Tag: vagina

Let me explain to you why I know about more than just the vagina.

I get asked or questioned all the time about how I seem to have knowledge about things that are not just about the pelvis. People say things like how do you know about that? Aren’t you just a lady doctor? Don’t you just care about the vagina? How do you know about anything else well enough to make recommendations about other health issues. I think that literally other physicians, internists, and family practitioners are somehow threatened or feel insecure about this.

Trust me, there are no worries here. Let me explain. I was fortunate enough to have completed my training in the 90s. During this time, Obgyn was temporarily reclassified as primary care. Therefore, during my residency, I got training in family practice, internal medicine, er, surgical ICU, in addition to my root Obgyn training. I am very grateful for this because it has allowed me to know more than just my specialty. I also make it my business to keep up on the latest in these other health issues as well. Do I portend to know more than a family practitioner? No. In addition to that there should be no worries about my taking over the care of your patient. I am well aware of my limitations and know exactly when to refer the patient back to you for further direction and care. I am now and have always been a physician who knows her boundaries and limits. I am also aware that we should all be members of the same patient team and should be willing to work together for the patient’s interest. That should always be our mutual goal. Have a great day everybody.

Dr. Katz

No, it’s not ok that your vagina hurts and no, you don’t have to just accept it as a part of the natural course of aging….the vagina manifesto!

Oh lord, people. I hear this from patients all the time. They have been in pain and discomfort, sometimes for years, to the point that they can no longer enjoy any part of an intimate relationship or ever feel comfortable in the hinterlands. I am now understanding that this is being told to women by both male and female physicians. What the? I can sort of see it coming from male physicians because they have no personal perspective to relate to but female physicians saying this too? Shame on you ladies! You know better. I am willing to bet that you are just not willling to spend the time dealing with it. I am not sure why though.

Well, I am here to tell you that you don’t have to just accept that….from any physician. Is it true that our vaginas become drier with age? Well, yes they do, but there in fact is all kinds of stuff we can do about it! It is not just something you have to deal with and suffer. I am hollering bullshit over hear when I hear that.

I know we are always going around telling ourselves that sex isn’t everything and it is not the key to a relationship. I am not saying it is either, but we are kidding ourselves if we think that depriving ourselves of that level of intimacy with a person that we really care about, or lust after as the case may be..lol has no consequences.

So, let’ s first talk about why the vagina changes so much as we age. It is time now to bring out the hormone blame. As the hormone levels drop or lose their equilibrium, the vaginal tissue becomes thinner, more friable, more delicate, looser, and unable to self-lubricate. The PH also gets off and leads to increase risk of infections. In fact, the angle of the vagina also changes to the point that hitting that magic g spot becomes almost impossible at times. On top of that, as our testosterone levels drop as well, our libido goes down the toilet. How’s that for abject chicanery? We are dry, we hurt, we don’t want to do it in the first place or we don’t want to do it because we know it will hurt.

I have good news coming! All of this can be addressed and the pain can resolve and the pleasurable sexual functioning can be restored! There are all kinds of creative and safe options that can be individually tailored to the specific woman.

First let’s address the dryness. I said that the vagina gets thinned out and irritated right? So, we need ways to plump it up and relubricate it. I have several. One is to do it with hormones, either orally or directly into the vagina. Usually estrogen is the key here and testosterone too.This is a potentially awesome option with relatively quick positive effects. There are several things to consider before entertaining this option though. You have to know your patient’s entire history. Women are not a candidate for these hormonal options if they have a history of certain cancers or blood clots. Women who have these conditions are not a candidate for hormonal therapy. Also, you have to keep in mind that if they still have their uterus, you cannot give them estrogen only because it could overstimulate the uterus and potentially lead to endometrial hyperplasia or cancer. But, no problem there, just balance it with some progesterone too and you are all good.

The good news is that there are plenty of alternatives for the patients that cannot take hormones. You wouldn’t think of this first but regular fresh out of the kitchen extra virgin olive oil is an excellent lubricant. So is coconut oil. My personal favorite is olive oil because you need less of it and it tends to be less greasy and get everywhere. All of those amazing feminine lubrication products out there tend to be the devil in my opinion. If you read the fine print there, there are all kinds of those things in those products that actually irritate the vagina more than they lubricate it. All that scented stuff that makes us think we have to smell like flowers, cake or pie? I say run in the other direction. The vagina has it’s own smell and no one is going to swoon away by letting it have its own natural odor. But, I have to admit that the packaging is very attractive. They also tend to be expensive too. I say forget it and just go with the olive oil or the coconut oil. Or, at least pick a water-based lubricant like astroglide. It seems to be the safest.

I have another good option for those that cannot do hormone therapy, the forma V intimate rejuvenation treatment. It is a radiofrequency treatment that involves inserting a wand into the vagina multiple times for a ten minute or so, in-office treatment, that replumps the vaginal tissue, relubricates the vaginal tissue, tightens the muscles, resets the vaginal angle and tightens the skin as well. It has no significant risks. You can even get it done if you have had a history of cancer or a previous sling or anything like that. We are using this awesome procedure lately to even return 80 plus year old patients back to the bedroom. There really has been no significant discomfort with this procedure so far in the last several years of doing it besides some pressure at the time of treatment only. The catch is that insurance does not cover it so there is an upfront charge, but every patient I have treated with this procedure has thought it was very effective.

There are other reasons to develop vaginal and vulvar pain as well. The most concerning ones are something called vulvodynia with or without vaginismus. Vulvodynia is a condition when there develops certain pain trigger points around the clitoral hood, around the urethral opening or at the bottom entrances (the vestibule) of the vagina. This trigger points become so inflamed that any attempt at penetration causes an extreme pain response. This can sometimes lead to an intense spasm of the muscles called vaginismus. Sometimes you get lucky and can determine a specific lesion or area of irritated skin that is causing the pain and you can treat that and the pain goes away. More often that not, there are just these trigger points with no set lesion. If this is the case, temporarily treat these areas with topical hormone cream for a month or so and then convert to a long-term topical combination anti-spasm, analgesia, anti-pain medication that the patient may have to use daily for the rest of her life. But these options do really work well and can even help return these patients to an intimate relationship. The other thing i do with these patients is that we take a deep dive into their cleansing regimens and use of certain detergents, soaps, and toilet paper and make any changes to their routine that could be contributing to any inflammation or irritation. I call it my be kind to your vulva tip sheet. You would be surprised at how many things you could be doing to harm yourself without realizing it.

Let’s talk lastly about libido and its relationship to intimate relationships. If you have no desire to have sex because you are afraid it is going to hurt, then you treat as above and once you eliminate the fear of pain, libido will usually return. If your lack of libido is due to a testosterone deficiency, you can either treat with oral micronized testosterone or local vaginal testosterone with great results. If you are not a candidate for hormone therapy, there are a variety of excellent herbal alternatives like schizandra or argin max or even yohimbe that can be very helpful.

The bottom line is that all is not lost. Ask for help. Seek a physician who is actually willing to take the time to get to the bottom of your particular issues. It will be worth it. The bedroom is calling!

Dr. Katz

Please, just leave the pelvises to me.

closeup photography of pink rose flower

Hey there folks. Dr, Katz here. I have been an Obgyn for the last 28 years. I have delivered thousands of babies. I have performed thousands of surgeries. I have done thousands of paps. All of these things are essential parts of the specialty that I was specifically trained for. I was also fortunate enough to have gone through residency at a time where Obgyn was temporarily reclassified as primary care so I also have training in internal medicine, er, icu, pediatrics, and family medicine. As a result, I know how to diagnose things outside the scope of regular Obgyn practice, but, at the same time, I realize that I am not the expert in those areas so I know when to refer when necessary.

Sometimes, I feel like the same does not apply to obgyn care. There are a lot of family physicians and internists out there that still do the occasional pap when they have to or if the patient does not want to visit an actual obgyn.

Most of the time you get lucky and the pap would have been normal regardless so no harm done. But, then there are those other times when the patient has been getting “normal” paps for years by their family doctor and then they come and see me and actually have an invasive cancer that could have been caught earlier. Thank goodness these times are rare, but they happen nonetheless and are preventable.

To me, this says don’t dabble. You are potentially putting someone’s life at risk, even if unintentionally. I know that a lot of people think that doing a pap is a no brainer and that is the complete story as far as Obyn. I tell ya. It’s not true. There is an art to it from the performing of the procedure without harming the patient and actually knowing what you are looking at and being able to pick up on the subtlest of cues that something is off. Obgyn stuff is that sneaky. You usually don’t get any symptoms until something is already bad. Then, it can be too late. However, if you just stop into the Obgyn once a year, a lot of that is both preventable and/or treatable.

I know how to treat blood pressures and treat a multitude of various diseases, but I know I am not the expert so I refer appropriately. I think that every patient needs a primary care physician and an Obgyn because they both care for different necessary aspects of health. I think that both are necessary to achieve total health and well-being. I think we are different specialties for a reason. All I’m asking is, please leave the vaginas and the pelvises to me. I promise I won’t let you down.

Dr.Katz

“I don’t mean to overshare, but”…..the words every Obgyn loves to hear.

What does it mean to overshare? To overshare is to reveal an inappropriate amount of detail about one’s personal life. I think it is somewhat subjective to determine just what is inappropriate. I think it’s different for everybody and even somewhat situational. In my profession, it is just a way of life.

I just heard these words the other day. “I don’t mean to overshare..but”. I am never sure what the point is of leading with that statement. Does the patient expect me to be shocked? Ask them to refrain from saying what they were going to say? Heck no! My usual reaction is to just buckle up and lean in closer. I can’t wait to hear what they have to say. Usually it is something pretty juicy and intimate….my orgasm was mind blowing from that treatment you did, I had the best sex ever after I started that medicine, a very personal description of a vaginal sensation, etc, stuff like that.

Why worry about saying stuff like that? If you can’t tell the gynecologist stuff like that, who the heck can you tell? My very profession is all about oversharing. It’s not like you can just blurt out stuff about your pelvis just anywhere. But you can here! The best way for me to help you with any of your concerns is to know everything!…every…last….detail. There is nothing embarrassing about it. If you tell me everything, we can either celebrate it or get to the bottom of the problem together. It is a win win. So, c’mon. Let’s start sharing.

Dr. Katz

It really isn’t supposed to smell like flowers, cake or pie down there.( To douche or not to douche)

Say it with me…feminine…hygiene…products. Whenever I hear a patient say,” Eww. It smells like vagina down there,” I find myself wondering well what the heck is it supposed to smell like for chrissake? It SUPPOSED to smell like vagina….BECAUSE IT IS A VAGINA! C’mon people. Let’s get real here. I would just like to know who first started the trend of convincing women that it shouldn’t.

Let’s go over a few vaginal facts and a few feminine hygiene product facts. Spoiler alert! They are not actually good for you! I am going to attempt to rationally explain why so bare with me please. What you choose to do with this information is completely up to you, but don’t say I never tried to save your hinterlands from ruin.

OK. Here we go. We all know that feminine hygiene products have been around for what seems like forever. I am talking decades at least. There are wipes, washes, deodorants, douches, creams, sprays, etc. You name it. We’ve got it. Everyone of them is geared toward reducing odor, using after intercourse, or cleaning up vaginal discharge. Did you know that there was a study in 2006 that reported that most women start using douches or feminine washes in their teen years, usually between 15 and 19 but some start as early as 10 years old! Whoah. There are mixed results demographically regarding whether Black and African American women tend to douche more than White and Hispanic women. Some studies say yes. Some say no.

You can see how the advertising gets you. Who hasn’t seen a commercial or a ad about getting rid of period funk or that not so fresh feeling? This kind of marketing can easily make some women ashamed of their own natural odor and set up an unrealistic expectation of some flowery fresh scent that is supposed to be down there. It is just one more way that we are potentially messing with a healthy self image. I am not on board with that. I think I have even found some of that stuff in my daughters’ bathroom!

Let’s talk next about what the biological environment of the vagina and vulva are supposed to be like. Vaginal ph changes throughout the lifetime of a woman. Usually during reproductive years, the pH ranges from 3.8 to 4.4. This range is essential because it allows the normal bacteria of the vagina to flourish. Bacteria called Lactobacillus are supposed to be there to protect it. Well, the pH balance in feminine hygiene products, regardless of what they tell you, is widely variable and usually contain ingredients that make the vagina way too acidic. We have studies that show that these products start wiping out the Lactobacilli within 2 hours and can even eliminate them all together by 24 hours! When this happens, an inflammatory reaction occurs because a substance called interleukin-8 starts increasing because the normal healthy bacteria are not there to stop it. This potentially leads to a much more wide varied growth of different bacteria, which in turn leads to bacterial vaginosis, yeast infections, urinary tract infections, generalized itching and discomfort and even a greater risk of sexually transmitted diseases. A lot can happen when we get rid of the vagina’s natural defense system. On top of killing all the normal bacteria, the chemical in some of the products actually breaks down the vaginal wall. Here’s a kicker on top of that. Once women start having itching or discomfort from the products, they think they need more product to stop the itching! It really is a vicious cycle.

This is the last thing that I would like you to think about. Once you have damaged the vaginal environment, it can be very tough to impossible to restore it. Most research indicates that it will require at least two weeks after the last time a woman used an irritant to get any relief. Let me tell you, that is a rough two weeks without out much recourse available. Those are my patients that end up coming in chronically miserable and there is not a lot we can do but wait for all of the product to leave their system.

Listen, I am not about to call out any products by name but I am telling you that I am not a fan of anything out on the market right now. You never know, new items may come out in the future that are more conscientious of the natural vaginal flora. But, in the meantime, I advise you to just say no!.

Dr. Katz

Man! It’s hard to feel sexy when you have cancer.

Picture the scene: Your partner gives you the let’s get frisky look. They start petting you in the way you are normally into. The sexy dance has started. The lights are dimmed aaaaaaand……nothing. You are laying there all bald and post chemo( well it has been a few days but you get the idea), fresh off your latest chemo hot flash, tired, bloated and not the least bit sexy….in your mind. You just aren’t up for it. It’s not you. It definitely isn’t your partner. It’s the freakin absence of sexiness that sometimes comes with cancer and chemo. I tell ya, the changes in appearance alone are a real confidence killer at times. My husband is the most amazing partner and best friend on the planet and regular me can’t get enough of him. But, cancer me is another story.

Cancer and cancer treatment can have a very significant impact on a woman’s sexuality in many ways. Disfiguring surgery may be required that can significantly affect your self esteem and confidence. Treatments can sometimes put you into premature menopause with hot flashes, vaginal dryness, pain with intercourse and decreased libido. Certain pelvic cancers require such extensive surgery, radiation, etc that a woman is left without proper function of her sexual organs permanently.

I get it, this sounds all doom and gloomy. The good news is that not all women are left with permanent sexual dysfunction after cancer. Sometimes the effects are temporary and things go back to normal when treatment is over. I am seriously hoping that I fall into this category.

Fortunately the data shows that if a woman was able to have satisfactory sexual experiences before cancer, she will be able to again. The American Cancer Society has a whole section of helpful tips and information for women who are having sexual issues resulting from cancer treatment. Some of these are in fact very helpful. The bottom line of all of them is that sometimes you have to get creative and you have to reinvest in your own self-love and confidence. Sometimes the same techniques for sexual satisfaction that you used before will not be successful anymore. You might not even have the same parts anymore. You may have to use more lubricant when you didn’t have to before. You may have to explore different things that excite you. You may require a vibrator for extra stimulation. You may need to try different positions. You may need to employ more fantasies into your sexual relationships. You may need dilator therapy to re-stretch the vaginal canal. These are just a couple of examples.

There is an interesting set of exercises recommended by the American Cancer Society for patients feeling anxious about sex and the way that their appearance has changed and adjusting to those changes. They suggest looking in the mirror, dressed at first, and noting the changes in your appearance: your surgical scars, ostomies, missing parts, etc. Then notice what you try to avoid looking at. Then while dressed, try to find three things that you like about your appearance. Once you are comfortable looking at yourself as a stranger might see you, then change the exercise and repeat it with you being dressed “sexy” for your partner. Finally, repeat the exercise nude with the same steps until you are able to look at yourself and adjust to the changes and feel comfortable. Don’t stop until you can give yourself 3 compliments like you did in phase one of the exercises.

The last thing to address regarding the impact of cancer on sexuality is the anxiety that goes along with it. It takes time to realize even when treatment is over that you are actually better and that life can go on, including sex. Clear communication is the absolutely paramount here. Talk openly with your partner about your fears and issues. Don’t leave them in the dark and just reject them. They can’t possibly understand what is going on in your head unless you tell them. Get therapy if you need to. Talk openly with your doctors. You be the one to bring it up. I can tell you right now that most physicians are not comfortable enough to make sure to address sexual issues at any time, much less with their cancer patients. This will be something that you really need to take charge of and advocate for if you want things to change and improve. As much as we try to deny it at time, our sexuality and sexual health are key components to our relationships and overall health. Sex is just as important for cancer patients as it is for every day folks. So, do what you can to preserve it. It’s for your health!

Dr. Katz

What do you look for in an obgyn?

This question actually has multiple answers and is a more complicated process than selecting a primary care physician. The usual selection criteria apply of course: 1) Is the doctor in your network? 2) Are they local and easy to get to? 3) Does their availability(office hours) fit your availability? 4) Do they have good reviews? 5) Do you know anyone personally in your family or friend group that already sees them so that you can get firsthand feedback?

These are good to go by when attempting to select any physician, bearing in mind that reviews on google can be written by anyone anywhere, even if they have never been in the office in question. Having family feedback is good as well, provided that you know the whole story surrounding their comments. ( i.e Grandma Martha hates Dr. X, but also has multiple no show appointments and owes the office a lot of money that they are rightfully trying to collect) You see what I mean? Even the seemingly best source of information does not compare to your own personal experience.

Having clarified all that, I feel that selecting an obgyn adds yet an additional level in selection complexity. Finding the right obgyn means finding someone with a communication style and listening skills that make you feel comfortable enough to discuss some of your most personal and potentially embarrassing issues. I mean, you can’t go discussing your vagina and hormones with just anybody. Hopefully you are able to find somebody that listens and “gets you” at the same time.

This is the kind of thing I strive for the most….the listening part I mean. It is so so important. Many of the women that I see are frustrated because they have spent years dealing with unresolved issues because they either did not feel comfortable mentioning them to their previous physicians or they were dismissed. This should never happen. Every single patient deserves to be listened to and, in my opinion, if they have an issue that you are not prepared to deal with, they should be referred onward to someone that can. The patient should never have to suffer due to your lack of comfort or familiarity with their particular problem.

I received a compliment once from a patient that I did not understand at first, but now I consider it one of the best compliments I have ever gotten. She said that coming to my office was like coming to a girlfriend’s house. At first I thought, what the heck does she do at her girlfriend’s house? My face must have registered my confusion for a minute because she went on to explain what she meant. She meant that I was able to make her so comfortable at my office that she was able to disclose and discuss anything and everything that she wanted to. That is my job, my sacred mission, and what it’s all about. Have a great night everybody!

Dr. Katz