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Sexuality in the Aging Female
Sexuality in the Aging Female
Sexuality in the Aging Female
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Welcome to today's webinar. I'm Jennifer Byrne, the moderator for today's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, but you can submit them any time by typing them into the question box on the left-hand side of the event window. Today's webinar is Sexual Function in the Aging Female, presented by Dr. Carol Kuhl. Dr. Carol Kuhl is a consultant and assistant professor of medicine in the Division of General Internal Medicine with a second appointment in the Division of Preventive, Occupational, and Aerospace Medicine at Mayo Clinic in Rochester. After completing a family medicine residency at Broadlawns Medical Center, where she was elected chief resident and later served as chief of staff, she completed a geriatric fellow at Mayo Clinic in Rochester and then was the founding director of a Mayo Clinic-affiliated geriatric fellowship. She then completed a fellowship in Preventive, Occupational, and Aerospace Medicine at Mayo Clinic in Rochester and a Master of Public Health degree at the University of Minnesota in 2011. She was awarded Teacher of the Year on five occasions as faculty in the geriatric fellowship and Mayo-affiliated family medicine residency. In addition, she was appointed Senior Medical Advisor to the Public Health Department of Iowa by Governor Tom Vilsack and was the founding president of the Board of Directors for a not-for-profit company that brought discounted prescription medication to seniors in Iowa prior to the creation of Medicare Part D. She is presently the director of the Women's Health Clinic at Mayo Clinic in Rochester, Minnesota, which specializes in complicated menopausal, hormonal, and sexual health issues for adult women with a special focus on cancer survivorship. Welcome, Dr. Kuhl. Thank you. Thank you. So, as you can see on my first slide, we have a name change, so our clinic is now going to be called the Menopause and Women's Sexual Health Clinic, more defining of what we actually do, so we're about to launch that name. So, I have no disclosures, and today what we'll do is we'll talk about the physiology and the neurobiology of sexual functioning and then what happens as women age to their sexual functioning and review the urogenital changes, which will be important to you as your gynecology residents, and then look at potential treatments. So, one of the things that's really important as we go forward is that myth that older people do not have sex, they do not enjoy intimacy, which is totally untrue, and as we go through the world, we find these beautiful images of what is important to everybody, closeness, intimacy, sexual activity, and then we went to also, so this was in Lima, in Peru, where I gave a lecture on sexuality and aging to the residents there, and in Machu Picchu, which is beautiful, behind those golden walls that we all cherish seeing are images of the other ideas of what goes on in, what went on at that time, so these are artifacts of which there were multiple people making love. So, what happens as people age? So, this study actually looked at both men and women, and as you can see, there is a decline in sexual activity with age. Women were significantly less likely than men to report sexual activity, but then the question is, is this something that's distressing to them? So, this study was a large observational trial that looked at different domains of sexual functioning, so we break it down into desire, into arousal, and into orgasm, so if you look at the ages, you can see that the highest distress level is around the menopausal time, and this is when women are experiencing these changes, and they're distressed by it because it's impacting their relationships and their own enjoyment of sexual activity, and as people age, it seems to decline, and we're not sure why that is. They're less distressed. Is it because there's other health issues that predominate, or there's just something going on with their partner? So, it's always important when we're assessing sexual function that we think about the partner as well as the patient themselves. So, looking at exactly what happens during sexual functioning. So, there's the anatomy. So, instead of just talking about the clitoris itself, we talk about the clitoral complex. So, we say when we have the embryo, and the embryo becomes a male, you get the head of the penis, and you get the shaft of the penis, and the female actually gets about the same thing, but in different ways. So, the glands of the penis is comparable to the glands or the clitoris in the female, and then here, the root is the shaft, and histologically, they're pretty much the same. The female also has the bulb here, which creates the lubrication, and as you see very closely, it's the urethra and the vagina, and they have both estrogen and testosterone receptors, so those play a role as people age. Then there comes the innervation of the vulva, which is really important. So, anything affecting nerves is going to affect sexual function. So, the origin of these nerves are from the pudendal nerve, which actually originates from S2 through S4. So, anything happening there can affect what happens with sensation and response to sexual stimulation, and so when women come in with these complaints, we also have to consider, you know, is there something going on at a higher level and not just at the vulva and just at the vagina? And then we have the arterial supply, so that plays a role as well, and so when you were thinking about surgeries, and we'll talk about those a little bit more later, and certainly any activity, chronic diseases that affect those arteries, that's going to be important in sexual functioning. And then to make things even more complex, the neurobiology of sexual functioning is considering neuromodulators. So, there are certain neuromodulators that will increase sensation, increase arousal and interest, and those that will decrease it. So, you can see dopamine is an important one for sexual arousal, and so these things are actually primed in the brain by estrogen and testosterone, and so when that is diminished over time, that will affect all these neuromodulators. And then there are those things that will inhibit, one being serotonin, as you're familiar with the SSRIs impacting sexual functioning. And then on top of that, we think about what's the circuitry that's in the brain, and even if all things are well, so if the arteries are healthy, the nerves are healthy, the neurotransmitters are healthy, if a person has bad experiences with sexual learning, what they learn about sexual activity or bad experiences with sexual activity when they were growing up, it gets encoded in this prefrontal cortex, and that can play a huge role in how women perceive sexual activity, good or bad. And even if everything's right, that will play a role pretty quickly and can make a negative or a positive impact on what happens functionally. Then we look at aging, and so what is normal aging that affects sexual functioning? So the decline in estrogen, as you know, will affect the epithelial lining, not only of the vagina, but also of the vulva and the urethra, so the pH and the cytology inside the vagina change, so we'll see connective tissue changes and muscular changes, the vagina actually becomes a little more rigid and lubrication more difficult, touch perception decreases and women are always complaining, I just don't feel the same anymore, I'm not having a good response, I'm having more difficulty having orgasms, so this is commonly related, can be related to just the lack of estrogen. So this is a healthy vagina, and you can see the vaginal atrophy, so just a model of looking at what that looks like when a person has estrogen and a person doesn't have estrogen. And this is another image of how that atrophy actually looks at the vulva as women age, and I'm sure as residents you've seen these changes over time and how that affects the urethra, which is right there, and impacts urinary continence as well. So when we're talking to women about treating, someone will say, well, I'm not really sexually active, but it's not just about sex, it's about your genital health as well. And so what kind of sexual disorders do we see in older women, so certainly the interest in arousal disorders, orgasmic disorders, but more commonly we see this pain disorder and women will come in and say, it just hurts, and so trying to define what hurts, is it initial penetration or is it deep penetration or is it both, it's not uncommon to have atrophy, and then the woman will crunch up, and so then she makes it worse by having pelvic floor tension, and so trying to discern what those issues are and work with both the vaginal atrophy and also the pelvic floor dysfunction becomes very important. So to compound things, then there are these medical conditions as people age that affect all the different domains, so again we were talking about desire, arousal, orgasm, and pain as the domains that are impacted for sexual functioning, and you can see that coronary artery disease can affect arousal and orgasm, diabetes, of course if you're thinking about vascular and neurologic impact of diabetes, it's going to affect those areas in the vulva as well, anything that's neuromuscular or neurologic can affect neurotransmitters, and urinary incontinence becomes very important, and I'll show you a study that was very interesting in terms of genital sensation around urinary incontinence. Cancer is a whole other area of interest for us, and it can affect all of these domains depending on what kind of surgery they have or what kind of chemotherapy were they put into menopause because of their therapy, did they have pelvic radiation, so this is really important in discerning out which things are affecting them from a cancer standpoint and how we can help them. So in particular, diabetes can affect the vibratory sense and also affect engorgement, and if you have a diabetic neuropathy, you're going to have a vulvar neuropathy as well, so it's always helpful to help patients understand, you know, this is what's happening in controlling your diabetes just like in a man, I mean, I will tell men too that uncontrolled diabetes is going to affect your erection, and sometimes that makes them pay attention and want to control their diabetes a little bit better, but that is an important piece of it, and the same thing with heart disease, that they find that women who have heart disease will have a decreased libido and they'll have painful intercourse, and is that from medication or is that from fear of having another event, but they have actually looked at who gets counseled in the hospital before they leave, and if they have not been counseled, then they're probably not going to resume sexual activity, so it's important initially and then afterwards to talk about when they can go back to sexual activity, and people who did actually did not, they did not find that they had any worse incidents, cardiovascular incidents, when they were sexually active, so that's an important piece. When we look at the vessels themselves with aging, you can see these are healthy vessels of 11-year-old and a 45-year-old, and then this 83-year-old with just normal aging, you can see that the blood flow is going to be affected, and that includes going to the clitoris, and there have been some studies looking at clitoral blood flow with aging and impact on sexual activity, so medications certainly are important. Anything that makes you dry is going to make you dry, and so these agents can all cause vaginal dryness, and so differentiating out medications, of course, with aging patients, it's important to look at all these CNS medications as well, which can impact their sexual drive. So looking at birth, so delivery, what happens during delivery? I mean, even a normal vaginal delivery with an average-sized baby puts a lot of pressure on the pelvic floor, impacts the vessels, impacts the nerves, most of them return to normal, but not all. So if you look at studies that assess cesarean section versus vaginal delivery and look at the incidence of pelvic organ prolapse, you can see that there's a difference between the vaginal, just the normal vaginal delivery. So over time, there's a higher incidence of urinary incontinence related to the pelvic organ prolapse, and in these women, even over 10 years later, you can see that there's a high incidence of both pelvic organ prolapse and urinary incontinence. And then if you look at, okay, what about the size of a woman, how old they are when they deliver, and the birth weight, certainly there's some incidence, there's some significance with the actual BMI of the patient, but certainly the size of the baby is going to make a difference, and I'm sure you've experienced that yourself. So what difference does that make in sexual activity? So here, we have some studies done with quantitative sensory testing. So what that is, is there's a probe here, the probe is placed at the clitoris, and it's placed on the anterior part of the vagina. So studies have looked at how is the clitoris and the vaginal sensation affected by different entities. So as you can see, multiple sclerosis decreases vibratory sense, not surprising, but pelvic organ prolapse can also affect vibratory sense and cold and warm, both at the clitoris and the vagina. Incontinence seems to affect everything. And then hysterectomy, while it doesn't affect the clitoris itself, can affect by vagina, the vaginal sensation. So my challenge to people who are doing hysterectomies is to ask the question, how do you have your orgasm? So some women will have it just with clitoral stimulation, some with just vaginal penetration, some with both, but I will get patients in my office who've had a hysterectomy and say, it changed, and nobody had the discussion with me, and they're not real happy about the whole thing. So certainly we know when the uterus is removed and the cervix is removed, sometimes it can change the orgasmic experience. But certainly women who have had vaginal stimulation as their core for their orgasm, it may change if you're cutting nerves there. So something certainly to think about. So what about vaginal health and sexual response? You know, it says 20% to 30% report vaginal dryness, but there's a lot more out there. And certainly women who remain sexually active do better. There are lubricants. And so the importance of lubricants is that they're shorter acting. They have been shown to demonstrate greater sexual comfort and pleasure. There's water-based and there's silicone-based. So water-based are more used for women who are using a vibrator or if their partners, if their male partners have erectile dysfunction, the silicone lubricants are actually too slippery so that they do better with the water-based. And so the moisturizers are different because they actually provide longer benefits. So they attach to the epithelial cells of the vagina and then they carry water into the vagina and it stays there for about 72 hours. So depending on how atrophied a woman is, they may just use moisturizers three times a week and do just fine. And then they find that they may not need a lubricant quite as frequently. So things to be thinking about, though, with moisturizers and lubricants is that there are a lot of additives and they can irritate. So this article by Penne is excellent and I would refer you to the particulars of that because osmolality plays a role and higher osmolality can be very irritating. pH changes with women, their pH being higher as they age and so it's actually a lower pH is protective from bladder infections and then people who engage in rectal intercourse will require lubricants with a higher pH because the rectal pH is higher. So there are parabens in a lot of these lubricants. They are weakly estrogenic. While there's been no direct correlation to breast cancer, there have been tumors that they have found parabens in them, breast tumors. Glycols can increase risk for yeast infections and then if you're trying to help somebody get pregnant, it's important to avoid some of these moisturizers and lubricants that actually can impair motility. So while this is a very, it's hard to see, but what I'm pointing out here is there are a lot of moisturizers and lubricants that have very high osmolality and two of them that I underlined here were Astraglyde and KY Jelly which we use all the time. So these can be very irritating. So the lubricants and moisturizers that are within this osmolality are really helpful and not harmful. Same thing with pH. So these gray areas, these gray bars are high pH which is not helpful and so the pH, we're trying to bring the pH down to make the vaginal microflora more acidic which is protective from infection and also makes for a healthier environment overall. So the recommendations for lubricants and moisturizers specifically. So Pre-Ceed is great if you're thinking about somebody who's trying to get pregnant. We talk about avoiding the parabens and glycerins. There's one here rectal anal sex. So this lubricant is very beneficial and not harmful. And then again, we talked about silk lubricants versus satin moisturizer being, this is more slippery but then again, we don't use it if there's erectile dysfunction or if somebody is using a vibrator. And the reason for the vibrator is because the vibrator is made of silicone so there's interaction between silicone moisturizers and the product. The satin moisturizer is organic so we have found that one to be very helpful. And then women who are on aromatase inhibitors really have a difficult time with drying out and thinning out. Aromatase inhibitors are not females' friends. And so Hyaluronan, a moisturizer, seems to be a friend of our patients that have breast cancer on aromatase inhibitors because they find it penetrating better than some of the other moisturizers. What about vaginal estrogen? So estrogen works well and it takes about three months to get full benefit and then we always tell women if you stop it, it's going to go back right the way it was. So it can promote revascularization and increase that lubrication elasticity. It does decrease those symptoms. Women will have vaginal dryness and irritation and it's also been found to improve their sexual drive and arousal. And we don't know if that's because it's not hurting as much and so they're more inclined to want to participate. You know, if it hurts, our adage is if it hurts, don't do it. And so we try and work with women in learning non-penetrative sexual activity while we're trying to get them better so that they are remaining intimate with their partners, especially our cancer patients. So we have a psychologist and a sex therapist and we work with these patients so that we're not saying sex is out of the question, we're saying sex should be different now. And sometimes you have to create a different mindset in the patient and their partner so that they can remain intimate. So different types of estrogens. We use the Estrace cream quite a bit because we find that what women do is they take the estrogen syringe and put it way up inside their vagina and then it just leaks out and they don't get anywhere. So we actually instruct them to take just the one gram and actually massage, massage it into the vulva and massage it into the distal 1 3rd of the vagina because that's where the atrophy really happens and encourages them again to use it twice a week. The DHEA cream, so we're looking, this Interosa just came on the market. So it's a suppository of DHEA, it's 6.25 milligrams. You have to use it every day to have the benefit. But it's interesting as I read more and more about it, it even goes into deeper level layers of the vaginal mucosa. And so there've been studies looking at sexual functioning related to DHEA cream and the questionnaires that they've applied during the FDA process look like there's actually improved sexual functioning with the DHEA. Both products, the DHEA and the vaginal estrogens do not need progesterone with them. There's one year of safety data with the vaginal estrogens and a little shorter acting with the DHEA but there was no increase in the lining of the uterus with these products. And so endometrial cancer was not a concern. I direct you to this paper that was just published like last week. And so this is really important to us and I'm sure to you as well because when we're thinking about, okay, how do we manage our breast cancer patients and we're worried about giving them estrogen or other cancers as well that are a higher stage, can we use estrogen? So there was a nice consensus paper that reviewed the recommendations and so I'll direct you to that. I'm just trying to get through it myself and review it but it looks like it has some very good information. We had also published another paper on looking at all the different kinds of systemic hormone therapy in different cancers and who could have it and who could not. So that's really important because your patients may need systemic therapy and we're happy to help you with that. So looking at then the pelvic floor. So a lot of times like we were saying is that they may have problems here and they're having initial pain but then if they have deep pain, what's that about? So when you're doing your exam, you can actually sweep across on the sides of the vagina and palpate the pelvic floor. So these particular muscles, the ischiocavernosis and the bulbospongiosis are part of your general diaphragm. So that's that initial part where women may have vaginismus and then the deeper muscles, the levator ani muscles are back further and those muscles get really hard. So women will say it feels like somebody's hitting a wall while they're having penetration. And then of course you can also see problems with constipation and those muscles, the pupal rectalis can be involved too. So we work a lot with our pelvic floor physical therapists with our patients because oftentimes patients need both. And so again, this is another diagram of the anatomy where you can see if you put your finger up here, you can actually feel those muscles and they can tell you sometimes there's like a trigger point there and you can just go in and release it and then have them work with yoga exercises that help relax the pelvic floor. And depending on the amount of discomfort they're having, we actually sent them to pelvic floor physical therapy. Sometimes we do have to use dilators if the patient is having vaginismus or is having had pelvic radiation and there's fibrosis there. So we sent quite a few of our patients to pelvic floor physical therapy. And then there's our therapeutic vibrators. So when patients have discomfort and also have decreased sensation, we'll recommend trying a vibrator. And so we make it usual stuff. Our sex therapist office says, don't ask them if they use a vibrator, ask them how often they use a vibrator. So it's just like normal conversation and then they're like, okay, well, so we talk about that and their comfort with their husbands and using a vibrator. And so there's all different kinds. So this is more targeted towards the clitoris. This can actually be used if somebody needs a dilator. So it's a vibrator that has the tip here that can be used as a clitoris, but it also can be used inside the vagina. And then here's the infamous rabbit. And then this is the high-tech one. So someone like a person with multiple sclerosis may need something like this. And then for our elderly patients too with arthritis and they're having difficulty with positions, there's pillows and all different kinds of aids to help with comfort during sexual activity, which would be certainly important. So in conclusion, there are physical active changes and certainly chronic diseases and medications make a big difference. The mode of delivery can impact sexual functioning. And so talking about lubricants and moisturizers are really important in understanding which ones are better than the others and which topical estrogens to use in selected patients. And that sexual health is really an important quality of life issue. And as we travel here again in Peru, it was this beautiful bronze sculpture of dead people enjoying each other and sex three times a day. Well, maybe that might be a bit, but we try and keep our sense of humor while we're working with these patients and we're able to laugh and talk about sex in a very non-threatening way. And they're so happy to be able to have the discussion. And this is our group. So we have five physicians, sex therapist, a nurse psychologist who actually has helped a lot in terms of just sex education because a lot of people just don't understand how things work, our pelvic floor PT. We have nurse educators that are fabulous in teaching people on how to apply a patch, how to apply the vaginal dilate, how to apply the moisturizers and lubricants because a lot of times patients walk away with a prescription and they don't know what to do with it. So they don't use it. And then we did publish a book called The Menopause Solution. Dr. Fabian, our editor, did a great job and we have all kinds of issues related to menopause and potential solutions. And it's been well-received. And in fact, Time Magazine is doing a magazine out of it. And I was like, what is a magazine? The magazine is where they take the book and they put it into a magazine and then put it on the market and they sell 42,000 of them. And so they're going to be reissued. So that tells you that people are interested and there's a lot of information about sexual activity in that book. So I'm happy to entertain any questions. Thank you so much for such a great presentation, Dr. Poole. We have a few minutes for questions. You can submit your question for Dr. Poole in the question box on the left-hand side of the window. We do have a question so far wanting to know a little bit more about this slide on the pH of the moisturizers and lubricants. Is that something that you created or is that from an article that our participants could reference? Right. So this slide here, right here, Edward D. Penne, this came, those two diagrams, and that's why I just put them up there. I know they were hard to read, but they are in that article. So if you get that- Perfect, awesome. Yeah, so if you get that article, it's really, he does a great job spelling out all the different lubricants and moisturizers, and I thought that would be highly beneficial for the urogynecology residents. Yeah. We have another question about patients who are on SSRIs or SNRIs who present with decreased desire and difficulty achieving orgasm. How do you approach that patient? Is there anything in particular you'd recommend first? Sure. So if, number one, if they're on antidepressants for a reason, we don't stop them. We talk about alternate ways to approach it because we're finding that some women who have depression, if you don't treat their depression, they're more likely to have sexual dysfunction than if you treat it, and that it is dose-dependent. So we actually use peroxetine for hot flashes, a non-hormonal treatment for hot flashes, and at the lower dose, it's just 7.5 or 10 milligrams. We're not seeing that dysfunction, but there are other things, and there was a very nice article, actually, at Mayo Clinic Proceedings on treating sexual function in women on antidepressants and some alternatives. MAC was one of the herbal medications that was actually studied. So it's an herbal medication that you can take 300 milligrams daily and was found to actually help with sexual functioning in people who are on SSRIs. Sometimes we'll add Welbitrin because Welbitrin is dopaminergic, so that offsets sometimes the SSRI. And then using vibrator helps. Yeah, yeah, for sure. So it's so nice that you have such a wonderful team kind of supporting you, but what can we do to increase referrals and screen our patients better? Is there a certain questionnaire you recommend or a screening question that you find really picks these women up who most benefit from meeting with you? Sure, so oftentimes, we're giving lectures on how to ask the question. It depends on the relationship with the patient, but oftentimes, we'll say, hey, this condition exists sometimes. Women will have sexual concerns related to this. Is that, are you having any of those issues? You know, and I've tried to encourage primary care patients just to make that part of their review of systems. You know, how's your heart? How's your head? How's your sexual life? You know, and just make that a very casual thing. I am on a board for an organization, and I'd be happy to send it to you. I thought about putting it in here. We are looking, so the organization is the Scientific Cancer Network, and we are focused primarily on sexual health outcomes in cancer survivors, and so we, the PROMIS questionnaire, we have taken parts of that and developed a single-item questionnaire that can be used for patients, you know, who come into your clinic, and it kind of, it goes through the key points of sexual function. Is it about orgasm? Is it about moist lubrication? Is it about desire? And just, so it actually helps clarify which are the domains that are a problem for that patient. So we just, that's been published, and I'm happy to send you the resource on that. Yeah, that was great. How long does it take a patient typically, you know, when would you schedule your first follow-up, and how do they move through your group? So what we usually do is we have initial consultation with the provider, the physician, or the NP or PA, and then we decide how this patient needs to be followed up. Do they need to see the sex therapist? Do they need sex education? Do they need pelvic floor physical therapy? And then oftentimes, especially women who have atrophy, we'll treat the atrophy first, and then have them come back in three months and see how they're getting along. Then if we feel like they need pelvic floor physical therapy or they need ongoing therapy with our sex therapist, then we'll schedule that. We're working with all the different cancer entities at Mayo in terms of how do we work as part of their team and get these patients in, and then we try and coordinate our follow-ups with their follow-ups as well. So a lot of the cancer patients are seen back every three months or so. So we try and bring them back at the same rate so that, you know, it's hard because a lot of people are traveling here. And that seems to work because they do need ongoing support and encouragement to continue or they'll stop their therapy. And what's really important is women who have breast cancer or who run tamoxifen or aromatase inhibitors, they'll stop their therapy because of the symptoms. So it's really important for us to support them and encourage them and make things better for them so they stay on their therapy. One of our participants is wondering if you've had any patients who have been using either radiofrequency ablation or like vaginal laser therapy for their sexual function and what your thoughts are about that. Yeah, it's an important question because, I mean, that's a big future that we're looking at. In fact, you know, we reviewed the literature and there are small studies that there's only one so far that really followed out for a year. So we don't have good safety data, but here we are in the process of opening our research protocol in breast cancer patients using the laser because that's a really good population to make this work. And so far, I mean, our anecdotal experience is that women seem to like it. We haven't seen any bad effects. Certainly it's expensive. It's not paid for by insurance companies, but we've not seen anything bad, but there's still, the use is under research protocol. We don't use it for treatment. We're using it only under research protocol right now until we feel more comfortable with it. And for the patients with breast cancer, when you're using vaginal DHEA, is there a particular dose or formulation or anything that you find is either well-tolerated or covered by insurance that you're using with the patient? Yeah, we've been actually working with the company that developed Enterosa. They have a coupon now. And so the coupon is for a year. This is very smart on their part because it's not on formularies yet. It's on Mayo's formulary now. But the suppository, it's just a waxy suppository. It's 6.25 milligrams and it melts. And so it actually will penetrate the vulva and they have to use it daily. So there's a coupon that goes with that, that if you have insurance, so it doesn't allow for the Medicare patients, that you can get it for $25 a month for a year, and they're anticipating that by then it'll be on all the formularies and people will be able to, the insurances will start to cover it. But we do like it, we do like it. And so far there's limited data, but we are using it in our breast cancer patients on aromatase inhibitors and some of our more advanced endometrial cancers as well. The idea is that DHEA is aromatized estrogen. And if you're on an aromatized inhibitor, that blocks it. And so the studies so far, and the studies have been in not women on cancer, have shown a little bump in estrogen, as well as with topical estrogen that's in the lower levels of postmenopausal. So, so far we're not finding any recurrences. So we have carefully selected the patients that we give it to, but they have found that it's been beneficial. For treatment. That's great. It looks like we've covered the majority of our questions. Is there anything else that, oh, sorry, we have another one. Using intrarosa in history of breast cancer, we did address that you have been using that, but how about endometrial cancer? So depending on the stage, again, stage one, we have no concerns about either topical or systemic estrogen in stage one. And of course we work with our medical oncologist and gynecologic oncologist when we're treating these patients and we all agree. So we always start with non-hormonal agents. So the moisturizers, moisturizers are surprisingly beneficial. So we go there, we see how they're doing in three months, and then we have them come back. And if they're really symptomatic, then we all agree that they should be treated with either topical estrogen or DHEA. So the endometrial patients were more inclined to use the DHEA. I have one with a stage three, you know, cautiously, she can't get topical estrogen and she was having such a difficult time. And so we agreed, you know, and the patients understand that we're not sure about this, but they're so uncomfortable that we go ahead and try them and just watch them and follow them very closely. Is it just for patients who are on aromatase inhibitors that you typically reach for the Intrarosa or, you know, other chemotherapy agents, or if they're not on knee maintenance, is that your go-to or what would be? No, not really. Yeah, not really. You know, we certainly think about that in the aromatase inhibitor patients. And in this one incidence where we had the stage three endometrial cancer, but estrogen is our go-to. You know, we do the moisturized lubricants first, but if we're gonna use topical, we'll go to the estrogen creams. And then we'll see how they do. Yeah. All right. Any other questions from our participants? It looks like we've had a, oh, is there a favorite moisturizer that you use? Yeah. And we're not supposed to, you know, be commercials here, but we have, it's really kind of nice. We have a medical store, the Mayo Medical Store is down in the subway. The Mayo Medical Store is down in the subway. And so we have a satin moisturizer because it's organic. So it doesn't have any additives. And so we like that one. And then we have a brochure that you can mark what you want. So it's got the dilators on it, the vibrators on it, the moisturizers, the lubricants, and you can check it off. You can go into the store, give it to a clerk. They'll get it for you, wrap it up. And so you don't have to stand in line with a vibrator in your hand. So yeah, it is wonderful. Actually, our patient's like, what? Although I did have one patient ask me to go buy a vibrator for them. But I said, well, I wish I could because it was more of a cultural issue. I said, I wish I could, but I can't, you know. All right. I think we've addressed all of our questions at this point. On behalf of the Oggs Education Committee, I'd like to thank Dr. Kuhl and all of our participants for joining us today. Our next webinar will be on volunteerism, which will be presented by Drs. Gina Northington, Charlie Rairdon, Felicia Lane, and Sherell Carter-Brooks. And that'll be on June 13th. So looking forward to having you there. Thank you so much, Dr. Kuhl. Okay, have a good evening. Thanks, you too. Bye-bye.
Video Summary
In this webinar, Dr. Carol Kuhl gives a presentation on sexual function in aging females. Dr Kuhl provides information on the physiology and neurobiology of sexual functioning and the changes that occur as women age. She discusses urogenital changes and potential treatments for sexual disorders in older women. Dr. Kuhl emphasizes the importance of sexual health as a quality of life issue and addresses common misconceptions about aging and sexuality. She also highlights the role of hormones, medications, and medical conditions in sexual functioning and provides recommendations for lubricants and moisturizers. Dr. Kuhl discusses the impact of pelvic floor dysfunction and offers recommendations for pelvic floor physical therapy. She concludes by discussing the use of vaginally applied hormones, such as DHEA, in breast and endometrial cancer patients, as well as the use of therapeutic vibrators.
Meta Tag
Category
Education
Keywords
sexual function
aging females
urogenital changes
sexual disorders
hormones
lubricants
pelvic floor dysfunction
therapeutic vibrators
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