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Ask the Experts
Our experts Dr. Mary Jane Minkin,  Dr. Mache Seibel,  Nurse Barb,  Dr. Michael Goodman,   Dr. Verna Brooks-McKenzie, Dr. Murray Freedman, Francis Barbieri, Jr. DDS, Liz Allen, Dr. MeLanie Modjoros,, Dr. Natalya Danilyants, Dr. Paul Mackoul, Dr. Barb DePree, Pam Rand RD, LDN, CDOE, RYT, Dr. Rupen Baxi, and
Karen Giblin field questions from our members.
Submit your question.

Your Questions Answered
Dear Red Hot Mamas Experts,

Acne was not only problem as a teenager, now it's even a bigger problem at menopause.  Help! 

Can you offer some suggestions?  

Thanks.
Lorraine

Dear Lorraine,

Thank you for writing to our experts.

Over 25% of women in their 40's, and 15% of women older than fifty battle adult acne.  Adult acne can be caused by hormone fluctuations, stress and may be heredity. 

Here are some suggestions to help with the problem:
  • Unclog your pores to prevent pimples and clear out blackheads.   Use a salicylic acid-based cleanser twice a day in the morning and evening.  This will help scour your pores and reduce pimples from forming.
  • Kill bacteria and reduce excess oil.  Look for products with benzoyl peroxide which can help with excess oil.
  • Increase cell turnover with a prescription product such as tretinoin. 
  • Use a non-oily makeup, sunscreen or moisturizer.
  • Always remove makeup before going to bed.
  • Keep your hair off your face and avoid resting your hands on your face.
  • Don't manhandle those pimples.  Talk to your dermatologist about effective ways in handling pimples.
Thank you for writing to us.
For the newest and latest menopause information visit www.redhotmamas.org
FROM THE EDITOR...KAREN GIBLIN 
"The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed."
           - Carl Jung

Dear Red Hot Mamas,

If you have ever experienced hot flashes, mood swings, and have had other added stresses in your life at menopause, you know how much of a toll it places on family and personal relationships.  Staying calm and collected isn't always easy and it causes problems even in the healthiest of relationships. 

As our estrogen levels decline at menopause, it has an impact on regulating our moods.  Many of us feel fatigued due to hot flashes that keep us awake in the night; we also may become irritable; anxious and even have difficulty concentrating.  All of these things may make it difficult to deal with our relationships. 

However, during this trying time in our lives, it's important to communicate with your loved ones and stay connected.  Friends and family can provide comfort, support which may help to influence a better menopausal health outcome by their ability to express their compassion and love to you.  So, it's important to not isolate your feelings at menopause, but to be open about what you are experiencing in an effort to stay connected to these important people in your life. 
Strong social ties to our family, friends and other social connections are even linked to a longer life.  In contrast, isolation and loneliness are linked to poorer health, depression and even an increased risk to early death.  So, even though it might be a challenge for you at menopause due to its accompanying symptoms, you should try to take charge of your relationships and put some time and energy to make them work. 
 
Involvement with others can clearly have a very potent, very positive effect on your health.  

Here are a few suggestions to help you feel better; improve your relationships; and get involved with others:
  • Exercise regularly and only eat healthy foods
  • Find your inner calm by taking a class in yoga or tai chi, meditation, deep breathing exercises, etc. 
  • Join a group focused on a favorite hobby, such as reading, hiking, painting, or wood carving
  • Engage in outlets such as taking up a new physical sports activity to help you feel better
  • Help with gardening at a community garden or park
  • Volunteer at a school, library, hospital, or place of worship
  • Join a local community group or find other ways to get involved in things you care about
  • Avoid alcohol as it is a depressant and it may have an effect on mood changes
In closing, try to work and build your relationships at menopause.  Relationships require attention and care and are an important aspect to your well being at menopause.

Good Health to You All,
 
Karen Giblin

THESE CAN BE THE GOLDEN YEARS
   
Contributed by Dr. Barb DePree
Red Hot Mamas Medical Expert
Sex after menopause can be challenging. My work life--both in my practice and through MiddlesexMD, the company I founded--is dedicated to addressing those challenges. I spend a lot of every day talking about topics like dry vaginal tissue, pain with intercourse, and loss of libido.
But for once, let's turn the picture on its head. Let's look at postmenopausal sex from the sunny side of the street.
Sure, menopause isn't for the faint of heart. It's a hormonal roller-coaster with a chaser of unpleasant side-effects. Sex can become collateral damage during all the turmoil.
But the big picture? The view from the top of the hill? Not so bad at all. In fact, depending on your inner resources and resolve, both sex and life after the big M can look pretty darned sweet. Some women even report experiencing a resurgence of desire, sort of golden age of postmenopausal sex.
Several elements tend to coincide during those postmenopausal years that contribute to a more serene, predictable life and the potential, at least, for a renewal of romantic zest. For example:
  • More time; less stress. Retired or not, you're probably past actively building a career. The kids are independent and maybe out of the house. You aren't completing financial reports while sitting at basketball practice. You can linger over a pinot grigio and actually listen to the Tchaikovsky Concerto in D Minor without the distracting din of kids fighting.
  • No periods; no pregnancies.A lot to celebrate here. The years of birth control (and worry about the Whoops! factor), the discomfort and nuisance of menses-all in the rearview mirror. You can sleep in and take the triple gatehook locks off the bedroom door. Canoodling can last as long as you want.
  • Financial freedom. Generally speaking, the hamburger years are over. You can afford steak, a night out, a nice bathrobe, or even a romance-inducing cruise. All of which can make you feel relaxed, sexy, and vital-and more connected to your honey.
  • Fewer crazies. As the hormonal ride levels off, you'll feel more stable, mature, and confident. You know what you want, sexually speaking and otherwise, and you know how to ask for it. You're coming into your own-no one is the boss of you.\
  • Synchronicity.With maturity, the sexual needs of men and women tend to converge. Men slow down and value emotional connection. Women become more assertive. It can be a great time for playful exploration on all levels. 
Granted, aging comes with challenges, and they can be unpredictable. But growing older and staying sexy is more about your attitude, and the resources you bring to bear than what's happening below your neck. "So here's the big reveal," writes Barbara Grufferman in "Sexy after 50." "After 50, we're at a sexual crossroads, and need to make a choice: We could go through menopause, shut down that part of ourselves, lock the door and throw away the key. Or we could embrace this new life with a sense of freedom and fun..."
So that's the thing: it's a choice. There are no wrong answers (unless they hurt your partner); instead, you have lots of options. Barriers to good sex are very fixable, both for men and women.
Here's a list of simple things you can do to enjoy these golden sexual years:
  • Preheat the oven. You are responsible for your own arousal, so get to know your body and what it likes. Read erotica. Play with toys. Then teach your partner. Don't wait passively for Prince Charming to ring your chimes.
  • Just do it. Sometimes you have to begin in order to get aroused. Start the kissing and cuddling. It's quite possible that your brain will catch up. "If you've been ignoring, neglecting or denying your sexual self for a while, then you must consciously decide that you want sex in order to even let yourself feel desire," writes Grufferman. 
  • Sex leads to more sex. "Women who have regular sexual activity have less sexual dysfunction [and fewer] complaints," says Dr. Madeline Castillanos, a psychiatrist and sex therapist in New York City. It's that "just do it, you'll like it" thing again.
  • Take your time. You don't have to hurry, and you don't even have to please your lover. Turning you on is a big turn on for him, too. So you can relax and let go of the worn and useless sense of duty about getting him and yourself off expeditiously.
  • Engage in outercoursesays Dr. Sheryl Kingsberg, a psychologist with University Hospitals Case Medical Center in Cleveland. Involve all the senses; practice luxurious, languid, voluptuous sex that may or may not actually require penetration. Most of all, have fun doing it.
According to the experts, the most dependable predictor of good sex after menopause is good sex before menopause. And if it wasn't so great before, time's a-wasting. You can apply your hard-won life skills and your intimate knowledge of your partner to begin addressing the issues that stand in the way of intimacy and a solid sex life. 
Dr. Barb DePree gynecologist, NAMS certified menopausal provider and founder of the website middlesexmd.com
A BRIEF TOUR OF THE CAUSES VAGINAL AND VULVAR PAIN 
Contributed by Dr. Michael Goodman
Red Hot Mamas Medical Expert
NB: This will by no means be exhaustive, and is meant for introduction and entry-level information only. It is "...a place to start" for women experiencing pain & distress involving their genitals. For more information, use the search terms "dyspareunia" (painful intercourse), vulvodynia, "vulvar pain syndromes," etc., and visit the NVA (National Vulvodynia Association) website, http//www.nva.org... This is a list of causes only. Each of these issues has an excellent treatment(s), some relatively rapid, but most taking time and a knowledgeable physician and willing patient. Therapeutic options will not be discussed here, as these require a consultation and workup with a therapist knowledgeable in diagnosis and therapy of vulvar pain syndromes.
 
Causes of vulvar pain, aka "Vulvodynia" (pain outside of the vagina)  
[The Vulva encompasses the labia majora, labia minora, vulvar vestibule (the area just outside of the vaginal opening) perineum, and clitoral area]
 
1.       "Vulvitis" is pain secondary to infection (bacterial or viral) or inflammation caused by infection or an agent (powder, allergy, irritant, trauma, too low hormonal levels, etc.) causing secondary inflammation. Vulvitis is treated by removing the irritant, if any, treating symptoms with anti-inflammatory agents (topical and systemic) and occasionally with anti-bacterial or anti-viral agents.

2.       "Provoked vestibulodynia" (...used to be called "vulvar vestibulitis") This is pain in and around the vulvar vestibule, that area of the vulva just outside of the aginal opening, truly the "vestibule" of the vulva. While the pain may be considered "allodynia," or pain "...just everywhere" around the vestibule, usually most if not all the pain is in the areas of the vulvar vestibular gland openings, from 2/3:00 to 9/10:00 on the clock face just outside of the hymenal ring. This is pain provoked by touch, thus making insertion of anything (tampons, fingers, penises, toys...) distinctly uncomfortable to painful.

3.       "Unprovoked vestibulodynia (used to be termed "dysesthetic vestibulodynia") is burning/itching/pain that is "...just there" and not provoked by touch, although it may become more severe with touch, rubbing/chafing. It can be either localized or generalized throughout the vulvar vestibule, in which case it is termed "allodynia."

4.       Neuropathic pain may be post- viral (herpetic) or post surgical (after childbirth or labial surgery-related scarring.) Herpes genitalis settles into the nerve roots of the vulvar area, where it runs its course and then lurks inactive in the nerve roots where it periodically erupts every month, 3-6 months, annually, or never. So-called "scar tissue" may form in areas of childbirth laceration, or "iatrogenic" (physician-caused) injury secondary to injudicious labiaplasty surgery with removal of either too much tissue, or incisions too close to the clitoral glans. The responsible scarring "tugs," either superficially or deep, on sensitive nerve fibers just under and deep to the skin, producing pain.

5.       "Atrophic pain" is pain, usually just at the introitus or vaginal entry (in the "vulvar vestibule & sometimes out onto the perineum) secondary to long-standing low-hormone-caused atrophy, or thinning of the skin. These changes virtually never happen to hormonally complete post-menopausal women (those on HRT or consistent about using vagino-vulvar area estrogen therapy,) but are not uncommon in postmenopausal women not using local or systemic HT consistently. This can be burning; it can be sharp, and is from the thin skin and the chronic little "paper-cut" fissures that develop either spontaneously or from lovemaking.

6.       Psychodynamic issues can potentially cause vulvar pain. Vulvodynia is considered by many to be a "functional pain syndrome," along with interstitial cystitis, fibromyalgia, irritable bowel syndrome, some forms of migraine, etc. These very real pain syndromes are regulated via the "autonomic nervous system," that part of the nervous system that in not under conscious control, but which is strongly influenced by [sometimes deep-seated] emotions. (**see http://www.drmichaelgoodman.com/what-is-functional-pain-syndrome/ )

Causes of pain inside the vagina:  
The vaginal skin itself, termed the "vaginal mucosa" has no nerve endings for pain via pinching or cutting. An examiner can pinch it, cut it, biopsy it and the woman will feel little or no pain. However, the structures under the skin (muscles, fascial planes) do have both skeletal (under conscious control) and autonomic (not under conscious control) nerve supply and respond to stretch (including pain when the fascia & muscles are atrophic and cannot stretch), and to scarring and injury. Structures deep to the vagina inside the abdominal cavity (uterus, tubes and ovaries) also have pain receptors, and stretch, compression/expansion or inflammation of these organs can produce pain that can masquerade as vaginal area discomfort.
 
Causes of Dysparunia (painful intercourse): 
As this is an essay on vulvar and vaginal pain issues, the many intra-abdominal causes of pelvic pain are not covered here. Intra-vaginal causes include "stenosis," where the diameter of the vaginal canal is too narrow, vaginal dryness/chafing, usually from too-low estrogen levels. Vestibular and perineal causes are also atrophic, and involve thinning or the skin and small liner fissures.
 
Vulvar Dermatoses (not strictly painful, but these skin conditions are a source of consternation and often secondary pain...)
1.       Lichen sclerosis (used to be known as "white dystrophy.) "LS," as it is commonly termed, is an insidiously progressive atrophic skin condition of uncertain etiology (? Genetic; ? psychogenic; ? viral-really uncertain...) that involves the vulvar skin, especially the vulvar vestibule, labia, and clitoral hood, slowly and progressively causing atrophy, shrinkage, and gradual "disappearance" of these organs. During this process there are "flares" and remissions, but, unless aggressively treated, tissue shrinks and lost, never to be regained. When active, the disease can promote severe itching. There is good treatment for the itching and significant inflammation, but therapies have been less-than-successful for the shrinking and overall atrophy and flattening that eventually occurs, especially if prompt aggressive therapy is not undertaken. Unfortunately, many women wait until too late to go to competent clinicians, or are "on & off" with their therapies, and the condition progresses.

The "tried and true" therapies consist of potent anti-inflammatory topical medications, plus local hormonal therpy, but new hope for LS sufferers is presently being utilized in the form of PRP (platelet-rich plasma) injections, and topical fractional CO2 laser re-surfacing.

2.       "Red Dystrophy," or Lichen Planus is another dermatosis or inflammatory vulvar dystrophy involving severe inflammation of the lower layers of vulvar skin with severe reddish inflammatory changes and pain involving the vulvar vestibule, perineum, and vaginal opening. It must be distinguished from lichen sclerosis, as treatment differs. While frequently the proper diagnosis is obvious to the experienced and trained eye, the "gold standard" for diagnosis involves a careful biopsy of the inflamed area, interpreted by a pathologist specially trained in evaluating vulvar skin conditions.

3.       Pre-malignant and malignant changes can involve the vulva and occasionally are painful. Likewise, HPV can involve the vulva in the form of "genital warts" which can prove painful if they are damaged during sexual or athletic activities.

Dr. Michael Goodman specializes in labiaplasty and other vulvovaginal aesthetic surgeries, peri- menopausal and sexual medicine, lifestyle enhancement, bone densiometry, pelvic ultrasounds and both routine and difficult gynecologic issues.Stanford University trained in obstetrics and gynecology, Dr. Goodman is also a critically acclaimed author and pioneer in the development and advancement of Minimally Invasive Gynecologic Surgery. Through his private practice and writings he focuses on patient education and involving patients in the therapeutic decision-making process.
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