Transcription
You hear people say, “Use it or lose it.” So, is that true? If you don’t stimulate the clitoris, will it atrophy? Will it become smaller and less sensitive?
So, in general, with the genitals—and I think this is more after menopause—like we talk more about the changes that can kind of go through, more like the vagina. If you aren’t sexually active after menopause, you can have changes in the quality of the tissue. The vagina can become more narrow and a little bit, um, more tight, and you kind of lose the folds and like the moisture of the vagina. So, definitely, people, if they aren’t having penetrative intercourse, can have narrowing; they can have, um, you know, more pain if you try to be sexually active if you haven’t used it. So, you know, you hate that expression of like, “Use it or lose it,” like you make it sound like it’s like irretrievable, like, you know, if you don’t use it for a few years, like there’s no going back.
There are times that we can, uh, especially with things like pelvic physical therapy or use of dilators, to, you know, uh, increase the diameter of the vagina again if you have, haven’t been sexually active for a while. We have, obviously, um, vaginal estrogen, which you and I are both huge fans of, for postmenopausal patients to help improve tissue quality and elasticity.
Um, in terms of sensitivity, it’s actually interesting. I think of it more almost like the kind of the flip side is that if you are stimulating it more, you do have improved sensation and responsiveness. So, there are interesting—I didn’t realize this before a few years ago—there are actually great studies on things like use of vibrators on people who have issues with like arousal sensation, and you know, I love that there are research studies on that, but it really has shown that sometimes if you haven’t been using the clitoris for a while, you do feel like you’re like, “I’m not really getting great response from,” you know, even if I try and touch it or my partner is touching it. You can, with time, with things like using potentially like vibrators or suction devices and toys, increase and improve your responsiveness. Yeah, there are suction devices that actually, um, similar to a vacuum erection device, cause increased blood flow to the clitoris, which may help in those cases.
And I think I want to go back to the talk about having sex. I think that, you know, the studies that show that are probably somewhat self-selected, right? The people who go on to have sex probably have less hormonally related changes to their vulva, and so their sex is more comfortable for them, whereas probably the women who end up having these changes have less hormones, right, just at baseline, so sex is uncomfortable, so they’re not going to have sex, right? So, I suspect there’s probably some of that. And if your partner is having pain with sex, that, you know, that should be addressed, you know, rather than saying, “Oh, we need to have more sex.”
Yes. Yeah, and this is so important because a lot of times people will come to the office and they may say, you know, “I just have no libido at all,” and then when you kind of talk to them and you really, you know, ask about what they’re going through, they’re having painful sex. And then I tell people, like, “It makes sense. Like, who’s going to want to have sex if it’s so painful? It burns; it, you know, it’s just excruciating.” I’m like, “It would be crazy if you wanted to have sex.” So, sometimes people coming in for questions about libido, it’s actually, when you go back, it’s a problem with pain, and then you can kind of go and and try and fix all of the issues, both the interest and then also the physical, you know, discomfort. So, yeah. And sometimes they won’t tell their partner; that’s the other thing is they they don’t want to hurt their partner’s feelings, so they’ll just avoid sex, right? And then their partner’s frustrated because they’re getting rejected all the time, and they are just feeling like, “Well, I don’t want to be in pain,” um, but they never say, “Hey, it hurts,” right? And this is again, it comes down to like, we don’t know how to talk about sex. I say all the time, but we don’t know how to talk about sex, so we never tell our partner when something’s wrong, and then it leads to all these misconceptions, like, “Maybe my partner’s not into me; maybe they just they never want to have sex anymore; sex is important to me,” all these different things.
Exactly. Yeah. So, when people come to the office to ask about this, I always say, like, there’s a communication aspect. Like, people come in thinking, “Well, we’re just going to get like hormone replacement therapy or testosterone and, you know, like Viagra; there’s going to be a physical response, and that’ll be it,” but so much of it is it’s communication; it’s about talking about your needs, what you’re going through, your concerns, and, you know, clearing the air so that you can then focus on, you know, the pleasure and the experience.
So, absolutely. Let’s talk about periods. So, there are all these weird symptoms, and some of them I had never heard of until I binged your content recently. Um, so I knew diarrhea, but butt pain, leg pain, and obviously pain in general, but why do women get this variety of symptoms around menses, and what can you do about it?
Yeah. And so, you know, the first question is, you know, what’s normal? Because a lot of people say, “I have this; is this normal, or is this something to worry about?” So, in general, if we always say if something happens like occasionally, it’s not bothering you, like that could be normal. So, it’s very common for people to have some degree of changes of their bowel function around their period. So, very common for, uh, constipation kind of leading up to the period and then maybe some loose stools during the period. We call it “period poops.” It’s because of something called prostaglandin, which is like a hormone that causes the poop to get a little bit looser, and it also causes uterine cramps. So, prostaglandin can make your uterus cramp and can make your bowels kind of move a little faster. And then the uterus is sitting right near nerves that run down to your legs, and also the uterus has two ligaments that run to your back. So, a lot of times people will feel back pain or they’ll feel pain that goes down their legs. If you’re having that and it’s really severe—you’re like, “Oh my God, like I’m having the worst back pain; like I can’t move; I can’t exercise”—that’s where we get concerned because all of those symptoms can also be signs of endometriosis, which you we talked about is probably one of the most common causes of really painful periods, also pain with sex, also pain with bowel movements because the rectum is right next to the uterus can get inflamed.
So, what endometriosis is, just to kind of take a step back, um, it’s a condition where tissue that looks like the tissue that normally grows inside your uterus—that’s what comes out like period blood—grows outside of the uterus and can inflame everything near it, causing pain and like functional issues. Like I said, very common for people with endo have really painful periods, pain with sex, diarrhea, um, pain with bowel movements, sometimes like bladder issues like urgency and frequency that gets worse with ovulation or periods. So, a lot of your listeners are probably saying, “Oh my God, I have all those things,” because a lot of times people have all these things and they’re told they’re normal, even though it’s, you know, keeping them from going to school, going to work, having sex, doing all these things—that’s not normal. So, having all of these things to the degree that they’re affecting your ability to function or to do the things you want to do in life, like exercise, have sex, go to work, that is something that you should talk to your gynecologist about. Too often women are told, you know, “That’s just periods; everyone has that,” and that’s not true.
The butt pain, interestingly, one, it could be from endo because of the rectum being right next to your uterus, or sometimes people get pelvic floor spasm, so the muscles of your pelvic floor can kind of seize up really quickly, get kind of like a shooting pain that, you know, feels like they call like lightning bolt—like it feels like a sudden stabbing pain. Again, if it happens like super rarely, every once in a while—men get it too, obviously—you don’t, you know, it’s not just from endometriosis. Again, if it’s happening all the time with every period or most periods, then talk to your doctor.
Yeah. And I think this is a really common issue because I’ve had patients who are like, “Yeah, I have these horrible periods, but my gynecologist told me, ‘Well, there’s nothing really to do about it,’ or ‘Here’s some birth control; try this, and we’ll see you later,’” which I think is a real problem.
Yeah, absolutely. It’s so many things; it’s not just periods; it’s not just endometriosis, but also like menopause, perimenopause. So many women come to me for like second, third, fourth opinions; they’re like, “I’ve seen a million doctors, and they all tell me there’s nothing to do about it,” and it’s classic endometriosis, classic, you know, PCOS, classic menopause, and I’m like, “There are treatments for these things,” right? You know, it’s not something you just have to deal with. And I think this is part of just the misinformation that happens around, you know, especially like women’s health, sexual health, that it’s also normalized; they like, “Oh, just like everybody has excruciating pain, or everybody has horrible like night sweats; they can’t function; they can’t sleep.” Common things are common, but that doesn’t mean that they’re normal or that you have to deal with it. So, I want to make a t-shirt that says like, you know, “Even if it’s common, you don’t have to keep dealing with it,” which is so important. I don’t think that we would do this to men. Like I say this all the time, if men were like excruciating, excruciating pain, they couldn’t have sex, um, they couldn’t go to work, we would like be helping them; we would be trying to figure out what’s going on and offering them treatment.
So, yeah. Well, I think these men, uh, who are married to or fathers of or brothers of or, you know, even sons of these women want them to feel better, right? And and so a lot of my female patients will come from my from my male viewers who will send their wives or their girlfriends, and they’ll be like, “My wife’s been trying to get care for menopause, and some doctor drew her hormones and said they were normal and sent her out the door,” and I said, “Well, you don’t, you know, that’s not how we diagnose perimenopause.”
Yeah, I think, um, this is why I I think this is so important to have this discussion because so many people do really care, right? And if your partner or your mom or your sister is feeling better, they’re going to be better for you, right? And they’re going to be available to you, and that’s going to make your life better, right? I love that; I love that you know your viewers, like the male viewers are sending like their wives or partners; that’s incredible. That’s yeah, it’s really good.
In terms of you said the there’s these hormonal changes throughout the cycle, and that can really affect how people feel, what do people typically experience during different phases of the, and then how might their libido change?
Oh, yeah. So, this is interesting. I think there’s been a lot of interest in the ways that people feel and the way their body and their functions change throughout the cycle. Uh, there’s been a lot of talk about things like, like cycle syncing, where people kind of like almost like game the cycle a little bit, you know, we tell people it’s important to kind of to know how your body works, but not to get too worried about like changing your life to fit the cycle because there’s a lot—it’s almost like too much for people. Like, you have to do certain exercises at different times; have to like only eat certain things. I’m like, “That’s too much. Like, if it’s making your life more stressful, don’t worry about it.” In terms of like the the way that the hormones go up and down, the kind of the two big ones are estrogen and progesterone; they both come mostly from the ovaries. People may kind of feel differently throughout the cycle. So, around ovulation, like I said, your estrogen kind of goes up, and then after you ovulate, you have a hormone called progesterone that is released by the ovary; it’s released by, uh, the place in the ovary where your egg had kind of been released if you ovulated. People probably noticed progesterone changes more because those are what we call like the PMS type symptoms. So, people can get moody, you know, like mood changes; they can get like a little bit angrier, and then they can also have some of the things like breast tenderness, bloating, bowel stuff, and there may be more interest, you know, on the positive side, there might be more interest around ovulation, and that kind of biologically makes sense because your body’s trying to kind of, you know, like, “like when I get pregnant,” so maybe have more interest and more libido around ovulation time. And that’s not everybody; like I said, there’s always different. Is like some people, you know, have more interest in sex around when they’re having their period. So, nothing, you know, biologically kind of advantageous, but just that’s just the way that they respond to the hormone changes. Those are kind of typical findings, and like I said, some of them can be really extreme. So, people who have really, really bad, uh, PMS symptoms to the point that they have, you know, depression, anxiety, anger that is affecting their relationships, their ability to function, that’s called premenstrual dysphoric disorder, so PMDD. So, if you again are having such bad PMS that, you know, you are having trouble at work, it’s affecting your relationship, that again is not normal, so go see your doctor because there are things that we can do to help with that. I can’t tell you how many women come to me, and they they’re like, “I’ve just dealt with that for 20 years, ‘cause I thought it was normal.” I’m like, “No, my God, like I wish, you know, we need like a per public service announcements, like, ‘That’s not normal; you don’t have to just deal with it.’”
Yes, absolutely. And I think the other thing is that yes, there are obviously biologic changes, and so yeah, you might be able to lift heavier or or, you know, tolerate certain things better at certain phases of your menstrual cycle, but I don’t think that you’re doing yourself a disservice if you you know if you just if you just like give your body grace and realize that sometimes you’re not going to be able to do the same things as other times, and that sometimes you might not find yourself as focused as other times or whatever the case is. Like, unlike men, women have changes in their hormone cycle month to month, and yes, could it be advantageous to schedule things when you’re feeling great? Yeah, absolutely. So, like if you have a podcast or you have something big coming up, you know, that you really want to perform well for, sure, it’s good to know your body, but I don’t think the stress of changing your body for those things can actually lead to more harm than good.
Exactly. Exactly. Just being aware, like knowing you’re—I kind of feel more fatigued in kind of my luteal phase; like I have less energy—it’s good to know, but it’s definitely not something that you need to add to your list of stressors to be like, “Oh my God, like I have to only schedule certain things or exercises.” That’s too much; like there’s already too much for us to keep track of as it is.
Yeah. And so the luteal phase you mentioned, what what time of month is this? What time of the cycle is that?
There you go. So, yeah, the luteal phase refers to the corpus luteum, which is, um, I just mentioned the structure that forms when you’ve released an egg. So, right after ovulation, which is right around the middle of the cycle between the periods, the corpus luteum is releasing progesterone. So, that part of the cycle between ovulation and the periods is called the luteal phase, and so that’s—I’m saying people may feel some more of those PMS symptoms, like fatigue, bloating, like all the kind of, you know, the the stuff that we’re like, “G, period’s coming,” that sort of phase.
Yeah. And so a lot of the treatment options for those things are with hormonal birth control. So, how do those work, and what are, you know, in a short, like sort of summary, the risks and benefits—obviously having a larger discussion of risks and benefits with your doctor—but, um, you know, what are things people should know?
Yeah. So, a lot of times if people have symptoms that are related to ovulation, luteal phase, or the period themselves, we can treat them by getting rid of ovulation. So, we do that with birth control. The hormonal birth control methods, uh, work by preventing you from releasing an egg. So, again, you don’t get that kind of, you know, the the ups and downs of the hormones; it’s a little bit more like kind of hormone stabilizing. So, again, they’re treatments for PMDD. People do great with hormonal birth control generally for PMDD because you’re avoiding ovulation, avoiding the luteal phase, avoiding that kind of peak of progesterone, and we can actually skip the periods altogether. What normally makes you have a period or bleeding is a drop in progesterone, which happens like at the very end of the luteal phase. So, if you don’t get a drop, you can theoretically get rid of the periods. And so, for people with painful, heavy periods or lots of symptoms around their actual period, we can get rid of them by avoiding the periods, and you can just kind of skip them. People are like, “Oh, is that dangerous? Is it bad for you to not have a period?” If we are taking over and preventing you from having it, it’s not—the progesterone actually keeps the tissue from growing, so you don’t actually need to flush it out. People who aren’t on something hormonal do need to have periods so that the tissue doesn’t build up and become precancerous or dangerous or cause weird bleeding patterns, but the progesterone is basically keeping things, quote-unquote, you know, clean so that you don’t need to actually like flush it with a bleed.
And is there any danger to stabilizing hormone levels? Like, are there, you know, is there a physiologic issue with doing that?
Uh, no, not long-term. A lot of people may have heard things online like, “Oh, it’s going to affect your fertility,” it doesn’t. So, none of the methods that we use causes any sort of long-term impact on fertility. All of the fertility doctors have made videos about this, uh, so a lot of our friends who are infertility experts have been like debunked that myth over and over again because people get scared; they’re like, “Well, I don’t want to like harm my fertility if I do want to get pregnant later.” And like I said, as long as you’re taking something with progesterone, it’s fine to skip the periods because you don’t need to have a bleed. The main risks are the risk of the actual medication themselves. So, the estrogen hormone that’s in most birth control can have a slight increased risk of, uh, blood clots; there’s a small increased risk of breast cancer, but that’s only a few in many thousands. So, it just—like you said—you have to talk to your doctor; talk about your own risks; talk about your preferences, ‘cause you know, some people want to have a period; like they’re like, “I prefer to see my period so I know I’m not pregnant; I just want there to be a period,” um, so like I said, we can kind of take that into consideration.
Yeah. And then the one thing I do see sometimes, and I think this is very rare, but of course I see it because I’m a sexual medicine doctor, is that some women develop low libido when they’re on oral contraceptives. How common is that really?
Yeah, it’s not most people. So, I just say it does happen, and it’s like an antidepressant. So, it’s something that we talk to people about; the potential—the way that it causes the low libido—estrogen-containing birth control actually drops testosterone levels; it uh, increases a protein that kind of binds onto the testosterone and makes the levels go down. So, people can feel a little bit of a lowered libido because they kind of feel that drop in testosterone. So, the progesterone-only methods, in theory, shouldn’t have that sort of same impact. That being said, um, with anything hormonal, we always say you feel what you feel; sometimes even if it’s not logical, some people do have a little bit of decreased libido on progesterone-only methods. So, it is something that we do a little bit of trial and error, but if people are concerned about libido or if they’ve taken a pill before and they’re like, you know, “I really had no libido on that,” we can again take that into consideration when we discuss options, like maybe we go with with a non-estrogen-containing birth control or like an IUD or something like that if you’re just preventing pregnancy. So, we can use that information, try and find a good fit.
There’s been some Reddit posts and TikToks about how people either went on or off birth control and they were in a long-term relationship and they suddenly didn’t have attraction for their partner. God. So, so what is—is there any rationale to that?
Oh, God. I made a video, like a—it must have been a few years ago now—like there’s some guy who’s like, like a health influencer, and he like goes to grocery stores like and he’s like shirtless, and anyway, uh, he made a whole like scare-mongering thing like, “If you take birth control, you’re not—you’re going to be attracted to the wrong person,” like what does that even mean, “attracted to the wrong person”? So, you know, there are these very, very tiny, tiny studies that were—and again, there—there—how do you define like attraction? How do you define like picking the wrong or right partner? They’re all like terrible studies basically like showing people like pictures of someone, and um, there’s nothing about, you know, if you’re in a long-term relationship, like will your feelings about your partner change because you’re on birth control? Like, no, there’s no such study like that. And I always tell people, you know, you might have different like mood fluctuations, like you might be a little bit more short-tempered or, you know, things like that, but it shouldn’t like change the fundamentals of your relationship or how you see your partner because, you know, attraction is so much about, you know, like personality and your communication and interactions, like it’s it’s not like birth control is like mind control; it’s not going to take over and make you or your partner different people. So, you know, I I kind of roll my eyes a little bit at that one because we always talk about all of these kind of scare-mongering videos about like the dangers of birth control. You know, there there’s also then you have to balance against the risk of pregnancy. Like if everyone’s scared and they’re like all going to come off their reliable birth control and then they have an unintended pregnancy, like that affects your relationship too; that’s going to be a stressor. I always tell people, we have to balance everything; in medicine, has like a risk, but you have to balance against the risk of everything else. So, the alternatives, you know, if you don’t do hormonal birth control, there’s downsides to non-hormonal birth control too; condoms and like the calendar methods and things have their downsides. So, you know, you have to kind of balance all these things against each other, and we always say, you know, it’s not that everything is for everybody. Like, definitely some people are not interested in hormonal stuff or they have really bad reactions to it, but it’s not just to say like, “No one should take hormone; it’s going to make everybody not love their partner anymore,” like that’s ridiculous.
Yeah. Yeah. And you mentioned these non—these other methods. I think one that’s very popular is the pull-out method.
Oh, yeah. So, um, I’m sure you’ve seen many pull-out babies, uh, but how reliable is that?
Yeah. So, we say the pull-out method is almost the same as doing nothing; it’s something like 80% effective, which is one of the worst effectiveness rates of any of the methods, and and part of the problem is, you know, there’s several things: one is it’s very hard to pull out before any fluid comes out; you have the pre-cum, the pre-ejaculate has some has some sperm in it. So, even if there’s some pre-cum, you know, in the vagina, that can get someone pregnant. So, even before you ejaculate, it’s not at all in the control of the female partners; the person with a vagina, you know, they they sort of are hoping that the male partner is going to pull out on time. So, there’s a little bit of that kind of lack of control aspect too; you sort of just having to hope that, you know, you are able to pull out in time. So, it is definitely not something that we tell people to use if they are absolutely certain they do not want any possibility of pregnancy. So, it’s, you know, if you’re in a long-term relationship, you would accept a pregnancy if it occurred; you want to avoid every other method, and you understand that that low success rate, then it’s fine; it’s good for some some couples, but for people who are like, “Oh my gosh, I do not want to get pregnant right now; there’s no chance I can be pregnant,” like, “We cannot have an oops baby,” do not just use withdrawal; use it as like a backup method; use it with something else, but not as its own solo method.
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