Posts from — May 2010

Summertime is high season for gardening.  Pregnant gardeners need to take extra precautions to avoid chloasma and melasma (dark blotches) on the face and neck, protect backs, knees and pelvic support, and avoid gardening aids that may be toxic if inhaled or coming in contact with skin.  For the full scoop on healthy gardening while pregnant read this piece from www.sheknows.com, including content from Dr. R:

Gardening during pregancy – your skin, your joints, your pelvis, your baby!

(c) Amy Wentz

Dr. Romanzi, 19 years ago I gave birth to my daughter, and while she was being delivered I was torn from my vaginal opening to my anus. The Dr. didn’t repair the torn skin correctly, and I am very self conscious about this. I also have a very hard time wipeing my BM all the way. Is their anything that can be done for this?

Thank K

Dear K,
Even with correct technique at the time of delivery these deep tears often don’t heal perfectly due to the swelling and hormonal changes in skin and deep connective tissues during pregnancy and delivery that result in less than optimal healing from childbirth tears. That said, it is very likely that your anatomy and function can be restored or significantly improved with reconstructive surgical repair of the perineum (perineoplasty) and/or anal sphincter (anal sphincteroplasty). Sometimes perineoplasty alone is enough. Whether one or both procedures might be advised can only be determined through clinical examination, after which various other imaging and colorectal tests might be advised to determine the optimal procedure(s) for your personal situation. It’s been 19 years! Pull this up to the top of your priority list and get the information you need. Thanks for sharing your story. Please keep us posted!

Dr R

Dear Dr. Romanzi,
I recently finished your book and found it quite informative. I had my first baby when I was 35, pitocin-induced with no pain medication. After a short but extremely intense labor, my labia tore off and although the doctor tried to repair it, it doesn’t feel (or look) quite right and seems to flap open all the time. I also feel like my vagina is a wind tunnel, especially when I do yoga–it makes a lot of noises. Ever since the birth I have suffered from stress incontinence but I’m not sure if I have prolapse. Several doctors have told me I am too young for a sling or surgery and simply recommended kegel exercises. I’ve tried kegels and even got the Myself (a biofeedback system) and nothing has improved my incontinence. I am now 38 and 20 weeks pregnant (not planning any other pregnancies). How soon I can get these issues fixed after I deliver? Do you think I am too young for a sling?

Dear Reader,
No one is “too young for a sling”, provided they suffer significant stress urinary incontinence. Two categories of incontinence apply to most women with bladder control problems, those being stress (”exert and squirt” leaking with cough, sneeze, lift, running, etc) and urge (overactive bladder, urination before seated on toilet), and about 1/3 of women with incontinence have a little of both problems.
Kegels are a good therapy for both types of incontinence in about 70% of cases, including mixed stress/urge. Once you’ve birthed the baby, you may be well served to spend 12 weeks working properly wtih a pelvic floor physical therapist rather than on your own with or without a Kegel exercise gadget. It’s like working with a personal trainer, typically yielding better results. If this fails, you may need medications or electric stimulation for urge incontinence, and a sling for stress incontinence. Slings do not reliably improve urge incontinence, an important distinction should a sling be recommended for you – it is likely that overactive bladder symptoms will persist after a sling, with the “exert and squirt” symptoms gone, or significantly reduced.
The vaginal laxity may also respond to Kegel exercise because the exercises can bulk up the vaginal muscles, making for snugger inner contour. If this does not work, reconstructive surgery may be done with or without concomitant sling, and your labum can be repaired at the same time. The exact best procedure for you, however, can only be determined with a proper pelvic support examination and bladder function testing.
Typically, women are advised to complete childbearing before undergoing reconstructive surgery for laxity, prolapse and stress incontinence, since pregnancy after said operation(s) may undo the results.
Thank you for sharing you story!
Best Regards, Dr R

Dr. R, I wrote to you about a month ago. I did decide to go ahead and have the Laproscopic Bilateral(other part of hysterectomy) done. I had the partial in 2000. I had it done one week ago today. I am feeling much better. Little pain in the navel area. Some “hot flashes” ocurring in the early hours of the morning for a few minutes and then they go away. My doctor said that the surgery went well and I am to follow-up with him in about 3 weeks. Dr. R, I hear some women say that they lost their drive for sexual intercourse. Does this happen in all women who have total hysterectomies or does it depend on the female. I am a little nervous about this. I have been married 18 1/2 years and my husband is a wonderful man. What advice do you have now that all my plumbing is gone. Thanks for your previous response to my question in April. I really love your website. God Bless R (Alabama)

Dear R from Alabama,
We are learning more every day about women’s sexuality, and we have found that a variety of hormones definitely contribute to sex drive. Some of these hormones are produced by the ovary, while others come from the adrenal glands (on top of your kidneys) and others come from your brain. Chances are your sex drive will be just fine, possibly better now that the source of pelvic pain is gone, along with the worry. The love and stability in your relationship trumps all, as this is the sexiest of sex drive factors.
Thank you for getting back to us and sharing your story.
Dr. R

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For the latest on vaginal dryness in your 40’s and beyond,  enjoy this guest-blogger entry written for Sweet Talk on the Spot. I’m talking user-friendly vaginal estrogens, over-the-counter lubricants, kitchen myths and the latest from Europe.

WD-40

Dr. Romanzi Talks Lubrication After 40Wednesday, April 21, 2010 by SweetTalk on the Spot

Our resident Vaginal Phitness expert, Dr. Lauri Romanzi, educates the SweetTalk community with answers to your most pressing, personal questions.

Q: Dear Dr. Romanzi, Why do women experience pronounced vaginal dryness after 40, and what lubricants do you recommend for women over 40?

A: Aaaah, the Magic of Estrogen.

First, a little background: Before puberty, estrogen levels in girls circulate at a tiny fraction of normal adult levels. At puberty, the ovaries start cranking out estrogen to full – range, grown woman levels, and stay that way til about age 35, when the slippery slope toward menopause goes gently into first gear.

By age 40-45, fertility, skin integrity, bone density, cardiovascular resilience and even memory can be affected as the reduction in estrogen production accelerates into third gear.  For many women this “Change before the Change” is confusing, because they continue to menstruate, and may even become pregnant, as these menopausal symptoms cavort erratically around the edges of their lives. One month is “normal”, the next nutty with late menses, heavy flow or light spotting, hot flashes, night sweats, aches and pains, insomnia and mood swings in a rollercoaster of unpredictability that heralds the life cycle book-end mate to the process of puberty. My New York City colleague, Dr. Laura Corio, coined this phrase, “The Change Before The Change”, and used it as the title of her book on health in the decade before menopause.

Regarding vaginal dryness and lubrication: The vulva, vagina, clitoris and lower urinary tract skin surfaces contain a high density of estrogen receptors, and as these receptors undergo peri-menopausal deprivation in the early to mid-40’s, many women report uro-genital symptoms.  In the vagina, these may include dryness, poor spontaneous sexual lubrication, reduced clitoral sensitivity, difficulty achieving orgasm, and muted orgasm intensity. And here’s the ironic truth – overweight women tend to fare better because body fat makes its own estrogen, called estrone, that, when present in high levels, minimizes the impact of reduced ovarian estrogen production, called estradiol. Skinny women make very little estrone, overweight women make a lot of estrone. Both skinny and overweight women’s ovaries run out of estradiol between age 35-ish and menopause.

A woman who is sensitive to reduced estrogen production in the 40’s and beyond, sex may be plagued by painful dryness that is often frustrating and confusing, both for her and her sexual partner. With reduced estrogen production, the exquisitely estrogen- sensitive skin of the vulva, vagina, and clitoris literally becomes thin, dry, and brittle. As a doctor, I’ve taken care of many women over the years in stable, happy, sexually active relationships who come in to the office utterly mystified by these symptoms, with partners convinced that the women don’t love them any more or accuse them of having an affair. so abrupt and intense can be the sexual impact of estrogen deprivation.

My favorite treatment option for hormone-related vaginal dryness is … hormones: Recoil not, as this does not mean total-body-dose (a.k.a. systemic) hormones. You can use ultra-low-dose vaginal estrogen therapy that rejuvenates the vaginal skin to youthful elasticity, sensitivity, and lubrication. It does this by making those poor, deprived estrogen receptors in the vagina, vulva and clitoris happy.  There is not enough estrogen in these local estrogen treatments to increase estrogen blood levels, and there is no evidence that they increase cancer risks, as some total-body hormone regimens might. Ultra-low-dose vaginal estrogen therapies come in cream (fingertip application), suppository (vaginal insertion) and ring (vaginal insertion 4 times per year) form.  I shared this low dose vaginal estrogen information on the Dr. Oz show a few weeks ago.

Lubricants help with dryness, but will not improve elasticity or sensitivity. The best lubricants are water soluble and paraben free. Glycerin-free lubricants are best for women who cannot tolerate this additive, and silicone based lubricants require less re-application. Lubricants contain no hormones.

Oils and herbs are purported to reduce vaginal dryness, however clinical trials thus far fail to demonstrate efficacy, and oils may throw off vaginal pH or turn rancid, ultimately causing vaginal irritation and possible increased risk of vaginitis.

Several of my European patients are using hyaluronic acid vaginal suppositories, which are not available in the U.S.  These novel vaginal ovules help maintain cellular hydration, and are marketed both for post-operation healing and menopausal dryness.  Given that these ovules contain no hormones, it is likely that this product will not improve sensitivity, but would restore lubrication and thereby improve elasticity.  Catch the red-eye to Paris and let us know if it works for you!

Back to lubricants before I finish: The shop shelves buckle under the voluminous assortment of 21^st century sexy lubricants with additives designed to improve blood flow, enhance sensitivity and super-charge orgasm intensity.  Marketing trials are not the same as scientific, clinical trials published in peer-reviewed medical journals, and it is not clear that the robust marketing claims are born out in the bedroom. That said, if these pumped-up lubricants rock your world, are paraben free and water soluble, have at it!

Dear Dr. Romanzi,
(I bet you don’t get too many men writing you for help!) My dearest sweetheart suffers from a prolapsed uterus/bladder and is considering having a hysterectomy at the advice of her gyno. Being a former pre-med student and having seen what my mother and sister-in-law went through in their hysterectomies (cancer related…) I keep trying to convince her that this a radical surgical approach for a problem that demands far less. She has had 2 children, is 52 years old and is physically active. However, “the bulge” is causing her discomfort in her exercising and she is talking more and more of the hysterectomy. I am ordering your book tonight, but in the meantime had some questions… 1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work? 2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery, and 3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure. If the former, what does it typically cost? She is a women of limited means and this obviously comes into the equation. Thanks so much for your help. D

Hello D,

Thank you for writing in – I know there are more men out there trying to help the women they love, and your willingness to post your questions will undoubtedly help other men actively advocate for the health of the women in the lives.
1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work?
She may do perfectly well with a pessary and I often advise pessary use before any other therapies are considered. But some women cannot be fit with comfortable pessary or a pessary that truly holds it all in due to the severity of prolapse (the worse the prolapse the more difficult to find a well fitting comfortable pessary) or idiosyncracies in the boney pelvis that make pessaries uncomfortable, in which case the next option is reconstructive surgery. Some women may be fitted for a pessary that works perfectly well, but they find it annoying or “unsexy” to use, in which case it may be worn until she has time to undergo reconstructive surgery and it’s recuperation (~4 weeks to return to work, 6-8 week til sex is possible). Pessaries that fit well physically and jive with lifestyle and body image provide an excellent non-surgical therapy for prolapse.
2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery,
The major university medical centers all have urogynecology divisions run by fellowship trained specialists – these are a good place to start. You may want to obtain several opinions should you choose reconstructive surgery.
3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure
Prolapse surgery is the same as any other reconstructive surgery, be it a hernia, a knee repair or a rotator cuff repair. While not an emergency, it is a recognized condition that insurance companies do not consider cosmetic.
Finally, hysterectomy does not improve the durability of prolapse surgery, and she DOES NOT need a hysterectomy to benefit from excellent long term (hopefully life-long) results should she choose to undergo reconstructive pelvic surgery. Recurrence is possible with any and all reconstructive operations done anywhere in the body by any technique, and prolapse repair is prone to recurrence in the same way hernias may recur and damaged knee ligaments may not last forever after knee surgery. Reconstructive surgery puts things back together, unlike extirpative surgery that takes things out – appendix out, guaranteed you’ll never have to have it removed again! Hernia surgery – might need another one someday.
In order to help women understand the causes, therapies and surgeries for prolapse, I wrote PLUMBING AND RENOVATIONS as an in-hand resource for women with prolapse and/or incontinence (www.plumbingandrenovations.com). She may find this book a helpful guide as the therapeutic options are considered. Thank you for writing in and please do keep us posted.

Best Regards,
DR R

Likewise, I am 43 and going through the same situation. I had a partial hysterectomy in 2008. For the past two months and currently, I am experience right side pain, and it has been diagnosed as ovarian cyst. The pain stopped for about two weeks, but now it is starting again. Does the cyst rupture and reoccur?

Hello GM:

The ovarian cyst could be de-compressing, leaking cyst fluid as it does so, and this fluid can cause severe but transient pain that is not a sign of damage. Or it could be twisting (this is called ovarian torsion) which IS dangerous and does require close follow-up and may well require surgical intervention. Or the cyst may be growing larger or may be infected, again both requiring close follow-up and intervention. You must report all these symptoms to your doctor immediately as the develop, as I trust you have done.

Best Regards,

Dr R

Plumbing and Renovations was written to demystify prolapse and incontinence. For starters, if you have prolapse, you do NOT need a hysterectomy, even if your uterus (take the kids out of the room) is hitting your knees.
A few reviews from readers:
1 of 1 people found the following review helpful:
5.0 out of 5 stars Informative and a surprisingly easy read!, December 26, 2008
By L. Y (New York, NY) -
This review is from: Plumbing & Renovations (Paperback)
This book truly saved me! After 2 opinions that I should get a hysterectomy, I found an alternative and am now working on my second child! After having my first, I needed help getting my pelvis back in shape. An incontinence issue acquired during my pregnancy also needed addressing. This book spelled it all out for me and with its amazing illustrations and information, I have seen a real improvement all of the way around.
I am hoping to see more of these “Beauty Call” books from this author, as I think they touch on subjects rarely addressed, in a thorough, concise and amusing way. Kudos! <

5.0 out of 5 stars Finally! An intelligent (and hilarious) surgeon, April 7, 2009
By EG “never_enough_books” (Athens, Greece) -

This review is from: Plumbing & Renovations (Paperback)
Ladies, if you have a dropped uterus (you’d be surprised how many women do) read this book first! You probably don’t need a hysterectomy. You also want to read this book if you suffer from a dropped bladder, your vagina is loose, or you want to know what treatments are available to, among other things, improve your sex life. Eminently readable, informative and wise, this book should be issued as a textbook for sex education classes, so thoroughly does it cover the subject of the female anatomy. Dr. Romanzi, I Kegel as I write this. Thanks!

5.0 out of 5 stars A hilarious entree into what your mom forgot to tell you – or never knew, December 30, 2008
By A G (New York) -
This review is from: Plumbing & Renovations (Paperback)
A friend gave me this book and I was SHOCKED by what no one – not your mom, not your doctors tell you. I learned more about my body from this book than I ever could have imagined. Plus, its a riot. It should be recommended reading for women.