When a post menopausal woman comes in to my clinic complaining of vaginal dryness or pain with intercourse, I get excited.  No, I am not a sicko.  I am excited because I  know I can usually fix the problem and make a big difference in her quality of life.  That  is very satisfying.  Women are very grateful and I become their hero. So what is going on “down there”?  Well, I’ve got bad news and good news.

The bad news is that unless you are taking hormones, sooner or later it is going to happen.  It is called vaginal atrophy.  It means the skin and tissue in the vaginal area gets thinner and more fragile.  It is caused by the decrease in estrogen which occurs during menopause.   It can cause a feeling of dryness, itching and pain with sexual activity.  The good news is that there is help for this problem.

Even women who may not be appropriate candidates for systemic estrogen may be able to safely use local estrogen creams with good result.  There are many estrogen recepters in the vaginal area which means that a very little amount of estrogen is needed to get relief from symptoms.  Because the amount needed is small, the side effects and risks are small as well.  Often just a small pearl size amount of estrogen cream a couple times a week is all that is needed to maintain vaginal  tissue health.  Other factors which contribute to vaginal health are important to consider too. 

• It is important to check for and treat any vaginal infections like bacterial vaginosis, candida vaginitis (yeast) or even sexually transmitted diseases.  Treating these conditions may clear up symptoms.
•  Maintaining sexual activity of any kind helps  good blood flow and lubrication, keeping vaginal tissues healthy.  I call it the “ use it or lose it” factor.   Widows or divorced women who may enter a sexual relationship after many years of abstinence are often greatly dismayed with their discomfort and greatly relieved that there is effective help for their problem.
• Over- the- counter vaginal moisturizers and lubricants can offer a good starting point for help with dryness  or discomfort during intercourse.  There are many good products on the shelves of any drug store.  If after trying these, you still are not getting relief, see your physician or practitioner.  They may end up being your hero.

written by Deborah McBain, CNM MSN

  Julie has a BFA in dance from the University of Michigan and has been teaching creative movement and ballroom dancing since 1977.  She completed her yoga teacher training and began teaching in 2000.  She has taught a wide variety of classes in the community for all age groups and continues to teach classes at West Bloomfield Parks and Recreation.  In 2008, she completed training in a yoga therapeutic program, “Yoga of the Heart,” based on Dr. Dean Ornish’s study on reversing heart disease.   She feels proud and fortunate to be an employee at Henry Ford Vita Wellness Center, teaching yoga classes which focus on the health benefits of yoga. In addition to the daily yoga classes, she also teachs Zumba, Ballet Stretch and Tone and Dance Your Way to Fitness.  She recently answered my questions about how Yoga may benefit women during menopause and beyond.

 I know you teach a Yoga for Wellness class now and have offered a Yoga for Menopause class in the past.  What prompted your interest in yoga and specifically yoga for menopause?

When I began my first yoga classes in 1995, I truly had little understanding of yoga.  I was recovering from a dance injury and thought yoga would be a good way to stay in shape while I was recovering.  I quickly recognized that yoga was as much about the body as it was about the mind.  In short order I began to notice the many benefits from practicing yoga.  I was inspired from my earliest classes to become a yoga teacher, guiding others to discover the benefits. The overall benefits of yoga, which include stress reduction, improved focus, mood regulation, improved sleep as well as strength, balance and flexibility have served me well as I have made the transition through menopause.  

 Yoga is well known for its benefits in managing stress.  How is it specifically helpful for menopausal symptoms?

 What  are the other health benefits of Yoga for women as they age ?

Is Yoga safe for everyone?  Are there any precautions women need to be aware of?

How would you recommend someone get started with Yoga?  Do you have any good resources you can share?

written by Deborah McBain, CNM MSN

Most of us tend to think of immunizations as kind of a kid thing.  Most of us  were pretty good at getting our kids in for their “baby shots”.  I did have some friends who were pretty adamant at NOT getting their children immunized due to concerns about side effects, but most of us figured the benefits outweighed the risks.   And we were right.  Pediatric immunization programs have been very successful in reducing and even eliminating  many childhood diseases, saving countless lives with very little risk.  But despite the fact that there are many vaccine preventable adult diseases,  rates of adult immunizations are low.  Why is this, when immunizations so clearly are effective in reducing the occurance and severity of many serious and nasty adult diseases?   Experts believe that a lack of a cohesive national program promoting adult immunization strongly contributes to  a lack of information among both patients and care providers.   When you go see your doctor, does he/she talk to you about immunizations?  Do you  bring up the subject?  Most likely not.  So here is a primer on immunizations you should consider getting and when.    These are recommendations from the Centers for Disease Control & prevention (CDC).  Next time you go to the doctor, ask. 

Tetanus, Diptheria. Pertussis (Td/Tdap)  All adults age 19-64 should get a Tdap once and all adults should get Td booster every ten years. Pertussis, which is known as Whopping Cough caused a great deal of illness in death in children and infants in the 1940s.  For years it was nearly wiped out  due to immunizations but has recently reemerged.   Adults  have largely lost their immunity to the disease.  Getting the Tdap booster will prevent you from getting the disease and passing it on to any children you may come in contact with. ( think grandchildren). Obviously, parents, teachers and health care providers are also important adult groups to immunize.

Varicella-  (chicken pox).  2 doses recommended unless you have evidnece of immunity.

Zoster- (shingles).  One dose is recommended at age 60 or above.  Shingles can be very debilitating and the pain can last for months and months. Vaccines don’t always completely prevent infection but can greatly reduce symptoms and time for recovery.  The disease seems to get worse as we get older so it makes good sense to get this vaccine. 

Pneumococcal- (Pneumonia). One or two doses for people with medical conditions putting them at high risk and one dose if you are over 65.  Most people who die from the flu actually die of pneumonia so  this vaccine is often given along with the annual flu vaccine.

Influenza-   Get the flu vaccine yearly.  Flu shots are safe for most people and even if you do get the flu your symptoms will be milder.

Other vaccines that may be appropriate for you to get  include Measles- Mumps- Rubella (MMR),  Hepatitis A and or B and Meningococcal.  Check with your doctor to see if you are in a high risk group for these disesases and should be immunized. 

I wish you health.

written by Deborah McBain, CNM MSN

One of the most important and controversal questions regarding hormone therapy (HT) for postmenopausal women is “ Does Hormone Therapy reduce or increase risk for heart disease?”  An important study is underway that may help answer this question.     The Kronos Early Estrogen Prevention Study- KEEPS is designed to address  whether or not  risk depends on the age of the woman when beginning HT.  It will also seek to answer whether  patches are any safer than pills.  Observational studies have long suggested that HT can offer protection against heart disease in some women.    In 2002 another very large and important study- (WHI) Women’s Health Initiative  not only failed to show protection but was stopped when participants showed increased incidents of heart attack and stroke.  The average age of women in WHI was 63 and 12 years past menopause with 20% over the age of 70.  KEEPS will attempt to address whether it was the older age of the WHI participants that made the difference by studying a younger group of women who more recently entered menopause.   The age range for KEEPS participants is 42-58 and 6 -36 months from onset of menopause.  KEEPS will also use different types of hormones than were used in WHI including bio-identical formulas.    Women and those of us who advise them are anxious to see  if  KEEPS can offer guidance when making decisions about HT.  Keep a watch out for results from this study as it comes out in the media.  The only way we can know the truth about what is safe and effective is through studies like this.  If you want to know more about this study, go to their web site www.keepstudy.org 

The importance of heart disease prevention for women can hardly be overemphasized. Coronary heart disease is the single greatest killer of American women, extinguishing more lives (approximately one death per minute) than the next seven leading causes of female mortality.  In other words heart disease accounts for 45% of deaths in women.  Compare this to breast cancer which causes 4% of deaths in women or all cancers which accounts for about 21%.  This is in sharp contrast to the perceptions of most women who see cancer,  particularly breast cancer as the biggest threat.  Women should be aware that far more is known about risk factors for heart disease than for cancer and in general, heart disease risk factors are more susceptible to interventions.

written by Deborah McBain, CNM MSN

The longer I live in my body the more amazed I am at how connected my mind and body is.  So many women who are  bothered by hot flashes and even urge incontinence do not realize that they may actually have some control over some of their symptoms by training their minds.  There is good scientific evidence that this is so.  Practice the exercise below during a hot flash or with urgency to urinate.  Concentrate on relaxing your abdominal muscles.  Don’t give up if you don’t see results right away.  Like anything, it takes practice to achieve effective performance.  It is not hard but takes just a little persistence. Good luck.

Paced respiration

With regular paced respiration, women reportedly achieve a noticeable drop in the number of hot flashes they have, as well as a lower average skin temperature (used to measure hot flashes).

Paced respiration takes practice. Try to do paced respiration twice daily, for 15 minutes at a time. Also, when you first feel a hot flash coming on, stop what you are doing, find a quiet place, and practice paced respiration until you are feeling comfortable again.

• Sit in a comfortable, quiet place.
• As you breathe, keep your rib cage still. You will be lowering and raising your diaphragm to fill and empty your lungs.
• Inhale for 5 seconds, pushing your stomach muscles out.
• Exhale for 5 seconds, pulling your stomach muscles in and up.
• Repeat this cycle of breathing until you feel calm and relaxed or your time is up.

To reduce stress, you can also use paced respiration for 1 to 2 minutes in the middle of a busy day.

written by Deborah McBain, CNM MSN

Here we go again.  I know you have the best intentions.    This year is going to be different.  It’s  barely one week into the new year so  how you doing with that diet so far? 

About 65% of us are at least overweight and over 30% of us are obese, that is having a body mass index  (BMI) of 30 or more.  (Go  to   http://www.nhlbisupport.com/bmi/  to calculate your BMI)  Fifty million people go on diets every year, spending  millions of dollars on programs, pills and other diet aides.   Only 5% will be successful.   Why, why, why do we do it?  Because losing weight is good for you?  Or because you really, really want to get into those smaller size jeans you wore 5 years ago?  Probably a little of both.  Most of us know that losing weight is beneficial to our health.  We know that being obese puts us at high risk for high blood pressure, heart attack, diabetes, breast cancer and other cancers, gall bladder problems and a host of other ailments.  But still diets don’t seem to work.  Why not?  Obesity at its core is very simple but fixing the problem is very complicated.  We are obese because we are taking in more calories than we are using.   The surplus is stored as fat.  Researchers are finding that the reason we are staying fat is complex.  It seems that lousy food actually changes our physiology.  Over consumption of nutrients changes  chemicals and hormones in our body reducing our ability to recognize when we are full.  It causes something called leptin resistance.  Leptin resistance also causes cravings, and interfers with our body metabolism.  The fatter you are the harder it is to lose weight but the more important it is to lose weight.  In other words, getting fat changes our chemistry and then our chemistry keeps us fat.  But don”t despair.  There is good news.  Science has identified some things that will  increase your chances of success with weight loss.  Here they are:

1.  Doesn’t matter what kind of eating program you use.  Atkins, Weight Watchers, South Beach, low carb, high carb, high protein- all will cause weight loss.   As long as the calorie intake is controlled.  The key is sticking with it.  Find something you can do and live with long term-like the rest of your life!  Very strict fad diets that you can’t stick with don’t work.  You go off the diet and gain back the weight.

2.  Get regular moderate activity like vigourous walking for at least 150-175 minutes per week.  That is about 25 min per day or 30 minutes 5 days a week. Got to, got to, got to keep moving.

3.  Use portion control for meals.  Learn what a normal portion is.  Meal replacements such as Lean Cuisine  or Weight Watcher- type meals have been found to be effective for this.  It teaches you what 300 calories looks like and  it is all portioned out for you, reducing the temptation to eat more.  To learn more about normal food portions  go to  http://hp2010.nhlbihin.net/portion/

4.  Start with a modest and realistic goal.  Studies have found that even  small amounts of weight loss can have dramatic effects on reducing your risk  for disease.  As little as a 6-7% weight loss makes a differnce. That means if you weigh 200 lbs even a 12 lb loss is important.  Fitting into those jeans may be nice but don’t be discouraged if you don’t get there.  As far as I’m concerned this is not about fashion, this is all about your health.

5.  Monitor your intake of food.  Writing down what you eat has been proven to be effective.  Everything that goes in your mouth.  It truly raises your awareness.

6.   Include behavior modification as part of your plan.    You must change your habits if you are to be successful.  That includes how you think about food, manage your stress  and  how you shop for food.   Also includes getting social support  through a program, friends or family and getting educated about nutrition.  Go on line, talk to your health care clinician, find out about community resources and programs.

There are numerous other tips and tricks that can help with weight management.  I am sure that many of the readers can share some that have worked for them.    Also keep in mind that some medications contribute to weight gain and hinder weight loss.  Be sure to talk to your health care provider about your weight loss goals and what options you may have for  changes in current medications.   If you have been attempting weight loss for at least 6 months without success, this may be a good time to talk about whether you are a candidate for weight loss medication or surgery.  And if you live in the Detroit metro area, be sure to check out our Menopause Support group meetings this month  for more support in reaching your health goals.  Finally, have a happy healthy 2010.

written by Deborah McBain, CNM MSN

I continue to get questions about and requests for bioidentical and compounded  hormones.  Follow this link for a nice summary of the evidence of safety and consenses among medical experts on this hot topic or read the article below.

http://www.medscape.com/viewarticle/711157?src=mp&spon=24&uac=127271SY. 

Question: Many patients ask me to prescribe compounded hormones, which they believe are safer. Some bring in saliva test results, and complicated charts and graphs with a suggested prescription attached. How should I respond?

Response from Susan J. Wysocki, RNC, NP, FAANP President and CEO, National Association of Nurse Practitioners in Women’s Health, Washington, DC

There is no evidence that so-called bioidentical hormones compounded in a pharmacy are safer than other hormone products. Furthermore, unlike insulin or thyroid hormone, female hormones cannot be titrated to customize a formula for an individual woman.^[1] Female hormone levels are very dynamic and no single measurement can capture what the hormone levels might be the next day or even later on the same day. In some circumstances, blood levels may help a clinician understand why a woman might not be responding to therapy.^[1] Overall, however, the woman herself is her own best “bioassay” for determining whether she needs hormonal therapy or when the dosage should be adjusted. Listening to her describe her menopausal symptoms and how well she has responded to therapy gives the clinician the best idea of what is going on in the target tissues.

In January of 2008 the FDA sent warnings to a number of large compounders of bioidentical hormone replacement therapy (BHRT) products, expressing concern about these manufacturers’ claims about the safety, effectiveness, and superiority of their products. In that same memo, the US Food and Drug Administration (FDA) warned about the use of estriol, a weak estrogen that has not been approved by the FDA for use in any product.^[2] Nevertheless, countless Websites, celebrities, other individuals, and pharmacies continue to make claims about BHRT. The FDA considers the term BHRT a marketing term.

Saliva tests are not a valid measure of female hormone levels. Female hormones that are found in saliva do not reflect what might be going on in the target tissues — including the brain, the bones, etc.^[2] It is in my opinion that these tests and products are a waste of money that would be better spent on something like a massage. Again, listening to a woman and what she says about her symptoms is the best way to “titrate” female hormones.

There are several issues about which clinicians should be aware. First of all, compounded products do not come with the class labeling that is mandated for any other menopausal hormone product, including warnings, black box, and other information. The absence of this label places on clinicians the burden of describing to the patient and documenting all these warnings. Second, there is no guarantee of the contents or purity of the compounded products. There is not enough oversight by the FDA to inspect all compounding pharmacies to determine if their products contain what they claim to contain.

Overall, there are no studies that demonstrate the superiority of any hormone product over another — compounded or not. The labels for all FDA- approved menopausal hormones are the same. There are some intriguing data from a case-controlled study of transdermal estrogens (not a compounded product) that suggest that there are fewer associated risks for blood clots even among women who are at higher risk for blood clots.^[3] The results are biologically plausible because of the lack of first-pass liver effect. However, as intriguing as these data are, I caution clinicians about making any absolute statements about the safety of transdermals. We need more data.

A wide variety of FDA-approved products is available to American women. These include oral forms, various transdermal forms, and a systemic vaginal ring. A wide range of doses is available. Many products fit the definition of bioidentical as used by the compounding pharmacies. Most of these products are covered by insurance. Compounding is very legitimate when a patient cannot take or tolerate FDA-approved medicines.

Ultimately, the clinician’s job is to help the menopausal woman ameliorate her symptoms, feel well, and have a good quality of life. The current range of FDA- approved options meets the needs of most women. Compounding claims have been a marketing ploy to seduce women and clinicians into taking or prescribing something for which the evidence of benefit is lacking.

written by Deborah McBain, CNM MSN

This month the menopause support circles are taking on the somewhat overwhelming subject of sex and menopause in our talks titled- “Sizzle or Fizzle.”  I say overwhelming because human sexual behavior and response is so complex.  Although it seems alot of women are concerned about their lack of desire or libido there seems no lack of desire to discuss it.   So we will tackle it the best we can.  Let’s see if we can get some clues to just where the excitement, the romance ,the “sizzle”  went and maybe even some ideas in how to regain some of it. 

It is important to remember that about 22% of all women regardless of age report lack of desire.  After menopause 47% report decreased desire.  But 37%  of post-menopausal women report no change in desire and 10% actually report increased desire.  So I guess I’m just writing to about half of you.  But just in case you have a “friend”  who might need some information the rest of you can read on too.  Although this entry is written from a heterosexual perspective it is easily applicable to any sexual relationship.

Back in the 1960’s Masters and Johnson’s landmark report on human sexuality described a linear model of female sexual response.   That is that sexual behavior starts with desire then  moves to arousal, followed by orgasm and then finally resolution. If only!   At least  it was a start but this model is unhelpful when dealing with much of the real world.   Although it can happen in that straight forward linear way, just between us, you know it often doesn’t.  Particularly if you have been married for say 30 years.  About 2001 a researcher/physician, Rosemary Basson  proposed a cyclical model of  female sexual response.  Her idea is that women often do not feel desire first but make a choice to have sexual contact for any number of reasons.   Actual desire may arise only after stimulation and arousal.   Emotional and physical satisfaction  then provides  more motivation.   This is not as true for men.  As a friend of mine might say, ” Women need a reason, men just need an opportunity.”  But as Dr. Basson might say ” Women’s sexual response is very contextual.”  So just why did that yummy anticipatory desire for sex turn into a desire to do it just to shut him up for a few days.  Well, what are the contextual factors?

Length of relationship- This is a normal consequence of being human.  We crave novelty. Research has found that it takes about a year for the excitement of  a new relationship to settle into routine.   Only thing you can do about that is get creative and find ways to make it new.  I don’t advise starting over for most of you; in a year you will just be in the same boat.

Environment-  If your 25 year old son is camped on the sofa and your mother-in-law is rearranging your kitchen cabinets or the roof is leaking over your bed- it ain’t gonna happen.  Kick him out, send her home, get it fixed.  Is your home safe  and stress free?  If not, why not?

Emotional closeness- Talk.  Plan dates.  Have fun together.  Where’s the romance?  Work on it.

Relationship issues-  Low self image , anger or trust issues may require professional counseling.  This has been found to be a  major cause of sexual dysfunction.  Depression also proves to be a huge issue with low libido.

Inadequate or inappropriate stimulus- Communicate clearly with your partner. Get a book. Get counseling.

Medical/Physical issues-  It really goes without saying that hormonal and physical changes do contribute to decreases in desire.  Certain medications certainly can cause difficulties as do some illnesses.  Limited mobility or partner’s ability to function as well as hot flashes, vaginal dryness and insomnia can really do a number on the libido.  Talk to your care provider.  More often than you might imagine,  medications can be changed or others prescribed to help with problems.     Menopausal symptoms can often be relieved with hormone therapy or even life-style changes. You don’t know until you ask.  

As far as I can figure, it all boils down to this-  How important is sex in maintaining a positive relationship between you and your partner?  If it is important then as you get older, sex is just going to need a little more attention and a little more effort.  Now how is that any different than anything else these days?

written by Deborah McBain, CNM MSN

DETROIT - Henry Ford Health System is harnessing the power of the popular social networking site Facebook to remind women to get mammograms during National Breast Cancer Awareness Month in October. By developing a new Facebook application called Pinky Swear, Henry Ford is spreading the word among Facebook users about the importance of regular mammograms for the early detection of breast cancer. Mammograms are recommended for women after age 40 and if there’s a family history of breast cancer. The application allows Facebook users to send Pinky Swear mammography reminders to friends, along with information about how to set up an appointment.

Facebook users also can sign up to become a “fan” of the Pinky Swear Facebook page to receive news and information about breast cancer from Henry Ford. In metro Detroit, an estimated 154,000 women, ages 40 to 64, use Facebook. For Facebook users who are not in Michigan, Henry Ford hopes Pinky Swear will encourage women to start a dialogue with friends and family, as well as their health care providers, about the importance of breast cancer screening. Facebook users can access the Henry Ford Pinky Swear application at  

Facebook users can access the Henry Ford Pinky Swear application at http://apps.facebook.com/pinky_swear.

 About Henry Ford Mammography:  Henry Ford Health System offers 17 mammography sites throughout southeast Michigan, the majority of which offer online appointment scheduling.

To schedule an appointment, visit www.henryford.com  for locations and real-time mammography scheduling, or call 1-800-HenryFord.  There is also a link to the right of this post.

A physician’s prescription is not needed for real-time online mammography appointment scheduling for women ages 40 and older who require a routine screening mammogram. Patients who schedule a mammography at a Henry Ford location on Oct. 16, National Mammography Day, will receive a pink carnation at their appointment.

written by Deborah McBain, CNM MSN

Seems I’m hearing a lot more about the importance of Vitamin D in the last few years.  And this time of year as the days shorten and sunshine becomes a rare treat, it is timely vitamin to address.  We have long understood the link between Vitamin D and bone health.  Those of you who remember the practice of giving cod liver oil to children  to prevent rickets are witness to this old-time knowledge.  Cod liver oil is an excellent source of nutritional vitamin D.  Since vitamin D is known to help absorption of calcium, menopausal women often are advised to take it with calcium  to help prevent osteoporosis.  Studies now suggest that Vitamin D does a whole lot more than effect the bones.  Low vitamin D levels during pregnancy are being linked to more preeclampsia, low birth weight and premature labor.  Low vitamin D levels in childhood are now being linked to development of  asthma, diabetes and high blood pressure in later years.     A recent study published in the Journal of Nutrition suggests that women with vitamin D deficiencies may have more bacterial vaginosis, a common vaginal infection.  Other research links low vitamin D  levels to higher rates of colon and breast cancer, depression, diabetes, heart disease,  weight gain and chronic pain. Wow!

Chances are that if you live in Michigan you are vitamin D deficientor at least insufficient.  Your risk is even greater if you are older, dark skinned or cover your skin while outside.  Experts in the medical community generally agree that vitamin D deficiency among women is widespread.  Some predict that as many as  70% of white people and 97% of black people are deficient.   Vitamin D is either synthesized in the skin through exposure to ultraviolet B rays in sunlight or ingested as dietary vitamin D.  However it is difficult for humans to get adequate vitamin D from diet alone.  And our Michigan climate and latitude make it difficult to get enough sun exposure.  Then there is the dilemma of increasing the risk of  skin cancer with sun exposure.  Sun screen blocks the skins ability to synthesize Vitamin D.  What is a person to do?

Get your vitamin D level checked.  Ask your health care provider about getting this simple blood test the next time you go for an exam.

Consider taking a supplement.  There is no general agreement about the optimal intake of vitamin D. Some researchers say the current recommended intake of 400 international units (IU) to 600 IU daily is inadequate and suggest a much higher daily intake, from 1,000 IU to 5000 IU.  Cholecalciferol is the preferred form.   It is easily available in any drug store and not terribly expensive. If your blood levels are low your health care provider may give you with a high dose prescription form of vitamin D.  Experts reassure that it is rare and dificult to get too much Vitamin D but check with your care provider.

Include nutritional sources of Vitamin D in your diet.  Look for vitamin D fortified foods such as milk,cereals, orange juice and yogurt.  Other foods with vitamin D include tuna, salmon, beef liver, egg yolks, cheese. ( and of course cod liver oil if you can stomach it)

Continue limited sun  exposure.  (if you can find it!)  Most experts say that 15-30 minutes of sun exposure without sunscreen is reasonably safe.  Getting this amount most days of the week can help boost most peoples vitamin D levels safely.

written by Deborah McBain, CNM MSN