(announcer) major funding for second opinion is provided by the blue cross and blue shield association, an association of independent, locally operated and community based blue cross and blue shield plans - supporting solutions that make quality, affordable healthcare available to all americans. additional funding provided by. (music)

(dr. peter salgo) welcome to second opinion, where each week we solve a real medical mystery. when we close this file a half an hour from now, you'll not only know the outcome of this week's case, but you'll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively. i'm your host, dr. peter salgo. you've already met our special guests, who are joining our primary care physician, dr. lou papa. pleasure to have you here. no one on the team has seen this case. and we're going to get right to work. let me tell you a little bit about dora. dora is 58 years old. she is an attorney, and she's in her doctor's office for her annual physical exam. it's her first visit with a new primary care physician, who happens to be a gynecologist. and i'll tell you that the chart shows that dora was diagnosed with hypertension about 15 years ago. she takes a substantial dose of a beta-blocker. she is on an arb as well. she's on

some hydrochlorothiazide. she's 5 foot 6, 142 pounds, and after her mother's death, she started an ssri for depression. her pelvic exam was unremarkable. but here's something interesting. after asking dora a number of fairly routine questions about her health, dora's doctor tells her that many of her patients have questions or concerns related to sexuality, and she wants to know what dora's concerns might be. now, dora is surprised by the question. should she be? (dr. lou papa) yes. (peter) why? (lou) because it doesn't happen that often. it doesn't come up in the office, either sex, all that often. (peter) how often in your combined experiment here on this panel, doctors just come out proactively and ask about sexual history? (dr. pepper schwartz) very infrequently. it happens infrequently. i just saw a study where women said, 90% of the women said their doctor never mentioned to it, period. (dr. coral surgeon) we ask all

our patients on our update sheet, to document what their concerns and questions are. we specifically ask that question about sexuality, and about sexual dysfunction. are you having any problems with sexual activity, is it uncomfortable. so, they're very open. (peter) these sound like very, very good questions. (dr. surgeon) specific questions. (peter) .and important and specific questions. but you all told me that it's very uncommon for this to happen. so, if they're that important, and it doesn't happen, the obvious question is, why not? (dr. schwartz) well, one thing i think is that the doctors as well as the patient, and this i think is unfortunate, is that they don't consider it part of wellness. you know, part of, you know, we're taking care of your body, we're taking care, making sure about your emotions. after all, she's already on an ssri. her emotions are involved in her wellness, and her sexuality is involved with both her emotions and her body. (peter) why don't patients bring it up? (dr. lynne shuster) there's a very interesting study about that, that showed that actually some, one of the top reasons that patients don't ask their doctor, or talk to their doctors about sexual concerns,

is they're afraid it will make their doctors uncomfortable. and secondly, that they think there's probably going to be no treatment for it. (peter) dora, i guess, was a bit taken aback. but then she said, "sex," and i'm quoting from the chart here, "sex really isn't a priority for me. i've got a demanding job. i have teenage children at home. my husband and i have sex, but i don't particularly enjoy it." and then she asks, "is this normal?" is it normal? (dr. tiefer) oh, the normal word, the normal word. but that is how people think about sex. it's not like, i haven't enjoyed it, so i want to talk to you about how i can enjoy it. it's like, how do i fit in the big picture of women my age (peter) what is normal? (dr. surgeon) normal is what, what feels good and what's emotionally satisfying. that's what normal sex is. (dr. tiefer) only, if only. (peter) what do you mean by that? (dr. schwartz) well, it may be average for older women to push sexuality away. but is it good? it may be average that we all weigh 50 pounds too

much, but is it good? average is often mistaken for normal, and i think the two need to be teased apart. (dr. tiefer) i would broaden the definitions out. we, we have a statistical one, okay, that's average. but then there's cultural and there's clinical normality. and where i think the problem is, is that cultural normality mistakes for clinical normality. and i think that's what happens to the average person, and maybe to dora, as well. when she comes in and says, am i normal, she wants to know clinically is she normal. is she healthy. (dr. surgeon) she's, she's now menopausal, she's 58. so women spend about a third of their life in the menopause, which is, a large part of your lifetime. and so if you're going to spend that much time in the menopause, you should enjoy it. and having a healthy sexual life, should be a part of that. so, is she having pain? is that why she's not enjoying

her sex life? (peter) well, she doesn't mention pain. (dr. schwartz) let me make a distinction. one between arousal and the other between desire. one is, if they have no desire, honestly, i've heard, i've heard women say, if i never did it again in my life, it would be okay. that's not having any desire. the other one is, i, i want my partner, i want to be sexual, i don't feel anything when i am. that's different. so those two things have to be distinguished. (dr. shuster) one of the things that's really useful in, in my care of women at midlife with sexual function changes is, teasing out drive and desire. so very commonly postmenopausally, there's not the same hormonal drive perhaps for sex, but often there is the desire for intimacy, the deep desire for intimacy. so for this woman, though, i would try to find out for dora, is this, is this distressing to her or not. because if it's not, if i'm sure, if it's not painful and it's not distressing, and she's happy with her relationship, and she's, you know, emotionally healthy. then i try not to assume that she needs to be having sex.

(dr. tiefer) i would go right to the distress question. is this a problem for you? but a lot of women are interested. i think that's a good word to use. a lot of women get turned on. that's a good word to use. a lot of women aren't interested, and a lot of women don't get turned on. (dr. shuster) but a lot of women will also say that they're, they're not concerned about it themselves, but when you ask them question further, or give them more time to talk about it, they say, you know, it is different between my husband and i. he, we don't show affection to each other as much anymore. we don't have the same closeness anymore. and for that reason, i miss the sex. and so sometimes they'll say they're not, that they're not distressed by it, but that it does matter to them. (peter) i'll tell you the buzzword that i keep hearing. it's female sexual dysfunction as a disease state. you name it, they like to name things in medicine. now you can treat it as a disease. (dr. tiefer) specifically with female sexual dysfunction is that it implies that there is a normal female sexual function from which this case is deviating. so i don't like the

term, female sexual dysfunction. i think it's a marketing term that the pharmaceutical industry is pushing. (dr. shuster) but in order to care for women with sexual concerns in the medical realm, we, we have to actually have a diagnosis to attach for it, for the visit. and so i think it is an artificial construct, and then because it's been so generalized, i think that is a problem. but within the medical realm, i, i think we just use it for, for the purpose that it serves, in order to bill. (peter) well, let me put you on the spot, since you, you at least would use the term, female sexual dysfunction. (dr. shuster) i wouldn't yet for her. none, none of the information so far would lead me to diagnose this as female sexual dysfunction. (peter) yeah. if you're going to use the term clinically, you need a definition. how would you define it? (dr. shuster) female sexual dysfunction in general? (peter) yes, (( )) (dr. shuster) it is a, well, it's broken down into four main categories, by the conventional wisdom. and so female sexual dysfunction may be classified as a dysfunction of desire, a function of arousal, a function or a problem with orgasm, or a

problem with pain with intercourse. and for defining that as a dysfunction, it has to be a problem in one of those areas, associated with personal distress. (peter) all right, well, what causes it? (dr. shuster) sexual dysfunction is multifactorial. it can be caused by medications, menopause, social issues, like childcare issues in younger women, birth control pills. (dr. schwartz) a bad marriage. (dr. surgeon) a bad, yeah, relationship issues, poor communication. (dr. schwartz) religion, education. (dr. surgeon) religion, cultural issues, postsurgical issues. (peter) you're the one who brought up age and menopause. is that part of it? and is that physical, with decreasing hormone levels with, with menopause? (dr. surgeon) absolutely. there's a, there's a distinct drop in testosterone when a woman becomes menopausal. (dr. tiefer) and there's no correlation between testosterone level and sexual dysfunction symptoms. (dr. surgeon) well, testosterone does decline as a woman ages. and, and.

(dr. shuster) i'm sorry, go ahead. (dr. surgeon) and all the studies have shown that it has something to do with your libido. (dr. tiefer) i'm afraid i can't agree with that. (dr. surgeon) well. (peter) why don't you agree. dr. tiefer) well, i don't think that's what the literature shows. i think we can talk about a lot of other medical possibilities that haven't been looked into as well as this one, but this is one that has been looked into so well, because the prescription of testosterone, unfortunately, is something that's really happening, even off label, and without any fda approval, and that's a problem. (dr. surgeon) clearly there's decline in ovarian function when you become menopausal. now, not all testosterone is produced just only by the ovary. you get adrenal production, and peripheral conversion from. (dr. tiefer) true. (dr. surgeon) .other hormones. but there is a decline when you become menopausal. (dr. tiefer) there's no question about that. but i think that the correlation with the presence of sexual symptoms, is, i just think, you know, the

data are not supportive of that at the moment. (dr. surgeon) i know, but that's why i said it's multifactorial. clearly there are some women who go through life and because their relationship is great, their marriage is great, they're comfortable with communicating with their partners, and they're comfortable with themselves. they continue to have very normal desire, they still get aroused, they have no problems with having comfortable sex. but there are some women who, they may have lower sex drive all through their lives, and when they become menopausal, it's totally gone. they have no desire, no arousal, and it's, it's uncomfortable for them. those are be treated. (dr. shuster) hormones are very important to sexual function, but they are not probably the most important cause of sexual function changes at midlife and beyond. testosterone and estrogen are two very different issues with regard to sexual function. if you look just

purely at testosterone blood levels in women, it is absolutely true that there is not a level of testosterone that's correlated with good sexual function or good health, in general. with estrogen, there are some interesting studies that show that the level of estrogen matters. when the estrogen level gets to a certain amount, interest or desire might change. and when it gets to the lowest level of all, there's often pain with intercourse. (dr. schwartz) you know, i, when i go back to the clinical case that is presented, you know, you sort of wonder, if it's not important, when did it stop being important, and when did, when did sex stop. because i really think that sometimes a lot of these hormones are produced by your behavior, by your activity. it's a reflexive kind of system. so, you know, the longer you've been away from it, the more likely you are to have pain, the more likely you are to, to have trouble, you know, being embarrassed to re-enter that, that area. (peter) does sex have to be important to dora? she

certainly didn't bring it up. (lou) how do you get out of that box, and that, that's part of what i, some of the difficulty having that conversation. how much do you push it, how much is an issue for the patient, because there's so much societal, you know. (dr. tiefer) pressure. (lou).pressure, where it was from one extreme to where it was, like, you don't talk about it, to where if you're not doing it three times a day, there's something wrong with you. (dr. shuster) this is part of the medicalization to assume that, that it needs to matter, or some, that there's a problem that needs to be fixed here. so this, this really is the, the issue, if we're assuming that she has sexual dysfunction at this point, that is a problem with the medicalization of, of sex. (peter) well, let me point something out that i, that i didn't hear. maybe the drugs she's on, are why. çovertalkñ (dr. shuster) absolutely. (dr. tiefer) ssri. (peter) she's on an ssri, she's on. (dr. tiefer) oh yeah, that's right. (peter) .she's on hydrochlorothiazide, and maybe the reason that she has this issue. (dr. shuster) there is not any doubt at all, that those would impact on it, especially the ssri medicine. (dr. schwartz) right. (dr. shuster) so ss. (peter) that's an antidepressant, yeah. (dr. shuster) that's an antidepressant. (dr. schwartz) yes. (dr. shuster) so those have profound effects on sexual function. (dr. tiefer) i just want to point out her mother died a year

ago, so maybe she's grieving. life experiences affect people's interest in sex, as well. (peter) all right, let's pause just for a minute here, and sum up what we've been talking about. we've covered a lot of ground here. sexual response is influenced by a number of factors. some of them are biological, there are social, psychological, cultural. all of them come into play in understanding your own sexual health, not the least of which is medication that you may be taking. dora says to her doctor, and again it's a quote, "sex is not a priority for me. i don't enjoy it." what do you think dora's doctor should ask now? (dr. schwartz) i would like to know this question, did you used to enjoy? but also, well what about it don't you enjoy? why, you know, have, have you always not liked it, and if you have, if you used to, what, what's changed for you? i'd like to know specifically. (lou) i'm not sure i'd get into that with the first visit, because very often from my point of perspective, it would be very different being a sex expert that you can get into that topic. this patient is coming to me for medical care. one of the things i'm going to

be concerned about is that getting too deep into that topic, it's not, you know, it's not (( )) (dr. tiefer) you, you raised it in the first place. i mean, you're either going to talk about it, or you're not going to talk about. (lou) no, no i disagree. because i'm a primary care physician. now i'm not going to see this patient (( )) never again. there's a good chance i'll never see her again if she goes home to her husband and says, this guy kept asking me about my sex life and i just met him. i have opportunities, multiple opportunities down the road to tackle that. çovertalkñ (dr. tiefer) so you would raise it? you would. (dr. shuster) .for another year, remember, she just came in for her. (lou) possibly. (dr. shuster) .yearly. (lou) but she's hypertensive, she's depressed, i'm going to see her again. (dr. tiefer) wait a minute. you would, you said, you would raise it. (lou) absolutely. but i also raise other issues as well with the patient. (dr. tiefer) and you don't follow up on those either? (lou) of course i do. (dr. tiefer) sure you do. (lou) of course i do. but this is a relationship. i just met this lady. and there's lots of issues patients may not be able to talk about or want to talk about on the first visit. (dr. tiefer) so she says, you say do you have any concerns. she says, well, i'm not interested anymore. you say, all right, we'll talk about that next time. (lou) no, no. no that's not the case at all. what i would say is, well, if it is a concern, or it becomes a concern to you, there are options for treatment, if there

is dissatisfaction in your sex life. i would something to the, the issue that where i'm not slamming the door, which you're implying i'm doing. i'm leaving that door wide open. you can walk through it when you want. i'm not pulling you through. (peter) all right, let me tell you a little bit more about what dora tells her physician. dora says she has no interest in sex. she denies pain with sex. her only real discomfort is dryness and even if she gets aroused she's dry. she has to use a lubricant. she doesn't orgasm. she says she used to enjoy sex, but in her mid 40s she began to lose interest, between her job, and her kids, she's tired, she's stressed, "just wants to be left alone." she doesn't really miss sex, but she does feel sorry for her husband, and sometimes she worries that he might lose interest in her. okay. with all this information, i'll go back to you, does she have fsd, female sexual dysfunction? does this make the diagnosis? (dr. shuster) i, i still, i personally wouldn't call it a

dysfunction, but i think that the semantics of that don't matter. the question is, are we going to address this further, and, and so if she's saying that it affects her relationship, then i would find out more about. (peter) she's worried about it. (dr. shuster) .about their relationship. and then we absolutely should explore it further. (peter) how do you help dora. (dr. schwartz) well, what i would say, if some patient came to someone here, and said, you know, i've given up tennis because my elbow hurts. we'd say, boy, it's important that you enjoy tennis. we'll fix your elbow, even though your elbow can get you through a normal day, you can't play tennis anymore. and i would hear this and think, this is a woman who hasn't had an orgasm. (dr. tiefer) ever, ever? (dr. schwartz) it's not clear from that. either. (peter) it's not clear from this note. she says she's certainly not having orgasms now. (dr. schwartz) .if she's ever had it or she doesn't have it. (dr. tiefer) this is important because it's one of the incentives, and sometimes over, overemphasized, but for her to actually say that, i think is to disclose an important thing. (lou) it's very different when the patient makes an appointment.

(dr. tiefer) yes. (lou) comes in and says, my elbow hurts, i need it fixed. versus, they're coming in to have their blood pressure checked and on the review of systems, said, yeah, my tennis elbow is bothering me a little bit. i used to play tennis, but, you know, it's okay. (peter) well, i'll tell you. (lou) i'm not going to jump in and say, we'll do surgery. (peter) but lou, she's already said that's she's worried. (lou) right. (peter) .about her partner. (dr. shuster) about her marriage. (peter) she's worried about her husband. (lou) right. (peter) so, i, let us for the sake of argument, take this as an admission that she's concerned and would like somebody to intervene. what do you do? (dr. shuster) my opinion is that, if she wants to pursue this further, and she is indicating that it's a concern, i think referral to someone that can help address the whole of this issue, is very important. because if we just look at the medicine aspects of it, or just the blood pressure aspects, or just the gynecologic or hormonal aspects, and not get at the, at the whole picture, then, then we're not going to get anywhere. so i think this is the perfect example that brings up the need for, for an approach by a team. (peter) who do you refer to? çovertalkñ (dr. shuster) .a sexual medicine team. (peter) okay. (dr. shuster) .that has expertise in caring for these concerns. (dr. schwartz) if you had a better vision of this person, as

lifestyle, as the things that are happening. you might say that her sexual dysfunction was completely, to use the bad word, normal. (dr.shuster) normal, exactly. (dr. schwarz) in other words, in fact, if she was having a fabulous sex life, you'd wonder, what's, what's with her? you know, because she has good reason. (dr. shuster) that's right. (dr. schwartz) ...to, to have all kinds of issues that would affect her, her erotic self. this is one of the most, as you said, multifactorial things you can have. and to treat it as any less, is not to do the woman justice. (dr. shuster) so coming back to this main point, i think normalizing it for this woman, is important actually, and that that is very comforting to some women. (peter) let's, let's talk about some of the pharmacology here. clearly, people expect, or they may expect, doctors to prescribe something. i'm having a sexual issue. isn't there a drug? (lou) you're right, and that's true of a lot of things, that's the mindset of the american mind, is there's got to be a pill, with a lot of things. (dr. schwartz) well, they would prefer that, but the fact is that there are some things, that do help. i mean, for

example, even telling. (dr. tiefer) lubrication. (dr. schwartz) .lubrication, saying that there are, and encouraging that. çovertalkñ (peter) you mentioned menopause. you mentioned estrogen. (dr. schwartz) right. (peter) what about giving estrogen? (dr. surgeon) estrogen does help because it lubricates the vagina, it improves blood flow to the genital organs. but sometimes you might also need a little testosterone, so. (peter) but do you give estrogen by pill, do you give it by cream, how do you give it? (dr. surgeon) well, there's lots of different ways to give it. pills, patches, gels, creams, lotions, vaginal ring. but i also use testosterone. not in everybody. but in some women, especially if they have had their ovaries removed, especially if there has been a distinct drop off in their sexual responsiveness, in their desire, when they become menopausal. i don't usually treat premenopausal women with testosterone, because, again, there are all of those multifactorial things that

filter into their decrease in desire. and desire is the, is the main problem in women. a third of all women have desire issues, when they report sexual problems, so. (peter) well, let me be clear. i mean, testosterone is the male sexual hormone. (dr. surgeon) yes it is, but women produce testosterone as well. çovertalkñ (peter) estrogen i understand, it's a female hormone. why would i want to give a male hormone, to a woman, who's having problems with her sexuality and her desire and her arousal and her orgasm? (dr. tiefer) i mean there is no approved prescription of testosterone for woman. so anything that you're giving. (dr. surgeon) it's off label use. (dr. tiefer) .is off label, it's at your discretion. there was a testosterone preparation that was actually, appeared before the fda, and they nixed it. so it's not as if. (dr. surgeon) they wanted more studies done. (dr. tiefer) well, they wanted more studies, yeah. (dr. surgeon) long on followup. çovertalkñ

(dr. tiefer) .done, because of the dangers of steroid hormones given over a long period of time. i don't think we want to trivialize this. (dr. shuster) but the problem is the, the global use of testosterone to fix all the woes of low libido. but if we take the patient that coral describes, which i see in my office every day, the woman who's had both of her ovaries removed, and bringing on menopause at a younger age. so i know that doesn't relate to dora. but this is the most clear and compelling group of women that sometimes benefit from testosterone in a huge way. so when a woman has her ovaries removed, and she hasn't already gone through menopause, she has an abrupt, at least 50% drop in testosterone levels. and that abrupt change seems to trigger very significant brain, and sexual function changes for many women. and for these women in whom estrogen does not restore the function that they had before, testosterone can be very important. it's absolutely true that we don't have enough years of experience, but when we're using this for women in replacement doses, this is not

supraphysiologic dosing. we have not seen any of the same problems. (dr. schwartz) but there are a lot of, you know, kind of things out now where you can rub them on, that tingle, little vibrations that you can use during intercourse. (dr. surgeon) right, right. (dr. schwartz) things that are done with herbs, niacin, whatever, that you, warming lubricants. it will give you kind of a rush, and, you know, between the psychology of that and the good feeling of that, those, those lower impact things are not, not a bad thing to this dimension. (peter) let's pause just for a minute. (dr. schwartz) .and people play with. (dr. shuster) sexual aids and devices. (peter) sexual aids and devices. (dr. shuster) yeah, you know, i mean. çovertalkñ (peter) and with that, i do want to pause. (dr. shuster) .when sex feels better, libido improves. (dr. schwartz) absolutely. it's a mind- body. (dr. shuster) libido is rarely a prime, the primary issue. (peter) all right, let's pause just for a minute. many women with sexual concerns can benefit from treatment that addresses medical and emotional issues. sometimes behavioral treatments can work. sometimes there are other treatments that can work. a combination approach seems to be what you're telling me works best. is that fair? (dr. surgeon) it's very fair. (peter) well, let me tell you

what happens with dora. dora made some adjustments, or her doctor made some adjustments to dora's medications. dora began using an estrogen cream. she and her husband as a couple, did seek counseling. it's been six months, and dora is telling her doctor that she's looking forward to enjoying sex again. so dora's story may have a happy ending. is that common? (dr.urgeon) i think if she's involving her husband with getting communication and, and having sex again, then yeah, i think she's on the road to recovery. (peter) all right. (lou) it's a big change in her opinion too. i mean, before she said, i wouldn't miss it, doesn't mean a thing to me. and now she's saying, well. (dr. surgeon) she's enjoying it. (lou) when's this appointment over. (peter) çlaughñ (dr. tiefer) saying that i'm looking forward to enjoying it again, is to me, a bit of a red flag, saying. (sr. surgeon) it's telling. (dr. tiefer) .things have come up. (dr. surgeon) right. (dr. tiefer) this turned out to be more complicated, and i'm optimistic. but i realize this

is not going to be a miracle over night thing. (peter) well, i want to thank all of you for being here. it's been a great discussion. we've covered a lot of ground here today, so what i want to do is just sum up some of the key things that i think our audience should remember. sexual response is influenced by a number of factors. biological, social, psychological, cultural. and all of them come into play in understanding your own sexual health. many women with sexual concerns can benefit from treatments that address medical, emotional issues. sometimes behavior treatments work, couples therapy, stress management can help. because the issues can be multifaceted, a combination approach often works best. and our final message is this. taking charge of your healthcare means being informed, and having quality communication with your doctor. i'm dr. peter salgo, and i'll see you next time for another second opinion. (music) (announcer) for more information on this and other health topics, visit our website at secondopinion-tv.org

(announcer) major funding for second opinion is provided by the blue cross and blue shield association, an association of independent, locally operated and community based blue cross and blue shield plans - supporting solutions that make quality, affordable healthcare available to all americans. additional funding provided by. (music)

óq?rf?txxxñ(l=íw

did you know that over 50% of most people wat bl is for watering their lawn and garden! and remember - you can reduceyr ter bills by collecting rainwater - simply catching the rain that down through your gutters anyway - and storing it in any kind of tank you like. when you need to water your plants, you've got free irrigation water through a hose at the base of your tank now that makes sense.

>> i'm going to show you some fun, easy ways to be active from exactly where you are sitting. get ready to sit d be fit. sit and be fit made possible in part by vq actioncare.com, makers of the resistance chair. when you imagine your future, you wanted to be healthy and active. stay strong. 1-800-570-6220. "sit and be fit" is a creation of mary ann wilson, registered nurse, teacher and recognized leader in the field of fitness and healthy aging. mary ann consults with a team of medical and exercise