treat. Patient: And what can be done? Doctor: The best way to take care of the problem is to increase the strength of this thin tissue in the vaginal area and make it healthy again. And we can do that best with a locally applied estrogen. Patient: And the cream is enough? Doctor: Should be. The locally applied estrogen will protect the atrophic – thin and easily irritated - vaginal tissue and make it able to handle rigorous exercise. Patient: If I can exercise more without the discharge and the discomfort, get fitter and lose the extra weight that would be a great solution for me. How do I use the estrogen? Doctor: There are three ways I can prescribe it -- as a cream, a vaginal tablet or a vaginal ring. The one you choose depends on what you’re most comfortable using. Patient: Well, Doctor, since the problem happens when I’m sitting on my bottom on the bike seat, I’d like to start with the estrogen cream. Doctor: OK. I’ll send the prescription to your pharmacy. Patient: 54-year-old divorced woman, post-hysterectomy and oophorectomy, who looks younger than her age, very physically fit. Patient: Eleven years ago after the surgeons took out my uterus and both my ovaries. I was only 43. Wow. It seems like years ago. Doctor: Yes. Patient: I vowed I would go with the flow (laughing) and move forward because the alternative, the endometriosis, was unbearable. And I have kept my word to myself. I don’t think I’ve ever missed a day, even when I’ve had the flu or a stomach problem or whatever, when I didn’t take my estrogen pill. Bottom line is I’m proud of myself for how I’ve handled the new me, the one with fewer inner parts. Doctor: You should be. Patient: I continue to try to make the right choices for my life and health. I’m obsessive almost about my fitness and nutrition [laughing], so much so my friends make fun of me. I never buy a grocery product without reading the label carefully. Same at work, same socially. I’m careful and selective about whom I hang out with and what I do. No regrets whatsoever. Until now. Doctor: Why now? Patient: All this time, you haven’t asked yet, my sex life has been good. I’ve had a few partners, some longer term than others, good relationships, I’m still friends with most of my ex’es, even though no one had totally rocked my boat or me rocked theirs! Doctor: OK. Patient: And now I’ve found someone. For the past 8 months. We’re really into each other. Mutually simpatico. Very accomplished. Very good person. Really attractive in a gray-haired kind of way. I wish I’d met him earlier in my life. He looks like he stepped out of a Viagra ad without the erectile dysfunction problem, you know what I mean? [Doctor smiles broadly]. But more often than in the past, intercourse has been painful. Plus my bladder gets kinda ancy. I have increased frequency. And sometimes I have to go all of a sudden, even if I’d peed just a while before. So I started drinking cranberry juice as my go-to beverage, cut down on coffee to one cup in the morning. For a few days, that seemed to help, but two weeks ago, after my partner returned from an overseas business trip and we had a full day and night of pleasuring, I developed a bad urinary tract infection. My G.P. gave me antibiotics and suggested I see a specialist, which is why I’m here today. Doctor: I’m glad you came to see me. Patient: I’m so sore down there after any sexual contact, even oral or manual, that I just find myself so angry and frustrated, him too! Doctor: Well, let’s have a look. FADE OUT/FADE IN: Doctor: Your exam shows vaginal atrophy, thinning and dryness of the vaginal and vulvar tissues. Patient: I realize I’ve had a surgical menopause for 11 years but I thought the estrogen pills were supposed to counteract the effects. Why would they have worked in the past, and not now? What’s changed? I don’t have cancer do I? Doctor: No, that would be highly unlikely. You have no abnormal patches of skin or suspicious vulvar or vaginal lesions. However, because you still have your cervix, we did do a Pap smear. You have been on estrogen, but at a very low dose, as is recommended. On this low-dose, natural aging of the vaginal tissue still occurs. Many post-menopausal women find it takes longer to become aroused and, even with arousal, have less lubrication, and occasional or persistently painful intercourse. Patient: What options are left if I’m already taking estrogen replacement? Are you going to up the dose? Or is that not a good idea? Doctor: We have several options, and “upping the dose” will not be necessary. Non-hormonal treatments include increasing stimulation, with prolonged foreplay, or the addition of vibrators, visual stimulation or other arousing materials are one possibility. In addition, lubricants can be used and they are very helpful at reducing the discomfort. In your particular case, I think the addition of a local estrogen, whether a cream, ring or tablet inserted into the vagina, would be quite successful. It would complement the oral estrogen that is helping to control your hot flushes, and give the vaginal tissues the estrogen boost they need! After a month or two of treatment, you should see a noticeable improvement in your symptoms. Patient: That is fabulous. Thank you from me AND my boyfriend! Patient: 43-year-old married woman, one year post-chemo for ER+ breast cancer Patient: I can’t tell you, Doctor, how much I appreciate all your help and support. It’s amazing it’s been a year since the chemo ended. I’m feeling OK, my hair is grown out, my energy is back, and best of all I kept my boobs. Other than still taking the tamoxifen, it’s as if none of this ever happened. It’s unbelievable. My older sister, she’s also ER+, but she had to have a double mastectomy. So I feel truly blessed that all I had to have was a lumpectomy and my mammogram is normal, and I just have to have regular follow-ups. That said, I was truly hoping to get my life back to where it was before all this. I’m still young and I have an especially close relationship with my husband. He really really stepped up for me. Doctor: Yes that makes a big difference. So everything seems OK. From what I’m hearing nothing has changed for the worse since your last visit six months ago. But is there something else that caused you to make an appointment that you wanted to speak to me about? Patient: Umm. [pause, looks down at her hands] Yes. My husband and I had sexual intercourse last week. It was really only the second time since all this began. [she pauses again] Doctor: And… Patient: …It was good, really good to feel so close to him again, but, honestly, it was painful. Which scares me. I can’t help but notice how dry I am. Like sandpaper. Maybe that’s what happens at age 43 with or without breast cancer, or maybe it’s the chemo, maybe it’s both, I don’t know. I’m worried I’m losing my femininity. Doctor: I know you have not had a period since the chemotherapy started, so it is likely your ovaries have shut down. You are in early menopause, and your ovaries may, or may not, resume function. So what is happening in the vagina is the dryness, which is a consequence of menopause, whatever your age at the time you hit menopause might be. Your symptoms are not unusual, and neither are your reactions to them. In the past year, have you and your husband tried any other forms of sexual intimacy? Patient: [blushing] We’ve had oral sex, but that is not very attractive to me. We touch and manually please each other. But I’m not into either especially. Doctor: Of course, I understand. Patient: I’d really like to resume our regular sex life, we’re too young to just let that stop. I’d like to feel like a woman again. And right, now, my vagina is standing in the way of the close relationship that we both want and need. And that concerns me. Doctor: I am sure I can make recommendations that should help. Let’s do a pelvic exam and than talk some more after. FADE OUT/FADE IN: Doctor: From your exam I can see you have what we call vulvovaginal atrophy. The skin there is now very thin and not as strong as when your body was producing estrogen. Which is why we often treat atrophy with estrogen supplements but because of your ER+ breast cancer that is not possible. Patient: So there’s nothing to do for me? [her voice rising] Doctor: I didn’t say that. There’s a lot we can do. Patient: Such as? Doctor: First, start with increased stimulation. This can be achieved with more foreplay or with materials or objects that maximize stimulation and arousal, such as vibrators, romantic novels or movies. Additionally, vaginal lubricants at the time of intercourse would be very helpful, usually using a water-based lubricant, although because birth control with a condom is not an issue an oil-based lubricant would also work. These are many “stimulating lotions” available, and for many women, add additional arousal but these can sometimes be irritating and should be tried carefully. Patient: Is that all I need? Doctor: I cannot say for sure. In some women this is sufficient, but I usually also recommend vaginal moisturizers, which are meant to help restore the vagina to a more healthy state. These are used once or twice a week, or more, not just with intercourse. Patient: Can you recommend anything in particular? Doctor: Of course. I like to try my patients on a few different things until we find the best option. We’ll work together and I am sure we can make sex enjoyable again for you. Patient: That sounds terrific. I’m ready.