posted by on Hormone Replacement Therapy

Jan looks in the mirror every morning and asks herself, “WHO AM I?”
She is 50 years old and a few months ago she started to feel out of control.
Jan has hot flashes and cannot get restful sleep due to night sweats.
She is irritable and has no patience with her family.
Her erratic moods have pushed her loved ones away.

Jan is normal and experiencing symptoms of menopause – an expected event in a woman’s lifecycle. The transition known as perimenopause often starts in the mid to late 40s with a median age of 51. There are multiple symptoms associated with menopause, but the event is different for every woman. Some women are fortunate to sail through menopause with no symptoms, but many experience a poor quality of life due to hot flashes, night sweats, mood and sleep disturbances, vaginal dryness, changes in sexual functioning, and unpleasant vaginal and urinary symptoms. If you are like Jan, you are desperate for relief, but you are concerned about the risks of hormone replacement therapy (HRT).

Are you confused about hormone replacement therapy?

Well, you should be with so many opinions out there. Who should you trust?
A friend? An article in the newspaper? Your healthcare provider? A celebrity?

                         “Squeeze your way to healthy hips and thighs”                            Suzanne Somers has given advice and published books about health, wellness, and hormone therapy over the past three decades. Do you remember the Thighmaster informercial? In the 1990s women rushed out to buy the twisty blue contraption and many were left disappointed with the same thighs. Need I say more? I am not saying that medical advice from a celebrity is wrong, but I do believe in educating patients based on sound scientific evidence. You need to know the facts about HRT. Understanding the true risks and benefits will help you feel confident in your decision to initiate, continue, or stop HRT.

The Study That Changed Everything…

In 2002, results from the Women’s Health Initiative (WHI) Postmenopausal Hormone Therapy Trial caused terror across the country. The WHI trial included three groups of women. The women were given Prempro (0.625 mg conjugated estrogen and 2.5 mg medroxyprogesterone), Premarin (0.625 mg conjugated estrogen), or a placebo. (Note: Prempro is like Premarin, but it contains progesterone, also known as a progestogen. Women with a uterus who take unopposed estrogen such as Premarin have a significantly increased risk for endometrial cancer and progesterone decreases this risk).

On July 9, 2002, the Prempro group was halted early due to an increase in breast cancer and cardiac events. Prescriptions for hormone replacement plummeted after the media publicized the findings. The headlines read “Hormone Replacement Therapy Linked to Cancer” and women were tossing their pills as if they had been poisoned. However, the results were not accurately reported and many would agree the risks associated with HRT were overblown. I will admit that I was also influenced by the media and 10 years ago I was scared to prescribe HRT due to fear of harming my patients. A few years later I decided to sit down and read the study. I was shocked by what I read…

For every 10,000 women taking Prempro each year we would expect:
*7 more heart attacks
*8 more strokes
*8 more breast cancers (in other words, 38 women taking Prempro would get breast         cancer and 30 women not taking any hormones would get breast cancer)

I then thought to myself, was this study flawed? Over half of the women were over the age of 63. How many women actually take that dose of Prempro in their 60s and 70s? In addition, we know that women have an increased risk for cardiac issues as they get older. The incidence of heart disease is 12 times higher for women in their 80s compared to women in their 50s!

What the media didn’t tell you about the WHI study…

Although the Prempro group was halted early because it was perceived that health risks exceeded health benefits, the Premarin group continued. In 2004 the results were published and I think you will be shocked by these results.

For every 10,000 women taking Premarin each year we would expect:
*5 fewer heart attacks
*7 fewer invasive breast cancers

Could it be that we overreacted? Perhaps, but more research is needed and this holds true in any area of medicine. In the mean time, you need to feel confident in your decision whether or not to use HRT. As with any medication there are risks and it is recommended that you use the lowest effective dose for the shortest amount of time. Hormone replacement has been shown to decrease the risk for osteoporosis and colon cancer, but HRT should not be used to treat these conditions. Hormone replacement therapy should be used for the treatment of menopausal symptoms and treatment should be initiated with the onset of symptoms such as hot flashes and night sweats.

Do you have questions about synthetic and bioidentical hormones? Stay tuned for the next blog!

posted by on Female Sexual Medicine

5603681683_845729d4b2_mThe World Health Organization describes sexual dysfunction as the multiple ways in which a personal cannot participate in a sexual relationship as he or she wishes. More specifically, female sexual dysfunction (FSD) is defined as disorders of sexual desire, arousal, orgasm, and pain, which causes a woman personal distress. In my professional experience, women usually present with more than one type of sexual dysfunction and the cause is often multifactorial.  This includes psychological, biological, medical, interpersonal, and sociocultural factors. For example, a woman presents with no sexual desire. After a detailed medical assessment, further information reveals that she is postmenopausal, she is worried about finances as their first child will be going to college, her job is stressful,  and she experiences severe pain with attempted penetration – even during a routine gynecological exam. It is no wonder that her sexual desire has diminished. As a result of these symptoms, she cannot become aroused with stimulation and the thought of any sexual activity causes her personal distress.

“I told my healthcare provider that I have no desire since menopause. She told me it was a natural part of aging and there were no treatment options.”

This is a true story and I felt sorry for my patient because there are safe, effective treatment options available. Based on research, we know that a woman’s testosterone level starts to decline in the mid to late 20s and continue to decline at a slow, steady rate throughout life. In addition, the surgical removal of one’s ovaries results in an immediate 50% reduction in the amount of testosterone produced.  There are several different treatment options including local vaginal estrogen or testosterone, and transdermal, injectable, and subcutaneous testosterone therapy. For more information, go to www.melissadahir.com.

“Shouldn’t my healthcare provider know how to treat issues with sexual functioning?” 

Not all healthcare providers are trained in this area of medicine. Unfortunately the formalized training of doctors, nurse practitioners, and physician assistants does not include in-depth education of sexual medicine and vulvar pain disorders.  In 1999, a survey of medical schools in North America revealed that less than half offered education in sexual dysfunction. In fact, I will be the first to admit that I did not have the knowledge or skills to treat these sensitive issues when I first started practice.  I read several books about female sexual medicine, but it was not enough. In the fall of 2006 I was accepted for an internship with national experts at the Pelvic Health and Sexual Institute in Philadelphia. The internship was life changing because the educational experience included in-depth didactic course work in addition to hands- on training with patients. I have also been fortunate to train with other experts in this field of medicine through the International Society for the Study of Womens Sexual Health and the International Society for the Study of Vulvovaginal Disease.

“How do I know if my healthcare provider can treat issues related to sexual functioning?” 

When looking for a qualified healthcare professional, it is best to look at their extended medical training. In addition, the International Society for the Study of Women’s Sexual Health (ISSWSH) offers a list of medical providers nationally and internationally with an interest in female sexual medicine. More importantly, a healthcare provider with the credentials of IF, or ISSWSH Fellow will ensure they are an expert in the field of sexual medicine.

To find an ISSWSH Fellow in your area, go to www.isswsh.org.

posted by on Female Sexual Medicine

Welcome to my first blog post. My specialties include sexual medicine, vulvar/pelvic pain, vulvar dermatology, and hormone replacement therapy. It may be difficult to understand this field of medicine, but I promise these issues are real and they leave many women suffering in silence. I am dedicated to breaking the silence and changing lives through evidence based medicine and research.

One might ask how I became interested in this field of medicine. The answer is quite simple – I listened to my patients.

My journey to becoming an expert in sexual medicine started in 2006. At that time I was frustrated because I did not have the knowledge or skills to treat women presenting with sensitive issues such as pain with intercourse or a lack of sexual desire. I felt compelled to help these women because many of them had asked their healthcare practitioner for help, but quickly became hopeless after hearing replies such as:

“No one ever died from not having sex.”

“Just have a glass of wine and relax.”

“Your exam is normal and there is no cause for the pain. The pain must be psychological.”

“You have breast cancer – be thankful you are alive. Having sex should be the least of your worries.”

To address this gap in medicine, I looked to the national experts for guidance. In the fall of 2006 I completed an internship with Dr. Susan Kellogg Spadt at the Pelvic & Sexual Health Institute in Philadelphia. Shortly thereafter I returned to the Midwest to start the first clinic devoted to sexual medicine and vulvar pain. I hope you will find my blog helpful and realize you are not alone.

Men vs. Women

Sexuality is an important part of a woman’s biological lifecycle that emerges from the first sexual experience and continues to evolve through the years past menopause.  My female patients often ask me why men have so many treatment options for issues with sexual functioning.

“Men have a little blue pill [Viagra]. Is there a little pink pill for women?”

The answer is no because the process of sexual functioning is very different between men and women. In the 1950’s, Masters and Johnson studied both genders through direct observation in the laboratory. They discovered similarities between both sexes and published their groundbreaking findings as a four-stage model of sexual response. Masters and Johnson’s model is described as “linear” in which each phase occurs in an orderly fashion: excitement, plateau, orgasm, and resolution.

Over the next several years, sexual health experts acquired a deeper understanding of female sexual functioning due to advances in research. The experts realized the importance of sexual desire and felt previous models did not recognize the fact that women have other motivations for engaging in sexual activity.  As we moved into a new millennium, Rosemary Basson proposed a new model of female sexual functioning. This model was “circular” and included psychological, biological, and physiological factors.  Many female patients of all ages related to this model because their motivation for engaging in sexual activity was complex and influence by outside factors such as fatigue, stress, raising a family, financial issues, depression, pain with intercourse, cancer, weight gain, unrealistic expectations, vaginal dryness, relationship conflict . . . the list goes on and on.

My first blog is a general introduction. My goal is to address the many issues a woman may experience throughout her life and bring the “pink elephant” out of the closet.  If you have thoughts about future blogs, please send me a message at melissadahir@creighton.edu. Your message will be confidential and I look forward to your feedback.

Melissa Dahir, DNP, IF