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Is This Normal? OB/GYN Edition

Lauren Streicher, MD on Hot Flashes, Incontinence and Sex

“Is this normal?” is one of the great preoccupations for patients of all shapes, sizes, ages and genders. It can be the reason you made the appointment, and yet you walk out without even asking. Almost every physician knows the kind of question and they’re more than prepared to explain what you may be embarrassed or uncomfortable to say.

Gynecologists in particular have a vast experience with the awkward ask, working as they do in a field that remains highly private and to a certain degree, taboo.

“I call them hand-on-the-door-questions – questions that women are too uncomfortable or feel too rushed to ask until the doctor's hand is on the door and they realize it is now or never,” says Lauren Streicher, MD, a gynecologist and sexual medicine expert at Northwestern Medicine who consults with patients on sexual health, menopause and complex gynecologic problems. “While you might think your problem is unique and beyond humiliating, your gynecologist has doubtlessly heard it many times and regards it as standard fare. Trust me, it’s virtually impossible to shock your gynecologist.”

In her own words, here are a few of the concerns Dr. Streicher hears most from women over 40 – and how she routinely responds: 

Since I stopped menstruating, I have been flashing about 20 times a day and have not had a decent night’s sleep in a year. When is this going to end?

While some women think they will just "tough it out" we now know that flashes can last ten years or more. For some women, hot flashes are extremely debilitating. The woman who flashes twenty to thirty times a day can’t sleep or get through a business meeting without sweating through her clothes.

Estrogen, even in very small doses, is the most effective treatment of hot flashes and sweats. Estrogen, prescribed appropriately, not only works, it works quickly and safely. Women who start one of the many oral or transdermal estrogen options generally experience relief within the first few weeks of treatment. If you choose not to take estrogen or have been advised by your doctors to steer clear, there are non-hormonal options as well so put your fan away and make the call.

I am 42 years old and had a heart attack last year. My cardiologist has not mentioned much about sex other than I am "good to go,” but my husband and I too terrified to try.

In one study, 71 percent of women avoided sexual activity after a heart attack specifically because of their own fear or the fear of their spouse. It’s reassuring that having sex with your spouse in your own bedroom involves the same amount of exertion as a leisurely stroll on a level surface for a few minutes and studies show that sexual activity is rarely responsible for a myocardial infarction. Risks are even smaller in men and women who are routinely sexually active and have regularly participated in a post-heart-attack exercise program.

My new partner and I attempted to have sex a couple of times, but it was too painful, so we stopped trying. Lack of lubrication is not my problem. Is something wrong with me?

This one requires a trip to the gynecologist. If everything is anatomically normal, one possibility is vaginismus, a condition in which vaginal muscles spasm when you attempt to have intercourse. There are many reasons why women suffer from vaginismus, but it’s particularly common in women who have a history of painful sex in the past. Essentially, vaginismus is a defense mechanism: the vagina clamps down in an attempt to protect itself from further pain. 

This is a curable condition. Gynecologists generally work in conjunction with pelvic physical therapists and psychotherapists in order to identify and eliminate both physical and psychological causes of an inability to have intercourse.

Every time I cough or laugh a little urine comes out. I do Kegel exercises all the time, but it doesn’t seem to help. Is there anything that actually works?

Approximately 80 percent of the estimated 15 million women who suffer from stress incontinence do nothing about it because they assume that it is a normal part of having a baby or of aging. But common is not the same as normal, and just because something is common does not mean you have to live with it.

Kegel exercises are commonly recommended to strengthen the muscles that support the urethra and bladder, but uncommonly solve the problem since most women are not able to do them correctly or consistently. Working with a pelvic floor physical therapist makes a huge difference, but many women don't have the access or time and prefer to do something on their own. Several pelvic floor-strengthening devices that use the principles of pelvic floor physical therapy are available to consumers and are good home treatment options.

I am a breast cancer survivor and since I finished my chemotherapy, my vagina is extremely dry. I tried a lubricant, but it didn’t really help. My doctor said it is safe to use some estrogen, but I am worried it might give me cancer. Are there any other options?

First of all, all lubricants are not created equal. If you have been using a water based lubricant, try a silicone based. If tissue is very thin, even the best lube won’t do the job. 

Your doctor is right: It is perfectly safe to use one of the local vaginal estrogen products and it will not cause a recurrence of your cancer. That said, many women, despite those reassurances, would prefer another option.  One over-the-counter option is Replens™, a long acting moisturizer that if used twice weekly increases lubrication and elasticity. At Northwestern Medicine, we’re one of only a few facilities to offer a five-minute laser treatment procedure in which a gynecologist places a slender wand in the vagina that painlessly treats the vaginal walls to restore lubrication and elasticity. That offers women another non-hormonal option to vaginal dryness.

I lost my husband a few years ago and recently started dating a great guy. We are ready to take it to the next step but he tells me he can’t use a condom because he will lose his erection. I’m 55 and not worried about pregnancy. Am I taking a big risk?

Most of my patients seem to think that sexually transmitted infections (STI) are limited to the 20- and 30-year-olds. However, women who are postmenopausal are at particular risk since vaginal tissue is thinner and more likely to tear during intercourse, allowing infection an easy portal. That’s why adults at midlife and beyond are the age group for which STI rates are rising most rapidly. 

Both partners should get an STI screen before engaging in unprotected intercourse. Be sure to request an STI screen (it is not automatic!) when you see your gynecologist. Since HPV, the most common STI, is not included in screening, also request a Pap plus HPV test.

I’m concerned about my vaginal odor. What’s normal?

Many women have concerns about the way they smell. Vaginal odor is often the result of unbalanced vaginal pH. Many things, including menstruation, sex, menopause and douching can cause pH imbalance.

If there truly is an unpleasant odor, the most likely culprit is bacterial vaginosis (BV), an imbalance of vaginal bacteria resulting in a watery grayish discharge with an ammonia or fishy odor. A prescription medication is used to treat BV. One of the frustrating things about bacterial vaginosis is the high recurrence rate. Thirty percent of women have a second episode within three months of treatment. If you are prone to BV, Rephresh™ is an over-the-counter product available to help maintain a normal vaginal pH and keep things in balance.

What are some other causes of a less-than-pleasant odor? If there’s a really strong smell, make sure you haven’t left a tampon inside. (It happens more than you think!) Sometimes even a new vitamin pill or change in diet can cause a funky-smelling discharge.

Have a hand-on-the-door question of your own? Learn about scheduling a consultation with Dr. Streicher and sign up for updates from the Northwestern Medicine Center for Sexual Medicine and sexual health education events.