Let’s talk vagina
Now that you are an expert on estrogen, vaginal atrophy, long-acting moisturizers, vaginal pH, and orgasms and know what questions to ask your doctor, how do you find one who can actually answer them? How is it that you’re such an expert but your doctor may not be? I hate to say this, but an “MD” after the name is no assurance that the person to whom you are about to bare your soul—and your vagina—is an expert in your particular problem.
So, sometimes the savvy consumer has to do a little legwork to find a clinician who is a real expert on sexual health for women. A sexual health expert is not necessarily your gynecologist—or a gynecologist period. This expert is someone who has an interest in this area and is informed about the diagnosis and treatment of the conditions that affect sexual health. So a sexual health expert might be your gynecologist, or an internist, or a family practice doctor, or a urologist. It’s also possible that the best clinician to help you with your particular issue may not even be a doctor but a highly trained nurse-practitioner.
I want to provide you with a quick and easy-to-understand guide to what you should look for to deal with your specific issues. If you understand who you are looking for, what kind of training is necessary for specific titles, how qualified a physician is, and how non-MD clinicians fit into the picture, you will have a better chance of getting the right treatment. Finding the right person to help you isn’t always easy, but success is a lot more likely if you know what to look for. This way of deciding on a practitioner not only applies to identifying someone to treat your sexual problems but can be applied to every aspect of your health.
Finding a Doctor
“Doctor”: What’s in a Title?
A “doctor” is anyone who has a doctorate-level degree. Anyone with “Doctor” in front of his or her name might be a physician, but might also be a dentist, podiatrist, psychologist, or English professor. If you are looking for a physician, look for an “MD.”
MD stands for “Medical Doctor.” Anyone who has graduated from medical school is allowed to put “MD” after their name. Forever.
DO stands for “Doctor of Osteopathy.” An osteopath’s training is essentially identical to an MD’s and should be considered equivalent.
Licensing
A licensed physician is a physician who is allowed to practice medicine. Each state has its own criteria for granting licenses, but in general, licensure to practice medicine requires only proof of graduation from medical school, at least a year of clinical training, and passing a qualifying exam. To verify that a physician is licensed, go to the Federation of State Medical Boards website (fsmb.org). Please note that licensure is not the same thing as board certification and does not guarantee expertise in a specific field.
Board Certification
Board certification is the gold standard that assures you that a physician is an expert in a specialty or subspecialty. The American Board of Medical Specialties (ABMS) is the medical organization that oversees physician certification by developing standards for the evaluation and certification of physician specialists. To be board-certified, a doctor must complete a residency (post-medical school training) in his or her specialty that has been recognized by ABMS, followed by rigorous written and oral examinations. If a doctor wants to subspecialize, he or she must then complete fellowship training after finishing residency. For example, to be a board-certified fertility specialist, a medical school graduate must complete a four-year residency in the obstetrics-gynecology specialty, followed by a three-year fellowship in the subspecialty of reproductive endocrinology and infertility.
If that wasn’t enough, a specialist or subspecialist has to maintain board certification by taking medical courses and passing tests to prove that he or she is up to date. The criterion in each field is specific to the specialty. Some, but not all, board-certified doctors designate their certification as part of their title. For example, a board-certified gynecologist with the letters FACOG after his or her name is a Fellow in the American College of Obstetricians and Gynecologists. ABMS.org is the site where you can check out whether a physician is board-certified and find out what he or she is certified in.
University Affiliations
It’s generally a good sign if a physician has an academic appointment at a medical school. Faculty ranks such as instructor, assistant professor, associate professor, and professor depend on physicians’ level of involvement in teaching medical students, their research, and the number and stature of their publications.
If a doctor is not board-certified or has no university affiliation, does this mean he or she is a bad doctor? Of course not! Many non-board-certified physicians are excellent doctors who keep up with advancements in their fields and give very good care. Let’s face it, though: if you needed brain surgery, would you go to the brain surgeon who’s board-certified, teaches at a medical school, and is current with the field, or would you pick the brain surgeon who finished a residency but failed her boards, took off five years to be an artist, and then returned and has privileges at a hospital that was in such desperate need of a brain surgeon that it didn’t require board certification?
By now, I’m sure you get the message.
But vaginal dryness isn’t brain surgery. What you need is someone who has an interest in sexual health issues and a knowledge base. Sometimes this expert is a physician, sometimes an internist, sometimes a gynecologist, sometimes a family practice doctor, and sometimes a physician’s assistant or nurse-practitioner (more on them later). You may be thinking, But I’m seeing an expert! If a gynecologist isn’t an expert in this area, who is?
Even in particular fields, doctors have particular areas of interest. A neurologist may be the world’s expert on seizure disorders, but not know a lot about stroke. Your ob-gyn may have an incredible expertise about twin pregnancies and preterm labor, but treats women with vaginal atrophy only a few times a year. So how do you know where a doctor’s areas of interest lie?
What About Referral Services?
Most hospitals have a physician referral service and will help you find a doctor who is interested in and knowledgeable about your condition. If the hospital you have chosen is well known as a leader in women’s health, then that hospital’s referral service is usually a great way to find the right doctor. Keep in mind that the people who work in hospital referrals are obligated to make referrals to all the physicians on staff, so if you just call up and say, “Hi, I have a dry vagina. Which ob-gyn is good?” you’ll most likely be given the name of whoever is next on the list.
What you need to ask are specific questions that will lead you to the doctor who is most appropriate for you. For example, instead of saying, “I need a gynecologist because sex hurts like hell,” you might try, “I’m looking for a board-certified gynecologist who has been in practice for at least five years. I would prefer a woman and would like someone who takes care of a lot of menopausal problems and has identified herself as having an interest or expertise in sexual issues.”
You can get a lot of information from physician referral, and it is well worth your time to tell the service exactly what’s important to you in a doctor. The referral service will also be able to answer questions about office location and accepted insurance. Frequently, a referral service will help you get an appointment, even if you can’t get one just by calling yourself.
Many hospitals also have a “physician finder” section on their website where you can type in a condition to find the physicians who list it as an area of expertise.
Hospital referral services are not the same as the commercial referral agencies that operate independently of hospitals. Take it from me—referral agencies that advertise in magazines, the yellow pages, or on TV are not a great source for good doctors. Participating physicians pay to be part of the service and tell the service what to say. As with any paid advertisement, healthy skepticism is appropriate.
Searching Online for a Doctor
The reason for the increasing popularity of doctor-listing websites is that people are desperate for an easy way to find information about a doctor without actually making an appointment. In our digitally driven society, this seems to be a reasonable desire. After all, wouldn’t someone who has already been to that doctor be the best judge of how approachable or knowledgeable he or she is?
Keep in mind that consumer referral lists are no better than asking strangers on the street what they think. Typically, there are no more than a handful of “reviewers” who are rating the doctors. The typical doctor sees thousands of patients a year, and the experience of two or three people is hardly reflective of a typical experience.
More important, you have no idea who is writing these reviews or what their agenda is. A glowing review may be from the wife or mother of the doctor. A scathing review may be from a disgruntled patient or employee, or from the wife or mother of the competing doctor in town. It has become common for “online profile management” companies to post positive reviews for businesses and products for a fee.
Even if reviewers’ comments accurately reflect their experience, their comments are usually more about how they were treated at the office than about the skills of the doctor. More than one five-star comment has been posted because the doctor was “really friendly,” “had a “great staff,” and offered free birth control pill samples.
Professional Societies
Professional societies such as the American Medical Association or the American College of Obstetricians and Gynecologists are all potential sources of referrals. In the case of sexual function, there are a few societies that are particularly appropriate.
North American Menopause Society
The mission of the North American Menopause Society (NAMS), a nonprofit scientific organization, is to promote the health and quality of life of all women during midlife and beyond through an understanding of menopause and healthy aging. To help meet its mission, NAMS developed a certification exam in 2002. Successful completion of the exam provides a doctor with a three-year credential as a NAMS Certified Menopause Practitioner (NCMP). Menopausal medicine has become increasingly complex, so you are lucky if you find a doctor with this level of commitment and competence.
You can pretty much be guaranteed that a NAMS-certified practitioner has not only the interest but also the expertise to evaluate and treat any of your menopausal issues, including the sexual ones. To find a certified menopause practitioner, go to www.menopause.org.
International Society for the Study of Women’s Sexual Health
The International Society for the Study of Women’s Sexual Health (ISSWSH) is an interdisciplinary, academic, and scientific organization dedicated to providing the public with accurate information about women’s sexuality and sexual health. The organization’s website not only is loaded with helpful information and links to resources but provides a list of providers who are experts in sexual health.
Finding Non-MD Clinicians: Advanced Practice Nurses and Physician’s Assistants
So, is an MD always the best clinician to help you deal with complex sexual health issues? Sometimes a nonphysician is more qualified than many physicians when it comes to diagnosing and treating certain conditions. I am a huge advocate of advanced practice nurses (some are nurse-practitioners and some have other advanced nursing degrees) and physician’s assistants. In addition, an advanced practice nurse or physician’s assistant is likely to spend more time with you than most physicians. I know this firsthand because I have a fabulous, invaluable advanced practice nurse in my office.
I made the decision to use the words “doctor” and “gynecologist” when referring to a clinician in this book because I am a gynecologist. In addition, most women in this country are still seeing a physician as their primary care practitioner. Also, it would have been cumbersome to use “doctor and/or advanced practice clinician/physician’s assistant” throughout the book. To add to the confusion, there are many different degrees that qualify a clinician as an advanced practice nurse.
In general, a clinician designated as a advanced practice nurse has completed the four-year education and clinical experiences necessary to have a bachelor of science degree in nursing, followed by an additional two to three years of a graduate-level nurse-practitioner program (either a master’s or doctorate degree) with board certification.
In some states advanced practice nurses work independently of physicians, while in other states partnering with a physician is required for practice. In any case, advanced practice nurses can function as primary care clinicians and diagnose, treat, evaluate, and manage both acute and chronic illness and disease. They also educate and counsel patients on health behaviors and treatment options.
The following are advanced practice nurse degrees:
NP: Nurse-Practitioner
DNP: Doctor of Nursing Practice
ACNP: Acute Care Nurse-Practitioner
ANP: Advanced Nurse-Practitioner
APRN: Advanced Practice Registered Nurse
ARNP: Advanced Registered Nurse-Practitioner
CRNP: Certified Registered Nurse-Practitioner
FNP: Family Nurse-Practitioner
CNM: Certified Nurse-Midwife
RNC: Registered Nurse-Certified
MSN: Master of Science in Nursing
Certified physician’s assistants (PAs) are not nurses but are licensed and certified health care professionals who practice medicine with physician supervision. A PA must complete an undergraduate degree followed by two to three years of PA school that includes learning both science and hands-on clinical skills.
Just like physicians and advanced practice nurses, PAs may choose to specialize in a specific area such as women’s health. Advanced practice nurses and physician’s assistants are eligible to take the NAMS test and be designated as a NAMS Certified Menopause Practitioner.
Tips for Choosing a Practitioner
After becoming familiar with the background information related to various providers, you can use these practical tips to find someone who can help you.
1. Ask questions when you make the appointment. The receptionist who is making the appointment may not have the time or the information that you need. If so, ask to speak to the practice manager. Find out before you make the appointment whether the physician/clinician has an interest in sexual health. You can get very specific. “I have difficulty with painful intercourse. Is this something the doctor treats routinely?”
2. Check out the medical practice’s website. It’s usually pretty obvious if the practice focuses on pregnancy and contraception or issues of midlife women or sexual health issues.
3. Consider an all-gynecologic practice. A busy general ob-gyn practice tends to focus on pregnant women. An all-gynecologic practice is likely to have a lot more experience, and a lot more interest, in treating the problems associated with sexuality. In a recent survey of ob-gyns, gynecologists were more likely than obstetrician-gynecologists to communicate with their patients about sexual satisfaction.
4. Consider a sexual function clinic. A number of sexual function clinics specialize in women’s sexual health. When you search for one in your area, make sure the doctors running the clinic are board-certified in a variety of specialties that treat issues associated with sexual health. Clinics affiliated with a university hospital are often your best bet.
5. Go to the specialty website. I admit I’m biased, but I think one of the most reliable ways to find an expert is to check out one of the professional society websites listed in the resources section of this book.
However, even if you do your homework, you may simply not have access to a sexual health expert. You may live in a small town, or your insurance may keep you locked into a particular group of physicians. Or maybe you simply like your doctor and would be happy to have a conversation with him or her, but just don’t know how to bring it up. The next section is for you.
Talking to Your Doctor About Sex: If You Don’t, They Won’t
From what I hear, the typical dialogue during a woman’s annual gynecologic visit tends to go like this:
PATIENT: Uh, doctor, I’m having some sexual problems. . . .
DOCTOR: Try a lubricant. So, about your blood pressure. . . .
Actually, this example is a lot longer than most discussions. What typically occurs is no discussion at all. Nada. Zip. If you’re in that majority, chances are that when you went for your annual exam last year, your doctor didn’t even ask you about your sex life, much less offer information on how to make it better! In the 2013 Revive survey, two-thirds of women having sexual problems stated they were never asked about it by their gynecologist. Only about 5 percent of doctors across the board initiate a conversation about sexual function and sexual satisfaction. Ob-gyns seem to do a better job than general doctors. According to a recent survey published by the International Society for Sexual Medicine, 65.6 percent of ob-gyns reported routinely assessing patients’ sexual activities. It would be really interesting to poll their patients to see whether 65.6 percent of their patients agreed that their sexual health had been assessed!
Doctor to her 80-year-old female patient: “I said you had acute angina, not a cute vagina!”
Physicians give three reasons for not routinely bringing up sexual health:
1. Limited time. It’s true that time is limited. There are a lot of issues to be discussed during an annual gynecological visit, and not nearly enough time. By the time you have talked about your elevated cholesterol, your low vitamin D, your overwhelming fatigue, and the swelling in your ankles, there isn’t a whole lot of time left to discuss your sex life.
2. Embarrassment. This explanation is offered frequently, but I don’t buy it. Yes, there are exceptions, but most doctors have no trouble talking about other “embarrassing” things. Have you ever had a doctor change the subject when you brought up your bleeding hemorrhoids?
3. Lack of knowledge. Bingo! This reason, more than any other, is probably the culprit. More likely than not, the person you see to check your blood pressure, do your Pap test, and get your thyroid medication doesn’t know much about the evaluation or treatment of painful sex.
Now that we have established that your doctor is probably not going to bring up the topic of your sex life, you are going to have to figure out how to bring it up yourself.
Bringing Up the Topic
Studies show that most women don’t broach the subject of sexuality with their doctors ever, and if they do, it takes an average of two and a half years from the time a woman perceives an issue until she finally gets up the nerve to mention it.
Sometimes women don’t bring up sexual health issues because they make the assumption that their issues, such as pain during intercourse, are a “normal part of aging” and should be accepted. It’s also not unusual for a menopausal woman to assume that vaginal dryness, like hot flashes and other menopausal symptoms, is temporary. Many are not aware that there are treatments available beyond lubricants. And sadly, too many women don’t feel that their discomfort during sex is serious enough to waste their doctor’s time talking about. And yes, a woman can be too embarrassed to mention her sex life to a doctor who looks like one of her son’s friends or, even worse, golfs with her husband, looks like he hasn’t had sex himself in 30 years, or is focused on “more serious” problems.
As one patient said to me during a seminar on sexuality:
The last time I went to the gynecologist I really wanted to discuss the fact that my interest in sex was essentially gone. The only thing my gynecologist seemed to want to talk about was my weight. By the time he told me that I was at risk for dropping dead from a heart attack unless diabetes got me first, it just didn’t seem appropriate to bring up my lack of libido.
There’s another big reason why women are often reluctant to talk to their doctor about sexual problems. . . .
Your Doctor Doesn’t Have a Vagina
Frequently, a new patient will say to me, “I’ve had the same ob-gyn for 20 years, and I love him, but he’s a man, so of course there was no way I could talk to him about this! I want a woman doctor who will understand.”
As a physician, I can tell you that I don’t need to have personally experienced vaginal atrophy to help my patient with vaginal atrophy, any more than I need to experience a urinary tract infection to know how to treat it. The gender (and age!) of your clinician really shouldn’t matter. Really. The exception is the patient who is totally uncomfortable being examined by a man or talking to a man about intimate issues. That patient will be better off with a woman doctor. If you feel somewhat guilty discriminating in this way, consider the number of men who go to women urologists. On the other hand, it would be foolish to go with the less qualified doctor based solely on gender, so keep an open mind.
Many women go to a woman gynecologist because they subconsciously—or even consciously—think that talking to a female gynecologist will be like talking to a girlfriend. While it is generally easier to talk to a girlfriend about sex than to your doctor, you are not looking for a new friend at the doctor’s office. You have plenty of people to invite to parties and have lunch with. When choosing your gynecologist, you are looking for someone who has the skills you need and whose judgment you trust. Your doctor need not be your friend, but she or he does need to be someone who will talk to you, listen to you, and help you. Sometimes that person is a woman, and sometimes it’s a man.
V-A-G-I-N-A, VAGINA!
I’ve come to the conclusion that one of the reasons women have a hard time talking about sex is that they don’t like saying the word “vagina.” It’s a weird thing. They have no problem saying “bladder,” “breasts,” or “throat.” But when it comes to discussing specifics about our genitals, some ladies just can’t spit out the word.
My patients will say things like:
“I’m having a problem—down there.”
“My good girl is itchy.”
“My v-jay-jay hurts.”
“My huh-huh (pointing) isn’t right.”
One of the many reasons I like Dr. Oz is that he brings the word “vagina” into our living rooms and kitchens on a daily basis. (The first time I appeared on The Dr. Oz Show I asked during the rehearsal if I was allowed to say “vagina,” as many television shows won’t allow it. I was told, “Are you kidding? We say ‘vagina’ on this show more often than we say ‘hello.’ ” Love that!)
However, while it’s one thing to say “vagina,” it’s another to have a conversation about your vagina. Even with your girlfriends, it’s not always so easy. Can you imagine going to lunch with your friend and saying, “Sophie, my vagina is so dry, it is like the Sahara Desert. George and I tried to have sex last night, and it was so painful we gave up. How’s your vagina?”
Mention What You’d Like to Discuss When You Make Your Appointment
When you book the appointment, this is a good time to mention that you have an issue you would like to discuss. You can simply say, “In addition to my annual exam, I have some concerns related to pain during sex.” It will then be noted as the reason for your visit, making it more likely that your doctor will bring up the issue. Some women find it easier to mention their concerns to the assistant who brings them into the examination room. The assistant lets the doctor know that the patient has brought up a specific topic, and then the doctor is likely to initiate the conversation.
Bring It Up at the Beginning of the Visit
At the time of your visit, immediately say (as in right after “hello”), “I know I need to lose weight, but since we have a limited amount of time, I would prefer to discuss other health concerns today.” Then go for it. “My libido is gone, my bladder is leaking, etc.” That way the topics you want to cover will be addressed as priorities, not tacked on during the last five minutes of your appointment.
Your doctor may totally surprise you and be very helpful and knowledgeable in this area. He or she will be pleased that you have come armed with a great deal of information as well—which you’ll have, of course, after reading this book! More often than not, your doctor will be appreciative that you brought up the topic because he or she simply wasn’t aware that it was an issue for you.
If Atrophy Is an Issue, Make a Separate Appointment to Discuss It
Often a patient will come for her annual “well woman” visit with 10 or 12 issues she wants to discuss. When I explain that there is not enough time to deal with all the problems in one visit and that another appointment needs to be made, sometimes I get an unhappy patient. I understand. You’ve taken time off from work, parked, and paid your copay. An additional visit is not only inconvenient but also expensive. But there simply isn’t time to adequately address the complexities of these gynecological issues at the time of your annual exam, and they can’t—and shouldn’t—be quickly tagged onto your routine visit.
Many women are reluctant to make an additional appointment, since their insurance may cover only “well woman” visits and not “problem” visits. But face it, you are having a problem! You deserve and need more time. Your doctor is going to take the time to evaluate and treat the problem if that is specifically why you’ve made an appointment to see him or her. If it is important enough to you to mention the problem, give yourself permission to go for another appointment.
Consider Seeing a Sexual Health or Menopause Specialist, Even if Your Insurance Doesn’t Cover It
While good health care is our right and I believe every man and woman should have access to a doctor who can help them, sometimes the care you need is not available within the limitations of your health care plan. If you really feel that you can’t discuss your issues with your current doctor, or if your doctor seems truly clueless or embarrassed when you bring them up, bite the bullet and spend the money to see an expert, even if that person is not covered by your insurance plan.
You spend far more annually on the person who fixes your hair than you will pay to see someone who can fix your vagina. Trust me. Even if you have to do a lot of research or travel a great deal to find the right expert, it is likely that you will need only one or two consultations. And you do not need to end your relationship with your regular gynecologist, whom you can continue to see for routine visits.
Make a List
It’s always easier to come up with a list of concerns when you are lying in bed at 3:00 AM than when sitting on an exam table wearing a silly paper gown. So, whether it is an annual exam or a visit with a specialist, make a list of what you are worried about before your visit.
When you see your doctor, you can start by saying, “I have some specific concerns, so I jotted down my questions.” If you can’t manage to spit it out, just hand the doctor the list. This happens more often than you would think. But keep the list short and specific. For example, “Sometimes when I have intercourse it seems dry. What options do I have?” Don’t whip out a three-page list containing every symptom you’ve ever had in the history of your life, as in: “Four months ago I had a pain in my stomach during sex. It hasn’t happened since, but I was wondering what caused it?” Be as clear and concise as possible as you list any symptoms that you’ve had recently and repeatedly.
If All Else Fails . . .
If you have a hard time talking to your doctor about your sexual issue and you don’t have the option of seeing another practitioner, I hope that this book at least will have helped you identify your issues and given you ways to fix them. If you think you need to see a pelvic physical therapist, ask your doctor for a referral. If you need a prescription for a local estrogen, just ask for the one you want. Most likely, your doctor will just give you the referral and the prescription, no questions asked. You’re welcome!