Q: I'm in my mid-40s and over the past year my periods have decreased in flow and length. At my last GYN appointment, I was told no big deal, and to let my doctor know when I had gone a whole year without a period.
A: This can be very normal. Perimenopause can occur two to three years before menopause. During that time periods can change, space out or come closer together (heavier or lighter, shorter or longer). Most women also sense their hormonal changes. They may develop hot flashes and night sweats just before their periods. And they may feel their estrogen levels are high and almost feel pregnant. This all goes together with the tremendous hormone fluctuations that occur as some follicles respond to hormonal directions from the brain and others (the duds) do not.
Q: I'm 22 and I have been on the birth control pill to regulate my sporadic period since I was 17. However, for the past month I have had unusual vaginal dryness and a noticeably decreased libido. Any idea as to why this would happen to me?
A: Yes, this is quite common. Low-dose pills may not provide sufficient estrogen to maintain lubrication in the vaginal area. And in preventing ovulation, the pill prevents cyclical production of testosterone, which physicians feel is necessary for libido. Also, the estrogen in the pill causes whatever testosterone is out there in the circulation to be bound up and powerless. It can't attach to testosterone receptors in the brain or other parts of the body — sort of like Samson without his hair.
To alleviate this problem, try to use a lubricant during sex. There has been some data that if you switch to a triphasic pill (one that changes the hormone levels during the cycle), libido issues may improve.
Q: Hello, Dr. Reichman, I had an episiotomy during the delivery of my 10-month-old. I am still feeling pain in that area at some times — is this normal?
A: There are two issues here — breast-feeding and the way the episiotomy healed. I usually tell my patients to wait six months after they've stopped breast-feeding to see if the pain continues. On rare occasions, nerves that were cut grow together and form a small benign tumor (a neuroma) at the base of the episiotomy and it becomes exquisitely tender. You might want to ask your doctor for a numbing ointment for the area. If you and the doctor can pinpoint where it hurts, you may need additional surgery to excise the painful area and redo the episiotomy.
If you are still breast-feeding, your estrogen level may be low due to lack of ovulation. This causes the vaginal lining to be very thin and dry. It's similar to what would happen to a woman who was postmenopausal, and this may contribute to the pain you feel during sex. On occasion, I prescribe vaginal estrogen cream.
Q: I am 44 and have been having clotty periods for the past several months. I have had regular exams and Pap smears with no negative results ... is this normal?"
A: If there are large clots and you need to change your pad or tampon every hour, you're hemorrhaging and need to be evaluated by a doctor, who will do a pelvic exam and ultrasound. It could be due to polyps in the lining of the uterus or fibroids within the uterus or a condition where the walls of the uterus become thick because of gland growth from the lining. This is called adenomyosis. Often bleeding can be reduced by either the birth control pill, the Mirena IUS (a progestin IUD) or, if necessary, surgery to remove the polyp or fibroid. There are also procedures in which the lining of the uterus is destroyed with heat freezing or laser (endometrial ablation) that can decrease or stop bleeding.
Q: I'm 28 and gave birth to my second child 10 months ago. Two months ago I started spotting ... about 20 minutes after intercourse ... I went for a Pap test, which came out normal. Could my spotting be a serious health problem?"
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A: If you are still breast-feeding, you may be producing only limited amounts of estrogen because you are not ovulating. If this is the case, the vaginal lining is thin and easily bruised. This may be the cause of the minor postcoital bleeding.
Q: I am a 47-year-old woman and for the past couple of years I have one vaginal infection after another. I do not have multiple sex partners ...
A: Getting recurrent vaginal infections on a regular basis is NOT normal. You should get checked out by your doctor. As we get older, women may get a vaginal infection because they don't produce as much estrogen as they used to and their PH level changes. This can increase bacterial presence, leading to more infections. Other causes for recurrent vaginal infections include, but aren't limited to ...
Bubble baths or hot tubs
Possible sign of diabetes or HIV/AIDS
Q: I am 55 (and 5 months) years old and still having a very regular period. I never miss — ever!!
A: Yes, this is normal. Women tend to stop having their period sometime between 47 and 55-56 years of age — the average age is 51. The time is really determined by how many follicles you had when you were born. To get an idea of when you might stop getting your period you don't have to look any further than your mother. If your mother stopped later in life, chances are you will too. There aren't any tests to determine how many more periods you will get. There is an FSH test that is used to determine viability of the eggs, but it doesn't predict when menopause will occur. It's only relevant to that particular cycle being tested.
The benefits of having your period later in life is that you don't have to worry whether to take hormone replacement therapy right now. The downside is that there is a slight increase in the risk of breast cancer. For women who think they should get their ovaries or uterus removed simply because it's time to stop their periods, know that it's not necessary. Let nature run its course. It's only an option if you have an underlying disease.
Let me just talk about surprise and unintended pregnancies. If you're still getting your period in your 50s and want to be sure you don't get pregnant, you should use a form of contraception. If you were to come to me stating that you want to get pregnant and you're hopeful because you are still getting your period, I would be highly skeptical and suggest looking into donor eggs. Just because you get your period doesn't mean your eggs are viable.
Q: I am a woman in my mid-20s. I have never had sexual intercourse. I have my pelvic exam every year but it is always excruciating ... Is this normal?
A: This is not an unusual question and it applies to both women who have had sex and those who have not. If you, or any woman, is in pain during the exam, you may want to ask your doctor to use a smaller speculum. The speculum comes in at least four different sizes. If the woman is under 21 and has not been sexually active, she does not need a Pap smear — meaning in most cases a speculum exam is not needed. If she's over 21 and has never been sexually active, a doctor may opt to do just a manual exam to check for pelvic abnormalities. The doctor can also use copious lubricant to ease the process.
Q: I'm 42 years old, have two children and have had a tubal ligation. I have had normal periods up until one year ago. They started getting shorter, but I get severe cramps. I never got cramps before ...
A: As you get older, cramps may increase. It isn't necessarily related to the tubal ligation. If the cramps are bad, you can try an over-the-counter anti-inflammatory. You can also talk to your doctor about going on the pill. (There is no age restriction if you do not have hypertension, severe diabetes, a history of clots or certain cancers.) Since you have already had two children, the chances of your having endometriosis aren't very high. You are not likely to need surgery (a hysterectomy).
Some women who have been on the pill until they get a tubal ligation get cramps after the surgery. Chances are they are getting the cramps because they are off the pill and it's not there to protect them from heavy periods or bad cramps.
Dr. Judith Reichman, the TODAY show’s medical contributor on women’s health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, “Slow Your Clock Down: The Complete Guide to a Healthy, Younger You,” which is now available in paperback. It is published by William Morrow, a division of HarperCollins.
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.
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