At least, that’s how Streicher sees it. When she has a say in the matter, her patients opt for HPV protection decades beyond the FDA’s cutoff age. They expose themselves to life-changing meds labeled—mislabeled, she would say—as potentially carcinogenic. They forget Kegels, and they jury-rig their birth control so they never get their periods. That is to say, when it comes to sex, hormones, and general gynecologic health, Streicher is recommending the opposite of many things your gynecologist likely advises. And it appears that her patients feel healthier and much better about their sex lives for it. As it turns out, Streicher’s peers in gynecology are availing themselves of similar rule-breaking habits, but not passing such secrets on to their patients. A few years ago, she conducted a formal poll of 1,000 board-certified gynecologists, asking them personal questions like how they chose totreat their own menopause symptoms, what they were doing about painful sex, and what they would choose for birth control. What she found was telling: More than 80% of the doctors she surveyed were making very different choices from those their patients made. “There’s something amiss in the world of medicine when most gynecologists would do things differently from most American women,” she says. MORE: What The Color Of Your Pee Says About Your Health Amiss, but maybe not surprising. “Doctors tend to get comfortable with one choice, sticking with certain options even as research evolves and shows that a more appropriate treatment may be available,” says Leah Millheiser, director of the Female Sexual Medicine Program at Stanford University School of Medicine. And, understandably, many practitioners are hesitant to prescribe treatments that aren’t backed by the FDA. But Streicher, who maintains a practice in Chicago and is a clinical associate professor of obstetrics and gynecology at Northwestern University, has a different approach. “The way I’ve always practiced medicine is to look at the literature and make recommendations based exclusively on the evidence,” she says. “My advice to patients is based on what I would do for myself—that’s how appropriate I know it is.” Streicher’s efforts to shake up her field started about 10 years ago, when patients going through menopause started coming to her for second and third opinions because they were frustrated by their symptoms and by the unsatisfying sex they found themselves having (or not having, as the case more often was). “There are needs out there that are not by any measure being met by gynecologists,” she says, with doctors telling patients to try lube, take a bath, or buy a fan. “Too often it’s the guy at Whole Foods advising women on what to do about hot flashes, or women talking to their nail technicians about painful sex.” (We did the asking for you; here are 12 embarrassing sex questions you’re too afraid to ask.) Why the disconnect? Streicher chalks it up to lack of time and competing interests on the part of many doctors. “The majority of gynecologists are also obstetricians,” she explains. “So if 90% of their practice is obstetrics and only 10% is gynecological patients, and of those patients some are young women coming in for birth control, then only a small percentage of their practice is women going through menopause, so that’s not something they’re going to spend a lot of time on.” Some fault also lies with patients, Streicher adds, for expecting to cover all their issues in one 15-minute annual visit. “I can’t tell you how often I tell women who are having vaginal dryness and painful sex to make a separate appointment,” she says. Many don’t follow up. “The patients have to make it a priority.” MORE: 6 Ways You’re Making Your Menopause Symptoms Worse When they do, Streicher makes the time, allotting 45 minutes to an hour for a menopause consult or a second opinion on a hysterectomy. “When our receptionist schedules an appointment, she asks the reason for the visit—not because she’s nosy but because she wants to know how much time to schedule,” Streicher says. Inspired by what she saw as practically universal complaints among her patients, Streicher wrote a book in 2014 called Sex Rx: Hormones, Health, and Your Best Sex Ever. She gives talks at conferences and luncheons, and writes a blog—Midlife, Menopause and Beyond—on EverydayHealth.com. Her next venture is as director of the Sexual Health Clinic at Northwestern Memorial Hospital in Chicago. “Sexual health issues affect 53 million US women,” Millheiser says. “Lauren has done something groundbreaking by writing content with research behind it that women can take to their doctors. That is novel.” Check out the rules that Streicher is breaking most frequently these days and circle back with your gynecologist as needed. “If you don’t get anywhere—because your doctor doesn’t seem open to discussion or isn’t knowledgeable about menopause issues—find a specialist who will listen,” she says. “Just because your doctor doesn’t have a solution to your hot flashes, incontinence, or painful sex doesn’t mean that there isn’t one. “In almost every situation,” she adds, “there is.“YOUR QUESTION: What do I do for vaginal dryness and pain?WHAT YOUR GYNO SAYS: Try a lube—hormones aren’t for everyone, ya know.WHAT STREICHER SAYS: Ignore the warnings and use vaginal estrogen. Vaginal estrogen products can be a major boon for easing symptoms of thinning tissue down there. But these treatments have all been slapped with labels warning that they could increase your risk of blood clots and even dementia. This is wildly misleading, Streicher says. They’re labeled that way because of a poorly considered regulation: Once the FDA has looked at the side effects of a specific substance—in this case, estrogen—any medication that has that component will get stuck with a warning. Research from the Women’s Health Initiative, an ongoing study of women’s health, found that oral estrogen—the stuff you take in pill form—increases the risk of blood clots and dementia, so now every single estrogen product has to have that on its label. “Thing is, it’s been shown in the research to apply only to oral estrogen and certainly not to local vaginal products like creams, tablets, and rings, but the FDA still requires that labeling,” Streicher says. Most doctors won’t offer such products as an option or will tell patients they’re not right for them. Streicher, on the other hand, prescribes local vaginal estrogen even to women with breast cancer—even though conventional wisdom says it could possibly fuel cancer cells that are receptive to the hormone. “Am I going to break the rules and give estrogen to women with breast cancer?” she says. “You bet, because that’s good medicine.” Research has shown that local vaginal estrogen—applied directly to the vagina—doesn’t raise breast cancer risk or increase blood levels of estrogen in women who use it. “The local vaginal estrogen companies have never tested their products on women with breast cancer; it’s too expensive,” Streicher says. “But observational data shows that it’s not a problem, and there’s no scientific reason to believe that it would be.” In Streicher’s poll of her fellow gynecologists, 90% agreed that they themselves would use local vaginal estrogen if they had dryness and pain, even if they had breast cancer. MORE: 8 Things To Never Say To Someone Going Through MenopauseYOUR QUESTION: Should I start hormone therapy after menopause?WHAT YOUR GYNO SAYS: Hormone therapy can be a dicey choice.WHAT STREICHER SAYS: It will likely be great for your health. “Many women come to me and say they’re going to tough their symptoms out because ‘How long will they last anyway?’ " Streicher says. “And now we have an answer to that question: longer than you think.” The latest buzz about hot flashes, which affect some 80% of women, is that they persist for an average of 7 to 8 years, even 13 or more for some people, according to a 2015 study in JAMA Internal Medicine. While most docs are reluctant to prescribe hormones at all—and if they do, they generally stop them within 3 to 5 years—Streicher believes in the safety and benefits of hormone therapy for longer, if you’re within 10 years after menopause and an otherwise good candidate for the treatment. While you may have heard differently, “there’s no evidence that women who initiate hormone therapy at the onset of menopause can take it safely for only a few years,” she says. “In fact, we have good data showing that women who continue it for years are not at risk and may, in fact, benefit.” Besides a cut in hot flashes and night sweats, there’s compelling evidence that if you begin hormone therapy within the first 10 years of menopause and keep taking it, it may help preserve brain function as you age. (These 10 questions can help determine your dementia risk.) If you’re weathering hot flashes and other pesky symptoms and want to start hormone therapy but it’s been more than 10 years since your last period, risks—including blood clots, heart disease, and a negative impact on cognitive function—do become a concern. If your primary doctor can’t help with questions about hormone therapy, consider scheduling an appointment with a menopause expert. (Go to menopause.org and click on “Find a menopause practitioner.") MORE: 5 Reasons It Hurts Down There YOUR QUESTION: Where the hell is my libido?WHAT YOUR GYNO SAYS: Accept that sex drive flags in menopause.WHAT STREICHER SAYS: There’s a fix out there for you. When women complain to their doctors about zero sex drive, they’re often told that it’s just a normal part of aging or to go buy lacy underwear. “The difficulty in treating low libido is that it’s multifactorial—are you having pain? Are you on birth control pills or antidepressants?” Streicher says. “Many doctors, because it’s so complex and because there aren’t any drugs available, will be dismissive or just not helpful.” Streicher takes a lengthy personal history and does a physical exam to try to ID the problem. Her probing questions elicited a eureka moment for one woman. “She interrupted me halfway through and said, ‘I just realized that I hate my husband. And I hate living in southern Illinois.’ She walked out into the waiting room and told her husband their marriage was over.” That’s certainly not the best-case scenario, but it illustrates that sex problems can have many root causes—and it takes a longer conversation to figure out what they are. Even patients who adore their husbands may not feel inspired to hop in the sack, and for them, Streicher will often try an off-label testosterone gel, which frequently does the trick. One new option is the drug called flibanserin, just approved by the FDA in August. “Flibanserin works on a neurotransmitter level, decreasing serotonin and increasing dopamine, which impacts libido,” Streicher explains. “It won’t be miraculous for everyone, but for some women, it will make a difference.” (Here’s what you need to know about flibanserin.) MORE: 9 Highly Effective Solutions For Yeast Infections YOUR QUESTION: I’m dating again! How do I avoid HPV, that STD that everyone seems to have?WHAT YOUR GYNO SAYS: Use protection and hope for the best; if you’re over 26, you won’t benefit from an HPV vaccine.WHAT STREICHER SAYS: Get the vaccine no matter how old you are. The vaccine protects against human papillomavirus, which can cause cellular changes that lead to cervical cancer. Although it’s FDA approved for women only to age 26 (a guideline most doctors stick to), it was studied in women through age 45 because the manufacturers were considering seeking approval for up to that age. While the vax won’t pack as big an immunological punch for women in their 30s and older since they’ve likely already been exposed to some of the strains, it can still have value. “The newer vaccinations protect against up to nine strains of HPV,” Streicher says. “The likelihood that someone has been exposed to all nine strains even in middle age is low to nonexistent.” Streicher’s aforementioned patient, who is now coming in weekly to have genital warts burned off her vulva, is a living example of why more doctors ought to reconsider the FDA’s age limit for the HPV vax, in Streicher’s opinion. You’ll pay out of pocket for the three injections, to the tune of about $250 to $300 each, but compared with treating an HPV infection or developing cervical, vulval, or other anogenital cancer, “it’s a bargain,” she says.YOUR QUESTION: I still have my period. Can I make my cycle easier to deal with?WHAT YOUR GYNO SAYS: Follow directions on your birth control pills.WHAT STREICHER SAYS: Skip the off week; it’s actually better never to get your period. If you’re on hormonal contraception, there’s no reason not to take it continuously—as in, to skip the bleeding part of the cycle. “The time off has no medical benefit,” Streicher says. When Seasonale came out, promising just four periods a year, Streicher asked the company why four—why not none? “They said it had nothing to do with science and everything to do with market research,” she reports. They said women are uncomfortable with not getting their periods, that it’s not natural. “But birth control pills aren’t natural,” Streicher says. “To be pregnant or nursing all the time and then you die—that’s what’s natural.” What’s more, the drop in hormones during that off week can wreak havoc: migraines, miserable cramping, and endometriosis pain, not to mention accidental pregnancy. If you’d like to pass on those, ask your ob-gyn to write a prescription that stipulates no placebo pills or is for four packs at a time instead of three. “Sometimes it takes a call to the pharmacy, but we can usually find a way,” Streicher says. MORE: The 10 Worst Things That Can Happen When You Don’t Get Enough Vitamin D YOUR QUESTION: Should I do Kegels to prevent leakage?WHAT YOUR GYNO SAYS: Yep, do them to keep in shape.WHAT STREICHER SAYS: Meh, don’t bother; there is a better way. “It’s not that Kegels don’t work,” Streicher says. “But studies show that the majority of women don’t do them correctly—they flex the wrong muscles or don’t do them consistently.” So Streicher tells patients to forget going it alone and instead work with a pelvic-floor physical therapist to truly master how to strengthen the pelvic-floor muscles that support your uterus, bladder, rectum, and small intestine. (Here are 4 essential moves that will strenghthen your pelvic floor.) Not only will that intensify orgasms (because the muscles will contract more robustly), it will also help prevent incontinence, which affects up to 57% of women between 40 and 60. “Even if you’re losing just a piddle of urine when you sneeze, you can benefit from pelvic-floor therapy,” she says. One patient, an active woman in her early 40s, told Streicher that she’d stopped running and playing tennis because she was peeing a bit in her pants every time, and Kegels weren’t helping. Streicher got her into pelvic-floor therapy, and after 2 months, the patient was completely dry. MORE: 6 Alternative Doctors You Should Consider Seeing To locate a pelvic PT, visit the American Physical Therapy Association site (womenshealthapta.org). “But if you’re not comfortable with someone’s fingers inside your vagina,” Streicher advises, “there are devices that can replicate what a therapist does.” Think of them as Fitbits for your vagina, providing feedback on your progress. Streicher is a former spokesperson for Intone, a prescription device proven to treat incontinence, but many more exist, including Elvie, KGoal, and PeriCoach, all of which work in tandem with your smartphone. Game on!
