Frequently Asked Questions

Designed to provide a better understanding

Frequently Asked Questions ( FAQs)

The answers to the following FAQ’s are generalized for the population-at-large and meant to help educate readers. Please be aware, however, that individualized therapy may dictate different approaches for specific patients that can differ from what is written here. That is why it must be emphasized that consulting with Dr. Altman, or any other expert in the areas of menopause, hormonal therapy or sexual dysfunction, is the only way to receive the appropriate individualized care that each and every patient deserves.

The Rectangularization of Life

What do you mean by the rectangularization of life?

Answer: The present graph of health as we age, looks like a triangle. With age, our health gradually declines. (picture) The rectangularization of life presents this same graph except that when we stay healthier longer in our lives, well into the 90’s, the graph loses the shape of a triangle and looks far more like a rectangle. Thus our optimal health remains at a high level longer, demonstrated by the top of the rectangle, and then finally drops off relatively rapidly around the time of our pending demise, (picture) turning out to be a more natural and rapid death as opposed to gradual suffering over two or three decades. This means prevention of disease as opposed to waiting until the disease occurs and treating it. Of course, there is no magic in the practice of medicine. We cannot prevent all diseases. But as we learn more about each individual’s genetics, through their genome, their genetic blueprint, we will learn about the disease risks and life style changes that are important for that individual. This is the direction in which the medical profession is beginning to head, towards prevention rather than just treatment. But we are not going to make disease go away and we are still going to need to treat them, but for the majority of Americans, staying healthier longer is a very important and achievable goal.

What medications or supplements can I take to help with this rectangularization of life?

Answer: The answer is different for each individual person, and is part of the consultation that Dr Altman has with his patients on a regular basis. Natural hormonal therapy, the use of the appropriate supplements, diet and exercise are especially important. Proper investigation of each person’s present state of health also helps determine their individual roadmap for continuing optimal health.

back to top

Questions on the WHI Study

You say that the WHI was misrepresented to the American public. What do you mean by that?

Answer: When the WHI was first presented to the American public at a press conference in July of 2002, there were many misrepresentations:

1. They said ‘hormones were bad for women’. However, the study was not about hormones . The study was about the oral hormone products, Premarin and Prempro. One cannot extrapolate results from Premarin or Prempro to any other hormonal product, especially not to non-oral estrogen products, nor to natural progesterone products. If a study shows that a certain blood pressure pill causes a specific problem, that does not mean all blood pressure medications cause the same problem!

2. The study was not about women. It was about women who averaged 12 years beyond their final menstrual period. Estrogen is a preserver of good function, not a repairer of bad function fifteen to twenty years down the road when the damage has already been done. Estrogen should be started within 5 to 7 years since the final menstrual period (the menopause). The women in the WHI study who started hormones within ten years of their final period and less than the age of 60, showed excellent results as well as prevention of heart disease and no significant increased risk of breast cancer.

If the WHI researchers who presented at that first press conference 8 years ago had broken the results down into the appropriate age groups, good news would have been reported which agreed with numerous studies that came before, and now, since, WHI.

WHI said there was an increase in breast cancer. What is the truth about that?

The breast cancer information from WHI was startling. As it turns out, in the Prempro arm, the women who were using the combination oral product Prempro, there was no statistically significant increased risk of breast cancer! That means that any slight increase in the incidence of breast cancer in the women who took Prempro could have been from chance rather than from the Prempro!

Even more fascinating about the WHI study, was that in the Premarin-only arm of the study, which included only women who had had prior hysterectomy, there was a statistically significant DECREASED risk of breast cancer, regardless of age, in the women who actually took their medication greater than 80% of the time!!! Over the years, the data on hormone therapy and its impact on breast cancer have shown no consensus. There are papers that show a slight increased risk, those that show no change in risk at all, and those that show a slight decreased risk. This means that the worst case scenario is that there may be a slight increased risk in breast cancer on hormonal therapy, but the data supports other conclusions as well. This is extremely good news for women!

How come the WHI showed a decrease in the quality of life?

Answer: This is one of the most frustrating and angering parts of the WHI study. In 2003, a paper was published from the WHI saying, not only was there not an increase in the quality of life in women taking hormones, but there was, in fact, a decrease in their quality of life. Many, of my patients called and said “What, are they crazy? How could this possibly be? Of course you feel better when you’re taking hormones especially when you’re having symptoms.” I explained to them that this was precisely the problem. Ninety percent of the women who enrolled in the study had no hot flashes, night sweats, sleeplessness, palpitations, headaches. If they had these symptoms, they would not have been allowed to be in the study!!! You see, this was a “double blind” study. That means that the study subjects would not know whether they were taking drug or placebo, which gives us much better answers to the questions that the study is looking at. So, women with symptoms were not allowed in the study because the doctors in charge of the study knew that women with symptoms who received drug instead of placebo would know they were on hormones because they would feel better!!! Hence, they would un-blind, so the study would not be valid. After all, the researchers knew that hormones take away the symptoms mentioned above, as all the data prior to WHI demonstrated increased quality of life in women taking these hormones, so they couldn’t allow those women into the study. Do you understand the absurdity of saying “we don’t want you in the study because we know that hormones will make your symptoms will go away and you will feel better?” And then publishing a paper saying that the women in this study experienced a decrease in quality of life!

That to me is a fraudulent academic study, because when you put a 72 year old women on Prempro who stopped having symptoms long ago, she will frequently get headaches, breast tenderness, bloating, maybe her blood pressure will go up and she will stop taking that medication within a couple of months. By stopping the medication, she will then check off “decreased quality of life” in her study questionnaire. Hence, the absurdity of this part of the study.

Was there good news about heart attack prevention and death in the WHI study?

Answer: There was exceptionally good news. For the women who started their Premarin less than the age of 60 and within 10 years of their final menstrual period, there’s a strong decreased risk of about 35% of getting a heart attack later and, most importantly, there was a decrease of approximately 30% in dying from any cause at all.

Are there other studies aside from WHI that show these benefits?

Answer: There are a number of major studies from both Standford University Medical Center in 2007 and 2008, as well as the recent Danish Osteoporosis Study (DOPS). These papers demonstrated that women who start their hormones less than the age of 60 and within 10 years of their final menstrual period, cut their future risk of heart attack by 35 plus percent. They also lowered their risk of dying from any cause at all by 40%! So it turns out that WHI confirmed the good news that prior studies had shown, and studies that came after WHI continue to agree on the benefits as well!

Doesn’t estrogen have an effect on breast cancer?

Answer: Yes, estrogen can promote an early breast cancer that is already present prior to starting estrogen therapy. There is no data demonstrating that estrogen causes (initiates or starts) a breast cancer. The difference between promotion and initiation is extremely important. Also, estrogen can only promote those breast cancers that are able to respond to estrogen…and these are usually the more “benign” cancers. This can also mean we are able to find these cancers sooner.

back to top

Natural Hormonal Therapy

Do all pharmaceutically produced hormones come from pregnant mare’s urine?

Answer: The answer to this question is absolutely “NO”. The only pharmaceutical, hormonal, post- menopausal products that come from pregnant mare’s urine are the brands of pills called Premarin, and Prempro (which is a combination of Premarin and a synthetic progesterone).

What are other hormonal products made from?

Answer: They come from plant-based material found in soy and yams. We can make natural bioidentical hormones from these sources. That includes estradiol, progesterone, cortisol and testosterone. Since these bioidentical hormones are “made” from these plant sources, we say they are “synthesized” from them. Made= synthesized. Hence, ALL bioidentical hormones are “synthetic” in spite of what you may read in the PR and advertising of natural hormone creams, etc. There is no such thing as “non-synthetic” hormones…at all! They all have to be produced…made…synthesized! You can obtain bioidentical estrogen and progesterone in many pharmaceutically produced products such as skin patches, gels, creams and vaginal rings, that are all FDA approved and usually covered by insurance. You can also get these bioidentical hormones made up by a compounding pharmacist in creams and tablets, but these are NOT FDA approved, so there is no quality control and no assurance that they contain what they claim to contain!

I have been told that natural progesterone cream is the best way to take progesterone.

Answer: Absolutely not. “Natural compounded” bioidentical progesterone cream does not absorb well enough through the skin to protect the lining of the uterus! And, after all, you take progesterone to protect the lining of the uterus from estrogen induced overgrowth that can increase the risk of uterine cancer. Progesterone protects against that increase and actually decreases the normal risk of uterine cancer. This is why, if you want to use natural progesterone, it should be taken by mouth…orally…to achieve uterine protection. That also means that if you don’t have a uterus, ie had a hysterectomy, you do not need to take any progesterone. There are “synthetic progestins” that act like progesterone and do protect the uterus. These progestins, called norethindrone and norgestrel, can be found in FDA approved patches combined with estrogen, but they are somewhat different from natural progesterone. This can be discussed personally in a consultation in far greater depth, but please understand, the bottom line is, progesterone creams rubbed on the skin are inadequate to protect the lining of the uterus.

Do I have to have my levels checked every month or every other month to figure out what my hormone medication should be?

Answer: A resounding no. You do not have to have this done at all! There are many practitioners, who prescribe compounded hormonal creams and base the dosage on blood or saliva levels taken monthly or every other month. This is expensive for the patient, as insurance frequently does not cover these tests…and well they shouldn’t! But it is generally unnecessary because there is NO DATA to say what these “levels” should be in a post menopausal woman. And, another important point; can you imagine all women walking around with the same blood or saliva levels???? That’s not individualized therapy! That’s “Stepford Wives” therapy!!! All women are different and have different hormonal needs. To make all women have the same levels, based on no data at all, is outrageously absurd!!! It’s anti-individualization of therapy. Every woman needs a different amount of hormone for her individual problems. That “niche” is different for each woman. We determine that niche clinically by a patient’s symptoms. We listen to her biology. She tells us what’s going on. And we respond as clinicians by altering the dose in order to modify her symptoms and to get rid of them. And that level is different for every woman. Some patients need just a little while some patients need a whole lot, and most patients need in between. But the canard of believing that every woman has to walk around with the same blood level is just an absurdity and you should not be fooled by this marketing tool!!! That does not mean we never draw any “levels”. Occasionally, these levels are necessary when the current hormonal dose is not having the desired effect and the clinician wants to raise the dose to a much higher level. We can find those patients who don’t absorb estrogen well through the skin and adjust the dosing accordingly.

Are saliva levels better than blood levels to determine what my hormonal needs are?

Salvia levels are marketed as being better than blood levels. The marketers claim that blood levels tell us how the hormones are being transported in the bloodstream, while saliva levels tell us the level of hormone in the tissue. The problem with this marketing logic is that there is no data whatsoever to correlate saliva levels with any other tissue! This means that saliva levels tell us the levels in saliva only! A better way to explain this is; if a salivary progesterone level is drawn, that level will tell us how well the uterus is being protected against uterine cancer only if that patient “spits into her uterus twice a day”!!! The level in the saliva tells us NOTHING about the level in the uterus where the protection is needed. So, please don’t depend on salvia testing.

back to top

Female Sexual Problems

Why is my sex drive down?

Answer: This answer will be different for each individual patient, but there are many reasons that sex drive can be diminished or absent: some of those reasons are hormonal, some are relationship-based, some are due to antidepressant therapy or birth control pills, some have to do with stress at work or within the family, and some are a combination of these reasons, but it’s not all due to hormones!!! It takes an in-depth consultation to determine each individual woman’s reasons or situation. In the end, there are many things that we can do about decreased/absent sex drive, but each patient is different, and the solutions are different. Most importantly, this takes time and patience, as well as an expert clinician who specializes in this area.

Does a woman’s sex drive change as she ages?

Answer: Some women find their sex drive diminished as they age, and others actually find it increased or unchanged. Everyone is different. Many women find their drive is “different” as opposed to increased or decreased. The “spontaneous” sex drive can change and become more “responsive”. This means that instead of wanting to tear his clothes off and have sex, she may need to first be stimulated sexually by her partner before the drive occurs; hence the term, “responsive”. It turns out that this is another variation of normal. This can be very reassuring to a woman who is questioning a change in her sexual drive.

I seem to have my sex drive, but I’m not responding vaginally and clitorally like I used to be?

Answer: This is called an arousal disorder, if it is distressing to the patient. Arousal problems mean that you still want to have sex but for some reason you are not responding in the genital area. Sometimes that lack of response comes from the brain, sometimes from the inability to “vaso-congest” or collect a lot of blood in the genital tissues including the clitoris and the vagina, so that you don’t notice arousal, lubrication, or labial and clitoral swelling. This can be a complicated problem, but therapies exist that can improve responsiveness.

What is the most common sexual dysfunction that you see in your practice?

Answer. The most common sexual dysfunction I see is pain with intercourse due to vaginal atrophy and the resulting lack of lubrication, leading to vaginal dryness in post menopausal women. We are actually seeing an epidemic of this problem in the United States because so many millions of women were frightened away from using estrogen by the misrepresentation of the Women’s Health Initiative study (see above), that they stopped their hormone therapy and won’t even use local vaginal estrogen that works just in the vagina and doesn’t get absorbed into the body. Within six months of stopping estrogen (or within six months of natural menopause), the vagina begins to loose its elasticity or “stretchibility”, and the opening begins to narrow. While the vaginal tissue normally stretches to accommodate the penis during intercourse, with vaginal atrophy this accommodation is less and can cause discomfort or pain. When the natural lubricating ability of the vagina is also decreased, the situation and pain can be even worse. That’s why many women find that they need to use a sexual lubricant to facilitate intercourse without pain. The problem is, “who wants to have sex if it hurts?” Pain can easily diminish your sex drive so that you have sex less frequently, which can cause further vaginal atrophy from “disuse”…hence the advice to “use it or lose it!” This self-perpetuating problem is a more common cause of decreased sex drive than lack of testosterone. And, nothing treats vaginal atrophy better than estrogen, occasionally combined with some gentle dilator therapy. I can’t tell you how many women come to my office complaining of decreased sex drive, who say, “Oprah told me to come see my doctor for testosterone to increase my sex drive.” They don’t need testosterone to increase their drive. They need estrogen to get the vagina back to being comfortable sexually after which their sex drive returns.

What’s the most important thing for women to understand about female sexual dysfunction?

Answer: First of all, it’s not a sexual dysfunction if it doesn’t bother you. Consider this…she has little or no sex drive…he has a prostate problem, and the medication he takes for it diminishes his ability to maintain an erection, so he’s not anxious to have sex either. Neither of them is distressed about not having sex, so they may have some sexual problems, but they don’t have sexual dysfunction! It has to cause distress in at least one of the partners to qualify as dysfunction.

As I mentioned in my book, “Men need a place, women need a reason.” Women have sex in a context, within the context of what’s going on in their lives, so everything has an impact on a woman’s sexuality. Whereas men are far more sexually driven by a quest for orgasm, women are far more complex and driven by a quest for intimacy. Women’s sexual desire and responsiveness is dependent on many factors including foreplay, “after-play”, and even “between-play”. Patients have said, “If my husband will help me with the wash or help me out with the garbage after dinner, that will make me more amorous, more sexual towards him.” Also, while for most women, spontaneous desire has been the norm, some women no longer notice spontaneous desire, but instead need to be stimulated sexually prior to noticing the onset of desire. This is called “responsive desire”…because she has to respond to stimulation before she accesses her desire to have sex. So she doesn’t lack sexual desire, it’s just different. All these things enter into it. In a private consultation, we look into each woman’s individual sexuality and concerns.

back to top

Frequently Asked Questions ( FAQs)

The answers to the following FAQ’s are generalized for the population-at-large and meant to help educate readers. Please be aware, however, that individualized therapy may dictate different approaches for specific patients that can differ from what is written here. That is why it must be emphasized that consulting with Dr. Altman, or any other expert in the areas of menopause, hormonal therapy or sexual dysfunction, is the only way to receive the appropriate individualized care that each and every patient deserves.

The Rectangularization of Life

What do you mean by the rectangularization of life?

Answer: The present graph of health as we age, looks like a triangle. With age, our health gradually declines. (picture) The rectangularization of life presents this same graph except that when we stay healthier longer in our lives, well into the 90’s, the graph loses the shape of a triangle and looks far more like a rectangle. Thus our optimal health remains at a high level longer, demonstrated by the top of the rectangle, and then finally drops off relatively rapidly around the time of our pending demise, (picture) turning out to be a more natural and rapid death as opposed to gradual suffering over two or three decades. This means prevention of disease as opposed to waiting until the disease occurs and treating it. Of course, there is no magic in the practice of medicine. We cannot prevent all diseases. But as we learn more about each individual’s genetics, through their genome, their genetic blueprint, we will learn about the disease risks and life style changes that are important for that individual. This is the direction in which the medical profession is beginning to head, towards prevention rather than just treatment. But we are not going to make disease go away and we are still going to need to treat them, but for the majority of Americans, staying healthier longer is a very important and achievable goal.

What medications or supplements can I take to help with this rectangularization of life?

Answer: The answer is different for each individual person, and is part of the consultation that Dr Altman has with his patients on a regular basis. Natural hormonal therapy, the use of the appropriate supplements, diet and exercise are especially important. Proper investigation of each person’s present state of health also helps determine their individual roadmap for continuing optimal health.

back to top

Questions on the WHI Study

You say that the WHI was misrepresented to the American public. What do you mean by that?

Answer: When the WHI was first presented to the American public at a press conference in July of 2002, there were many misrepresentations:

1. They said ‘hormones were bad for women’. However, the study was not about hormones . The study was about the oral hormone products, Premarin and Prempro. One cannot extrapolate results from Premarin or Prempro to any other hormonal product, especially not to non-oral estrogen products, nor to natural progesterone products. If a study shows that a certain blood pressure pill causes a specific problem, that does not mean all blood pressure medications cause the same problem!

2. The study was not about women. It was about women who averaged 12 years beyond their final menstrual period. Estrogen is a preserver of good function, not a repairer of bad function fifteen to twenty years down the road when the damage has already been done. Estrogen should be started within 5 to 7 years since the final menstrual period (the menopause). The women in the WHI study who started hormones within ten years of their final period and less than the age of 60, showed excellent results as well as prevention of heart disease and no significant increased risk of breast cancer.

If the WHI researchers who presented at that first press conference 8 years ago had broken the results down into the appropriate age groups, good news would have been reported which agreed with numerous studies that came before, and now, since, WHI.

WHI said there was an increase in breast cancer. What is the truth about that?

The breast cancer information from WHI was startling. As it turns out, in the Prempro arm, the women who were using the combination oral product Prempro, there was no statistically significant increased risk of breast cancer! That means that any slight increase in the incidence of breast cancer in the women who took Prempro could have been from chance rather than from the Prempro!

Even more fascinating about the WHI study, was that in the Premarin-only arm of the study, which included only women who had had prior hysterectomy, there was a statistically significant DECREASED risk of breast cancer, regardless of age, in the women who actually took their medication greater than 80% of the time!!! Over the years, the data on hormone therapy and its impact on breast cancer have shown no consensus. There are papers that show a slight increased risk, those that show no change in risk at all, and those that show a slight decreased risk. This means that the worst case scenario is that there may be a slight increased risk in breast cancer on hormonal therapy, but the data supports other conclusions as well. This is extremely good news for women!

How come the WHI showed a decrease in the quality of life?

Answer: This is one of the most frustrating and angering parts of the WHI study. In 2003, a paper was published from the WHI saying, not only was there not an increase in the quality of life in women taking hormones, but there was, in fact, a decrease in their quality of life. Many, of my patients called and said “What, are they crazy? How could this possibly be? Of course you feel better when you’re taking hormones especially when you’re having symptoms.” I explained to them that this was precisely the problem. Ninety percent of the women who enrolled in the study had no hot flashes, night sweats, sleeplessness, palpitations, headaches. If they had these symptoms, they would not have been allowed to be in the study!!! You see, this was a “double blind” study. That means that the study subjects would not know whether they were taking drug or placebo, which gives us much better answers to the questions that the study is looking at. So, women with symptoms were not allowed in the study because the doctors in charge of the study knew that women with symptoms who received drug instead of placebo would know they were on hormones because they would feel better!!! Hence, they would un-blind, so the study would not be valid. After all, the researchers knew that hormones take away the symptoms mentioned above, as all the data prior to WHI demonstrated increased quality of life in women taking these hormones, so they couldn’t allow those women into the study. Do you understand the absurdity of saying “we don’t want you in the study because we know that hormones will make your symptoms will go away and you will feel better?” And then publishing a paper saying that the women in this study experienced a decrease in quality of life!

That to me is a fraudulent academic study, because when you put a 72 year old women on Prempro who stopped having symptoms long ago, she will frequently get headaches, breast tenderness, bloating, maybe her blood pressure will go up and she will stop taking that medication within a couple of months. By stopping the medication, she will then check off “decreased quality of life” in her study questionnaire. Hence, the absurdity of this part of the study.

Was there good news about heart attack prevention and death in the WHI study?

Answer: There was exceptionally good news. For the women who started their Premarin less than the age of 60 and within 10 years of their final menstrual period, there’s a strong decreased risk of about 35% of getting a heart attack later and, most importantly, there was a decrease of approximately 30% in dying from any cause at all.

Are there other studies aside from WHI that show these benefits?

Answer: There are a number of major studies from both Standford University Medical Center in 2007 and 2008, as well as the recent Danish Osteoporosis Study (DOPS). These papers demonstrated that women who start their hormones less than the age of 60 and within 10 years of their final menstrual period, cut their future risk of heart attack by 35 plus percent. They also lowered their risk of dying from any cause at all by 40%! So it turns out that WHI confirmed the good news that prior studies had shown, and studies that came after WHI continue to agree on the benefits as well!

Doesn’t estrogen have an effect on breast cancer?

Answer: Yes, estrogen can promote an early breast cancer that is already present prior to starting estrogen therapy. There is no data demonstrating that estrogen causes (initiates or starts) a breast cancer. The difference between promotion and initiation is extremely important. Also, estrogen can only promote those breast cancers that are able to respond to estrogen…and these are usually the more “benign” cancers. This can also mean we are able to find these cancers sooner.

back to top

Natural Hormonal Therapy

Do all pharmaceutically produced hormones come from pregnant mare’s urine?

Answer: The answer to this question is absolutely “NO”. The only pharmaceutical, hormonal, post- menopausal products that come from pregnant mare’s urine are the brands of pills called Premarin, and Prempro (which is a combination of Premarin and a synthetic progesterone).

What are other hormonal products made from?

Answer: They come from plant-based material found in soy and yams. We can make natural bioidentical hormones from these sources. That includes estradiol, progesterone, cortisol and testosterone. Since these bioidentical hormones are “made” from these plant sources, we say they are “synthesized” from them. Made= synthesized. Hence, ALL bioidentical hormones are “synthetic” in spite of what you may read in the PR and advertising of natural hormone creams, etc. There is no such thing as “non-synthetic” hormones…at all! They all have to be produced…made…synthesized! You can obtain bioidentical estrogen and progesterone in many pharmaceutically produced products such as skin patches, gels, creams and vaginal rings, that are all FDA approved and usually covered by insurance. You can also get these bioidentical hormones made up by a compounding pharmacist in creams and tablets, but these are NOT FDA approved, so there is no quality control and no assurance that they contain what they claim to contain!

I have been told that natural progesterone cream is the best way to take progesterone.

Answer: Absolutely not. “Natural compounded” bioidentical progesterone cream does not absorb well enough through the skin to protect the lining of the uterus! And, after all, you take progesterone to protect the lining of the uterus from estrogen induced overgrowth that can increase the risk of uterine cancer. Progesterone protects against that increase and actually decreases the normal risk of uterine cancer. This is why, if you want to use natural progesterone, it should be taken by mouth…orally…to achieve uterine protection. That also means that if you don’t have a uterus, ie had a hysterectomy, you do not need to take any progesterone. There are “synthetic progestins” that act like progesterone and do protect the uterus. These progestins, called norethindrone and norgestrel, can be found in FDA approved patches combined with estrogen, but they are somewhat different from natural progesterone. This can be discussed personally in a consultation in far greater depth, but please understand, the bottom line is, progesterone creams rubbed on the skin are inadequate to protect the lining of the uterus.

Do I have to have my levels checked every month or every other month to figure out what my hormone medication should be?

Answer: A resounding no. You do not have to have this done at all! There are many practitioners, who prescribe compounded hormonal creams and base the dosage on blood or saliva levels taken monthly or every other month. This is expensive for the patient, as insurance frequently does not cover these tests…and well they shouldn’t! But it is generally unnecessary because there is NO DATA to say what these “levels” should be in a post menopausal woman. And, another important point; can you imagine all women walking around with the same blood or saliva levels???? That’s not individualized therapy! That’s “Stepford Wives” therapy!!! All women are different and have different hormonal needs. To make all women have the same levels, based on no data at all, is outrageously absurd!!! It’s anti-individualization of therapy. Every woman needs a different amount of hormone for her individual problems. That “niche” is different for each woman. We determine that niche clinically by a patient’s symptoms. We listen to her biology. She tells us what’s going on. And we respond as clinicians by altering the dose in order to modify her symptoms and to get rid of them. And that level is different for every woman. Some patients need just a little while some patients need a whole lot, and most patients need in between. But the canard of believing that every woman has to walk around with the same blood level is just an absurdity and you should not be fooled by this marketing tool!!! That does not mean we never draw any “levels”. Occasionally, these levels are necessary when the current hormonal dose is not having the desired effect and the clinician wants to raise the dose to a much higher level. We can find those patients who don’t absorb estrogen well through the skin and adjust the dosing accordingly.

Are saliva levels better than blood levels to determine what my hormonal needs are?

Salvia levels are marketed as being better than blood levels. The marketers claim that blood levels tell us how the hormones are being transported in the bloodstream, while saliva levels tell us the level of hormone in the tissue. The problem with this marketing logic is that there is no data whatsoever to correlate saliva levels with any other tissue! This means that saliva levels tell us the levels in saliva only! A better way to explain this is; if a salivary progesterone level is drawn, that level will tell us how well the uterus is being protected against uterine cancer only if that patient “spits into her uterus twice a day”!!! The level in the saliva tells us NOTHING about the level in the uterus where the protection is needed. So, please don’t depend on salvia testing.

back to top

Female Sexual Problems

Why is my sex drive down?

Answer: This answer will be different for each individual patient, but there are many reasons that sex drive can be diminished or absent: some of those reasons are hormonal, some are relationship-based, some are due to antidepressant therapy or birth control pills, some have to do with stress at work or within the family, and some are a combination of these reasons, but it’s not all due to hormones!!! It takes an in-depth consultation to determine each individual woman’s reasons or situation. In the end, there are many things that we can do about decreased/absent sex drive, but each patient is different, and the solutions are different. Most importantly, this takes time and patience, as well as an expert clinician who specializes in this area.

Does a woman’s sex drive change as she ages?

Answer: Some women find their sex drive diminished as they age, and others actually find it increased or unchanged. Everyone is different. Many women find their drive is “different” as opposed to increased or decreased. The “spontaneous” sex drive can change and become more “responsive”. This means that instead of wanting to tear his clothes off and have sex, she may need to first be stimulated sexually by her partner before the drive occurs; hence the term, “responsive”. It turns out that this is another variation of normal. This can be very reassuring to a woman who is questioning a change in her sexual drive.

I seem to have my sex drive, but I’m not responding vaginally and clitorally like I used to be?

Answer: This is called an arousal disorder, if it is distressing to the patient. Arousal problems mean that you still want to have sex but for some reason you are not responding in the genital area. Sometimes that lack of response comes from the brain, sometimes from the inability to “vaso-congest” or collect a lot of blood in the genital tissues including the clitoris and the vagina, so that you don’t notice arousal, lubrication, or labial and clitoral swelling. This can be a complicated problem, but therapies exist that can improve responsiveness.

What is the most common sexual dysfunction that you see in your practice?

Answer. The most common sexual dysfunction I see is pain with intercourse due to vaginal atrophy and the resulting lack of lubrication, leading to vaginal dryness in post menopausal women. We are actually seeing an epidemic of this problem in the United States because so many millions of women were frightened away from using estrogen by the misrepresentation of the Women’s Health Initiative study (see above), that they stopped their hormone therapy and won’t even use local vaginal estrogen that works just in the vagina and doesn’t get absorbed into the body. Within six months of stopping estrogen (or within six months of natural menopause), the vagina begins to loose its elasticity or “stretchibility”, and the opening begins to narrow. While the vaginal tissue normally stretches to accommodate the penis during intercourse, with vaginal atrophy this accommodation is less and can cause discomfort or pain. When the natural lubricating ability of the vagina is also decreased, the situation and pain can be even worse. That’s why many women find that they need to use a sexual lubricant to facilitate intercourse without pain. The problem is, “who wants to have sex if it hurts?” Pain can easily diminish your sex drive so that you have sex less frequently, which can cause further vaginal atrophy from “disuse”…hence the advice to “use it or lose it!” This self-perpetuating problem is a more common cause of decreased sex drive than lack of testosterone. And, nothing treats vaginal atrophy better than estrogen, occasionally combined with some gentle dilator therapy. I can’t tell you how many women come to my office complaining of decreased sex drive, who say, “Oprah told me to come see my doctor for testosterone to increase my sex drive.” They don’t need testosterone to increase their drive. They need estrogen to get the vagina back to being comfortable sexually after which their sex drive returns.

What’s the most important thing for women to understand about female sexual dysfunction?

Answer: First of all, it’s not a sexual dysfunction if it doesn’t bother you. Consider this…she has little or no sex drive…he has a prostate problem, and the medication he takes for it diminishes his ability to maintain an erection, so he’s not anxious to have sex either. Neither of them is distressed about not having sex, so they may have some sexual problems, but they don’t have sexual dysfunction! It has to cause distress in at least one of the partners to qualify as dysfunction.

As I mentioned in my book, “Men need a place, women need a reason.” Women have sex in a context, within the context of what’s going on in their lives, so everything has an impact on a woman’s sexuality. Whereas men are far more sexually driven by a quest for orgasm, women are far more complex and driven by a quest for intimacy. Women’s sexual desire and responsiveness is dependent on many factors including foreplay, “after-play”, and even “between-play”. Patients have said, “If my husband will help me with the wash or help me out with the garbage after dinner, that will make me more amorous, more sexual towards him.” Also, while for most women, spontaneous desire has been the norm, some women no longer notice spontaneous desire, but instead need to be stimulated sexually prior to noticing the onset of desire. This is called “responsive desire”…because she has to respond to stimulation before she accesses her desire to have sex. So she doesn’t lack sexual desire, it’s just different. All these things enter into it. In a private consultation, we look into each woman’s individual sexuality and concerns.

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