When it comes to pregnancy, sex or menopause, there are related health issues women often find too embarrassing to discuss openly with their doctors. That ends here, with a special report in which we asked medical experts to give us the straight talk on what might feel too personal for you to bring up.
Besides time spent with romantic partners, women tend to share their most intimate secrets with their doctors. Yet even in a relationship with their obstetrician/gynecologist—one that so often takes place lying down half-naked, with feet in stirrups—women can sometimes be circumspect when it comes to discussing things that seem, well, too intimate.
“Sometimes, you find out what’s really going on when their hand is on the door and they are ready to walk out,” says Dr. Scott Chudnoff, a certified sexuality counselor who is chair of the Department of Obstetrics & Gynecology at Stamford Hospital. “And it’s too bad, because usually that’s the stuff we should have been spending a good part of the office visit talking about.”
What’s keeping patients from bringing up concerns that physically and emotionally torments them with people who are in a clinically-trained position to help? “Shame is the overarching theme that keeps people from telling me or their medical doctor what’s really going on,” says Maud Purcell, a marriage and family therapist from Fairfield and founder of the Darien-based Life Solutions Center. “For some people—particularly those who have a good rapport with their caregivers—there can even be a fear of experiencing our disapproval.”
And yet all the doctors we spoke with voiced an I’ve-seen-it-all response. “I want my patients to know that you really can’t shock me, nor will I judge you, because the truth is—and I can’t stress this enough—I’ve seen and heard everything by now,” says Dr. Shieva Ghofrany, an OB/GYN with Coastal Obstetrics & Gynecology in Stamford who is affiliated with Stamford Hospital. “You may be mortified by your hemorrhoids, but honestly, on a typical day, I’ve seen a whole lot of them by noon.”
If you are nodding knowingly, this feature is for you. Here’s your chance to learn more about some health concerns the medical experts we spoke with wish their patients would feel more comfortable discussing. Who knows? Reading about it here may be just what you need to open up.
1. OH, BABY!
ON PREGNANCY & FERTILITY
Even though giving birth can strip a mother of her dignity (and physical privacy), there are some things that are harder to discuss than others with the doctors who help women bring babies into the world. We asked the pros to share some intimate concerns their patients are sometimes reluctant to discuss but should before, during and after pregnancy.
ENDING THE STIGMA OF MISCARRIAGE
One out of four pregnancies ends in miscarriage. It’s a tragic statistic that inevitably comes with heartbreak and a crushing sense of personal failure, says fertility specialist Dr. Andrew Levi of Park Avenue Fertility, which has offices in Fairfield, Norwalk and Trumbull. The shame of miscarriage, he adds, is particularly pronounced among those struggling to conceive. “I can’t stress enough that the loss of that baby had nothing to do with what they drank at a party, their workout on Saturday or what they ate for dinner,” he says. “Yet again and again, I see women blame themselves for a lost pregnancy.”
Dr. Scott Chudnoff says the unnecessary shame associated with miscarriage means it often remains a taboo subject. “And as a result, people don’t grasp how incredibly common it is,” he says. He recalls a recent dinner party where a female guest shared the emotional trauma of recent pregnancy loss and “every couple at the table went around and told their own story of miscarriage. It was remarkable to see the relief on her face. She felt alone until that moment and had no idea that this was an experience almost everyone trying to start a family has had.”
The Fix: If miscarriages are chronic and recurring, a medical evaluation can determine if there are physical issues or fetal genetic abnormalities contributing to failed pregnancies. “In most cases, the best thing to do is take some time to recover and then try again,” says Dr. Levi.
THE STATE OF THINGS DOWN THERE, Part 1
Sometimes private parts can change post-childbirth, particularly after multiple vaginal deliveries. The labia can become distorted and the vagina can lose some of its normal laxity. (Those changes can also be more pronounced post-menopause.) “I’ve had patients so upset about the state of their [genitals] that they’ve been undressing and having sex in the dark for years,” says Dr. Gregory LaTrenta, a board-certified plastic surgeon who practices in Darien and Manhattan.
“One of the things we need to talk more about is what normal female genitals look like,” says Dr. Chudnoff. “Because of the easy access to pornography in our digital world, there’s a perception of airbrushed perfection that is impacting women’s self-image and self-esteem.” For that reason, he suggests many labiaplasties are probably unnecessary. “There are certainly instances where such drastic changes have occurred. And some girls are even born with deformities that can be acutely embarrassing,” he says. “But in most cases, what people perceive as abnormal is not.”
The Fix: For those who want a cosmetic solution, Dr. LaTrenta, who is affiliated with Stamford and Greenwich hospitals, has been performing more labiaplasties lately. This cosmetic surgical procedure involves removing excess skin from the genital folds to create a more uniform appearance. Data released by the American Society of Plastic Surgeons says the procedure witnessed a 39 percent spike in popularity in 2016, with more than 12,000 procedures reported nationwide. “People tend to think it must be extremely painful, but it actually is a fairly simple procedure and recovery,” says Dr. LaTrenta. While sex is a no-no for about four post-operative weeks, he says patients who have been unhappy with the state of their genitals say the results are worth it. “It can do wonders for their self-esteem and sex life.”
While current estimates show one in eight couples experiences some form of infertility, it remains a highly emotional subject. “There is a sense of personal failure, which might be lessened if people understood how many couples are going through the same exact thing,” says Dr. Levi.
In many cases, infertility must be addressed in an aggressive way to beat the real and consequential ticking of the biological clock. “If you are a woman over thirty-five and have been trying to conceive for over a year, it’s time to come in so we can talk about it,” says Dr. Spencer Richlin, a fertility specialist affiliated with RMACT, which has offices in Stamford, Norwalk, Trumbull and Danbury. Since fertility declines with age, women older than forty should seek intervention after six months of trying with no success.
While fertility specialists are constantly expanding assisted reproductive technologies, there are some critical facts your fertility doctor needs to know to optimize chances for conception. “While I do a thorough workup with new patients, there are things I need you to be honest about to help you achieve your goals,” says Dr. Levi.
The discussion points may include:
• A history of eating disorders or extreme exercise “They can impact the regularity of the menstrual cycle, which can, and does impact fertility,” says Dr. Levi.
• Any unhealthy habit including smoking, vaping, drug use, and excessive alcohol or caffeine consumption.
• Is the man taking steroids like testosterone? “It has a major impact on sperm production and can even stop it,” says Dr. Richlin. “If we get [men] off it, we usually can see [sperm] production improve in about three months.”
• Sexual dysfunction “The reality of biology is: To get pregnant, the sperm has to meet the egg somehow,” says Dr. Levi. “Sometimes you dig deep and you find out that the male is experiencing premature ejaculation and the couple isn’t really addressing it.”
• Limited sexual contact “I’ve worked with couples who come in for fertility treatments, but you find out for a variety of reasons—including some religious or cultural ones—they are not actually having sex,” says Dr. Richlin.
• History of sexually transmitted disease “Something like gonorrhea or chlamydia when you are younger can block the fallopian tubes,” says Dr. Richlin. “We test for those things, but it is better to know up front.”
• Weight struggles or unusually pronounced hair growth “It can be a sign of polycystic ovarian syndrome, which has an impact on fertility,” says Dr. Richlin.
THE LADIES ROOM
You’re not alone—the lowdown on leaky bladder syndrome and how you can treat it
From slim, discreet pads to thick, adult diapers, the row devoted to leaky bladder products in the corner pharmacy speaks to an often mortifying problem that tends to affect women after childbirth and during menopause. “We need to start talking more openly about the fact that a lot of women are peeing on themselves,” says Dr. Scott Chudnoff. “It causes shame for so many, but the reality is it’s incredibly common.”
Indeed, the dribbles (and gushes) of urine associated with various leaky bladder syndromes are so common that Dr. Scott Serels, chief of Urogynecology at Norwalk Hospital and founder of the Bladder Control Center of Norwalk, estimates that as many as 40 percent of all women experience some form of urinary incontinence in their lifetime. Those percentages, he says, tend to increase with advancing age.
For some, the problem is relatively inconsequential; maybe a few drops of urine during a hearty fit of laughter. For others, incontinence is so common that donning protective undergarments—and stashing a ready change of clothes—can become a frustrating lifestyle. “I tell my patients it’s a problem when it’s interfering in their lives,” says Dr. Serels. “And from patient to patient, how they define that varies. I have seen patients who have been wearing diapers for ten years before they came in [for help] and patients who book an appointment the first time they have a little leak while exercising.”
Before seeking treatment, it’s important to understand there are two leading types of urinary incontinence with distinct treatment options, explains Dr. Serels. They are:
• Urgency Incontinence This syndrome is epitomized by intense, often frequent, urges to urinate. “It’s that, ‘gotta go, gotta go,’ feeling,” says Dr. Serels, and the underlying cause tends to be a change in the neuroanatomy of the bladder. “The bladder is just a giant muscle stimulated by nerves and sometimes, for a variety of reasons, those nerves can start to miscommunicate,” he explains. Those reasons may include childbirth, menopause and pelvic surgery.
The Fix: Treatment usually begins with behavior modification, says Dr. Serels. So, a patient with urges to urinate every twenty minutes will be encouraged to build up bladder stamina by waiting an hour. Depending on the severity of symptoms, treatments typically progress along a continuum that can include medications and sacral nerve stimulation, which involves the implantation of a small, pacemaker-like device to control the bladder.
Treatment may also include Botox. Injected through the urethra, Botox has proven effective in up to 70 percent of women who tried to control urgency symptoms with medication and failed; results can last for up to ten months, says Dr. Serels.
• Stress Leakage Leaking urine when you cough, laugh, sneeze or exercise vigorously is a form of incontinence that is often linked to anatomical changes that can follow pregnancy or menopause. Close to 15 percent of women who deliver a baby vaginally will experience some form of stress leakage, but this syndrome can also be related to genetics, says Dr. Serels. So, while women who’ve delivered babies by C-section are less likely to experience leakage, they are not immune. “I’ve seen this issue in teenagers and in women who have never had children,” says Dr. Chudnoff
The Fix: While exercise to strengthen muscles has proven effective in some milder cases, Dr. Serels says the approach is not always as curative as some sufferers hope. Combining physical therapy with biofeedback tends to be more effective and gives some sufferers a non-invasive approach to relief. Another option: Injections of synthetic bulking agents around the urethra, which curbs leakage by controlling the sphincter. When these don’t work, Dr. Serels says the most effective treatment is the surgical insertion of a mesh-sling device that supports the urethra. “It essentially functions as a backboard for the bladder” and boasts a 92 percent success rate.
Medical Advice: Understanding urinary incontinence is critical because it sometimes is an early warning sign of more systemic medical issues including multiple sclerosis and Parkinson’s disease, says Dr. Serels. Doctors may also look for tumors and polyps. “There are things that need to be investigated if only to rule them out.”
MORE THAN THE JUST THE BLUES
When Dr. Ghofrany discusses postpartum depression with patients parenting newborns, she makes a clear distinction between “feeling a little down” after childbirth and a clinical diagnosis of postpartum depression. “One reason I like to talk about the difference is because just about everyone is a little off and overwhelmed after giving birth,” she says. “We have this idea that we’re supposed to be blissed out, but it’s overwhelming and exhausting and for most of us, at some point, if we are caring for a newborn, we are not going feel our best.”
The distinction between normal stress and postpartum depression is an important one, says Dr. Chudnoff. “Postpartum depression is rarely discussed but has potentially devastating medical consequences,” he says. “I stress the words ‘medical condition’ because frequently, women downplay its significance. Many women experience mild depression around childbirth. However, in some cases this becomes truly disruptive and potentially dangerous.” He notes in some rare cases, the depression can lead to postpartum psychosis, a leading factor in the murder of children under age one.
Dr. Joseph Flynn, medical director of Behavioral Health and Psychiatry at Greenwich Hospital, says there is guilt about postpartum depression that keeps women from sharing symptoms, which can include anxiety, a sense of detachment and even anger toward their infant. “The problem is it’s supposed to be a happy time. They wanted this baby, were thrilled to have it and then, something feels completely off. The patients I’ve seen with it say they almost had to put on a façade; they were going through the motions trying to act happy when indeed they knew something was wrong.”
Still, coming forward is critical. Dr. Chudnoff says that the openness of celebrities like Gwyneth Paltrow and Brooke Shields about their devastating experiences with postpartum depression has helped to diminish some of the stigma. “When women start to realize that they aren’t alone, they can get the help and support they need.”
THE DONOR DILEMMA, Part 1
Often it seems like there’s a story about a Hollywood celebrity in the far reaches of her forties—or beyond—who has welcomed a baby. What’s usually not shared publicly is that donor eggs or embryos likely played a role in conception. Those mature first-time-mom stories can naively lull many hopeful parents into thinking their fertility has a longer shelf life than is biologically possible, fertility experts say. “The reality being that no matter how good someone looks on the outside or how young they feel on the inside, the eggs are still eggs of a certain age,” says Dr. Richlin.
“The truth is the oldest woman I’ve ever [helped] get pregnant with her own egg is forty-five,” says Dr. Levi. “Fertility diminishes so much in the forties that it increasingly becomes a challenge to have a baby using your own eggs every year older you get. People don’t talk about it, but so many pregnancies these days involve the use of donor eggs or embryos.”
Medical Advice: If you are in your twenties or thirties and thinking you might want to eventually have a child, consider visiting a fertility specialist to discuss egg freezing. “The technology is there,” says Dr. Richlin. “[Egg freezing] can put you in a position, when you are a little older, of not needing donor eggs or embryos if you decide to go forward with plans to have a family.”
THE DONOR DILEMMA, Part 2
The increasingly common practice of older, first-time parents of using donor eggs and embryos has triggered an ethical conversation between fertility specialists and their patients about how and when—and if—to tell children conceived using these methods that they are not genetically related to their mother (in the case of donor eggs), their father (if donor sperm is used), or both parents (in the case of donor embryos). “It can be a tricky thing for parents to navigate, but it is one reason why we have them work with social workers to sort through these things before they proceed,” says Dr. Richlin. “Even with counseling, people ultimately come to different conclusions about what they want to share.”
The American Society of Reproductive Medicine has weighed in with an official opinion: The organization, comprised of fertility specialists, recommends that children conceived with donated reproductive materials should be eventually informed, if only to have knowledge of and understand their medical history. “The fact of the matter is, they are your children but they have different DNA,” says Dr. Richlin. “The question really comes down to what is the right and best time? We tend to think it’s when they are teenagers and can process the information best.”
The Fix: Some fertility practices are now offering the increasingly popular option of choosing eggs of donors who are willing to be identified and contacted once a child reaches eighteen. Dr. Richlin estimates that more than 50 percent of the patients in his practice are choosing egg donors who have signed yes in the Donor Identity Release form.
2. UP CLOSE & PERSONAL
ON SEX & INTIMACY
In a digital world where the sparks of romance can now begin with the swipe of a screen, the dating landscape has certainly changed.For anyone of a certain age who’s looking for love again, there are a few things even scarier than learning your date used a fake profile picture. Doctors tell us these include STDs, age-related sexual dysfunction and other confusing facts of life. Read on for more details.
While most folks know condom use can prevent pregnancy and the transmission of many sexually transmitted diseases and infections (STDs), Dr. Scott Chudnoff notes a disturbing trend: A naive subset of single adults engaging in unsafe sex after divorce or widowhood. “What’s fascinating is the education deficiencies you see about safe sex in teens, you tend to see in older adults as well,” he says. “Often, it happens when they are reentering the dating world and don’t understand that even though they may have had families or entered menopause, they can still catch something. It’s almost like they need a refresher course on the facts of life.”
The alarming trend is showing up in data. The Centers for Disease Control reports a significant spike in diseases including chlamydia, syphilis, gonorrhea and genital herpes in men and women ages sixty-five and older. While adults in their twenties still claim the highest percentage of STDs, “I just treated a sixty-year-old woman who had chlamydia,” says Dr. Chudnoff, of the STD that can cause pelvic inflammatory disease in women. “In fact, it’s the STD I’m seeing the most in [older] women.”
Dr. Shieva Ghofrany says this risky behavior extends to adults of all ages engaged in extramarital affairs. “I’ve treated patients for sexually transmitted things they got from the person they were having an affair with,” she says. “They are shocked and humiliated, but I think they forget that if someone is cheating with you, who else have they been with? You are probably not the only one.”
Because of careless sex practices, Dr. Ghofrany says, infections like herpes and the human papillomavirus (HPV) “are fairly rampant. There are millions of people walking around with these things who don’t know it.”
Sometimes, Dr. Ghofrany adds, she sees warning signs of an undiagnosed STD in an inflamed vulva that “a woman has obviously been scratching for months. They usually don’t tell me they’ve been itching because it’s one of those embarrassing things, but I can tell during an exam by just how red and sore she looks,” she says.
The Fix: To keep STDs at bay, keep condoms handy whatever your age. Remember that STDs can spread by not only intercourse but also oral and anal sex. Tell your doctor about risky behaviors and honestly inventory your romantic partners. Get tested for STDs, especially if you’ve jumped back into the dating pool and have had unprotected sex (or suspect a partner has). See a doctor if you notice unusual discharge, itching, odors or sores, all signs of possible infection.
MAKING LOVE CONNECTIONS
Dr. Chudnoff says too many couples and individuals are hesitant to broach issues related to sexual dysfunction, as they impact one’s sense of virility. “Yet it’s critical to talk about simply because there’s so much misinformation out there,” he says.
Case in point: The sexually inexperienced newlyweds he counseled that weren’t connecting sexually. “The husband did a Google search looking for ideas to spark things up and comes home with handcuffs, whips and chains. [The wife] ends up running out of the house.” What the couple instead needed, Dr. Chudnoff says, was some matter-of-fact instruction on female sexual response and “the importance of foreplay.”
Dr. Ghofrany says her patients will sometimes reluctantly share their struggles achieving orgasm. “There can be so many reasons why, and since they deserve the pleasure and satisfaction that comes from intimacy, it’s really important to talk about it,” she says. Her first question to patients? “Is it something you are able to do on your own because, if we know it’s possible, we can rule out something anatomical and dig a little deeper.”
When it comes to male performance, Dr. Chudnoff says many women tiptoe around their male partner’s sexual dysfunction. “If he suffers from premature ejaculation, it may be impacting their enjoyment and satisfaction,” he says, “but they may not completely understand what’s happening. These topics—like erectile dysfunction or the fact normal coitus doesn’t last for ninety minutes—aren’t part of our normal sex education. Who teaches about premature ejaculation in a typical lesson?”
It’s important to know that performance syndromes could be a sign of more systemic medical problems like anxiety, heart disease, high cholesterol, diabetes and Parkinson’s disease. Female sexual response issues can also have links to diseases like diabetes and hypertension, and can be affected further by menopause and some prescription drugs, like some antidepressants.
In some cases, sexual dysfunction can also be a contributing factor in infertility. “It’s interesting that men start to experience problems with sexual dysfunction beginning in their forties, right around the same time their female partners begin to experience issues relating to menopause,” says Dr. Chudnoff. “It can cause a disconnect, even in relationships that were once healthy and vibrant. So discussing it is critical.”
3. THE GOLDEN YEARS
ON MENOPAUSE & HEREDITY
From thinning hair to—let’s just go there—those dry-as-the-Sahara private parts, there are some physical aspects of the change in life that are often more mortifying than those dreaded night sweats everyone talks about. The good news is there is help for these more disconcerting elements of the hormonal shift. Here’s the scoop.
THE STATE OF THINGS DOWN THERE, Part 2
Besides the changes that can follow childbirth, the shift in hormones that occur with menopause also affect the vulva and the vagina. “There’s a normal thinning and atrophy of the vaginal walls that takes place over time,” explains Dr. Scott Chudnoff, referring to the impact of estrogen loss. “And there can also be, because of hormonal changes, a lack of desire and arousal, and significant dryness, not to mention a change in body image which can also impact sexual response.”
Dr. Shieva Ghofrany points out that besides these anatomical changes, depression and other side effects of menopause, like weight gain and sleep disorders, can all play a role in diminishing libido.
“Sometimes when we talk about these, women will almost speak to me in code,” says Dr. Kim Nichols, a Greenwich-based dermatologist. “It bothers a lot of women but no one likes to talk about it. And yet, here we have men buying up Viagra like it’s going out of style. I wish my patients would bring it up more; they deserve to know there are solutions.”
Dr. Ghofrany says many of her post-menopausal patients will vent to her about a lackluster libido, which can be particularly frustrating if they once had a satisfying sex life. “And one of the things I talk about—besides that there are real physical causes for these things—is that familiarity makes all of us lose some interest in our partners over time. They need to understand that some of this is very normal with or without menopause being a factor. It doesn’t mean we love our partners less, but this is a normal progression in the life of most couples.” Yet, Dr. Ghofrany adds, pain and discomfort during intercourse are unnecessary, which is why women need to seek medical solutions.
The Fixes: For about a year now, Dr. Nichols has been treating her patients with Core Intima, a laser-based treatment device for vaginal rejuvenation. Used externally and internally, “it’s the new frontier for what used to be a surgical fix,” she says. “And I like it as a treatment because it’s comprehensive.” The treatments can improve sexual satisfaction, improve vaginal lubrication and even minimize stress incontinence related to childbirth and menopause. She recommends two or three treatments to see noticeable results, followed by an annual “maintenance” procedure. “I’ve found it tends to be appealing to divorced women who are re-entering the dating field.”
Besides laser therapies, Dr. Ghofrany notes it’s quite possible to get great results without turning to the hormone replacement therapy. “There are vaginal rings, creams, and tablets, and they are so safe that even some of my patients who have had breast cancer are taking them,” she says. She’s also intrigued by Intarosa, a once daily vaginal insert approved by the FDA in late 2016 to treat postmenopausal vulvar and vaginal atrophy as well as painful intercourse.
WHEN THIN ISN’T IN
Women who experience hair loss are among the most emotionally wrought patients who visit Dr. Nichols. “On a scale of one to ten, in terms of how things are impacting them psychologically, they are my nines,” she says.
“That’s because women tend to see hair as a critical element of their femininity,” says Dr. Ivan Cohen, founder of the Center for Hair Transplantation at Fairfield Dermatology and an associate clinical professor of dermatology at the Yale School of Medicine.
While hair loss can be blamed on a variety of reasons, including menopause, Dr. Cohen, who estimates some 25 percent of his hair loss patients are female, says the most common cause is heredity. “What we’re learning is if your problem is more long-term and chronic, the causes have less to do with hormones than we used to think,” he says. “You can usually go back in the family and find the pattern.”
The Fixes: As is the case with many disorders, treatments for hair loss in women tend to be progressive based on a patients’ response as well as the severity of symptoms.
Current options include:
• Rogaine Not just for the gents, this topically applied medication is Dr. Cohen’s first course of treatment. He often combines it with natural therapies including anti- oxidant supplements to reduce inflammation, which is considered an exacerbating factor in hair loss. “It can yield great results in as little as four months and has no side effects,” he says.
• Platelet Rich Plasma (PRP) This therapy, which involves spinning a patient’s blood in a centrifuge then injecting the plasma into the scalp, is having a moment these days, treating everything from fine lines and wrinkles to hair loss. Both Dr. Cohen and Dr. Nichols use PRP. “In the beginning, I must confess, even I was incredulous but I’m getting great results with it,” says Dr. Nichols. “We’ve been seeing significant hair growth after the third or fourth treatment.” Dr. Cohen cautions the treatment is not universally effective, “but it can be wonderful when it gets the desired results.”
• Scalp Stimulating Laser Cap Dr. Cohen has had success for some patients using head gear known as Capillus, an FDA-cleared device that emits lasers to stimulate hair follicles. “You can wear it around the house while you are getting a hair growth treatment,” he says.
• Hair Transplantation The transfer of small pieces of hair-bearing skin grafts from other areas of the head to bald spots can be effective, says Dr. Cohen, a nationally-recognized expert in this field. “The ideal candidate does not have all over thinness, but a place on the head where there is still plenty of hair,” he explains. “When someone is the right candidate, the results can be incredibly natural looking.”
Medical Advice: “Hair loss can be exacerbated by underlying problems such as thyroid disorders or anemia,” says Dr. Cohen. Also, in rare cases, diseases of the scalp can be destroying hair follicles, a problem that needs investigation and its own specialized therapies.”
4. CAN WE TUCK?
ON COSMETIC PROCEDURES
By a certain age, most of us have tugged at our faces to imagine the year-erasing impact of a nip here and a tuck there, or at least chatted conspiratorially with our friends about who is getting a little intervention. Even for those of us who shamelessly fess up to a Botox habit, some cosmetic concerns venture into more discreet territory. We asked medical experts to identify some of the common cosmetic concerns that secretly bother their patients the most and to recommend the latest solutions.
It can be tough enough riding out the hormonal waves of teenage acne, but emotionally, the adult version of zits is almost worse, says Dr. Kim Nichols. “You think you have been there, and then it’s back,” she says. In the same way the teen years can blemish the complexion, the hormonal fluctuations that accompany pregnancy and menopause can do the same. “It’s tough [for patients] because they are dealing with zits and wrinkles at the exact same time,” says Dr. Nichols.
The Fix: Originally formulated to treat hypertension, dermatologists now often prescribe the prescription medication Spironolactone to treat adult acne, says Dr. Jason McBean of Fairfield Dermatology. Dr. Nichols says some of the same anti-aging regimens she uses on her patients, including laser therapies and probiotics, are also effective in addressing residual effects of adult acne. And there’s a boon: “They’ll also make you look more youthful.”
Medical Advice: In some cases, pronounced adult acne can be linked to hormonal disorders such as polycystic ovarian syndrome, which also has links to infertility, says Dr. McBean. Tell your doctor if your periods are irregular, another sign of the syndrome.
Just like genetics can play a role in fat that clings to the abdomen, some women accumulate fat around the bra line or under the armpit, says Dr. McBean. “I’ve seen it in marathon runners and women who otherwise are incredibly fit,” says Dr. McBean, who blames heredity for a problem that can make tank tops off-limits for some.
The Fix: Dr. McBean treats bra bulge with Smart-Lipo, a minimally-invasive procedure done under local anesthesia, which uses lasers to destroy fat cells and tighten the surrounding skin. “The best candidates for this tend to be folks who are already relatively fit and of normal body weight.” Dr. McBean has also used Smart-Lipo to address fatty deposits on flabby knees, which bothers some women like those saggy armpits do.
Research suggests that as many as 25 percent of all woman have breasts of different sizes but a much smaller subset have breasts of noticeably different proportions. “I have seen patients who were a full C cup and saggy on one side, and barely an A cup on the other,” says Dr. Gregory LaTrenta, the plastic surgeon.
While reasons for asymmetry can vary—with hormonal changes, traumatic injuries and curvature of the spine known as scoliosis all being potential causes— the reasons for breast asymmetry are not well understood. “Regardless of the cause, when adolescent girls have this asymmetry, it can be acutely embarrassing,” says Dr. LaTrenta. The phenomenon can also keep girls and women who fall into this category from wearing bathing suits, or opting for loose tops to conceal the imbalance.
The Fix: A small cosmetic implant in the smaller breast, along with a surgical breast lift, can create the desired breast symmetry for most women, says Dr. LaTrenta.
Medical Advice: While pronounced breast asymmetry can be emotionally traumatic for adolescent girls, Dr. LaTrenta advises against any corrective surgical intervention before the eighteenth birthday. “Teenage girls are still developing, and it’s critical to reach full maturity before you intervene surgically,” he says.
Heredity influences breast size and it is not unusual for Dr. LaTrenta to see patients—sometimes petite ones—whose busts are so large that they are suffering physically and emotionally. “It’s not just that they are embarrassed, although many of them are,” he says. “If you have a disproportionately large chest and are carrying around a large cup size on a small frame, you can have back issues. It can affect your posture and the kind of clothes you wear. What bothers women most is that it’s a matronly look. It can make your body look older than it is, simply because of your chest size.”
The Fix: Research indicates women who’ve undergone breast reduction surgery—which involves excising tissue and a breast lift—have the highest satisfaction rates of any cosmetic procedure. “I think that speaks volumes about how burden-some it can be to have oversized breasts,” says Dr. LaTrenta.
Medical Advice: Maintain a healthy, steady weight after undergoing breast reduction surgery as gaining or losing weight can impact your bust size.
This syndrome, known as hyperhidrosis, is noted for excessive sweating that is profoundly embarrassing and difficult to control without intervention. “It also has a tremendous impact on self-esteem and can impact your confidence in professional settings,” says Dr. McBean.
The Fix: Botox isn’t just for wrinkles anymore. “A shot of it in the armpit can significantly eliminate the problem for up to six months, sometimes longer,” says Dr. LaTrenta. “It’s a win-win because it’s relatively easy to do and it saves the patient in the long run on all those silk blouses and cashmere sweaters they’ve been ruining.”
Medical Advice: While hyperhidrosis can be associated with the hormonal changes that come with pregnancy, menopause, and heredity, Dr. McBean notes it can also be caused by underlying medical conditions like hypothyroidism and Parkinson’s disease.
Medication and surgical options to help control excess weight
According to the Centers for Disease Control, more than one-third of Americans are now considered obese, with women falling into this category at rates slightly higher than men. The epidemic is even more staggering when you consider the numbers of people who are overweight but not tipping the scales into the morbidly obese range. “When you add them in, it’s about 75 percent of adults who are overweight or obese,” says Dr. Neil Floch of Fairfield County Bariatric & Surgery Specialists and the director of Minimally-Invasive Surgery at Norwalk Hospital.
So, it’s rather remarkable, as research shows, that discussions about weight struggles—which can be a contributing factor to diabetes and heart disease as well as orthopedic problems—are rarely part of the doctor-patient dynamic. “It’s become a taboo subject when it should be the opposite,” says Dr. Floch. “Patients don’t bring it up because there is so much shame, and doctors don’t bring it up because they don’t want to offend the person coming to them for care.”
Dr. Floch adds: For some women, the hormonal changes brought on by pregnancy or menopause can be triggers that catapult some patients from “someone who has struggled with their weight to someone who is experiencing obesity.”
The Fix: Dr. Floch says weight loss surgery, including procedures such as sleeve gastrectomy and gastric bypass, are now considered mainstream interventions for the obese. “Most people can lose twenty pounds with lifestyle changes, but when you are in territory where you need to lose much more than that, it becomes a situation where surgery is usually the most effective way to address these problems. The idea that these are drastic interventions is a thing of the past.” In his practice, more than 70 percent of the bariatric procedures he performs are sleeve gastrectomies, which he tends to prefer because the procedure, which involves removing about two-thirds of the stomach to diminish appetite, also results in a reduction in levels of ghrelin and leptin, two hormones that trigger hunger. “What we’re doing is not just making the stomach smaller but also changing the environment,” he says. “When the hormonal messaging changes, you have a much better chance for success with weight loss.”
People who need to lose between twenty and sixty pounds are opting for implantation of temporary, surgically-placed balloons into their stomachs to achieve weight-loss goals. The balloons are inserted and inflated for a period of six months, then removed, explains Dr. Floch. While the balloons give patients a feeling of fullness, helping them maintain strict portion control, there is a long list of pros and cons to taking this alternate approach. “For one thing, you have two procedures. One to put the balloon in and another to take it out,” says Dr. Floch. “Also, patients who have this done really go through a period of adjustment. There’s a lot of nausea afterwards. It takes some time to get used to it and while I’ve never had anyone say, ‘Take this thing out of me,’ I do have to prescribe anti-nausea medication for people who have it done.” The other potential downside? “This is a procedure that requires a real commitment to lifestyle change because it’s temporary.”
The Nonsurgical Approach
For reasons ranging from genetics to a culture weaned on processed foods, growing numbers of Americans are feeling like failures after years of yo-yo dieting. The good news is that there are medical interventions for folks who are not considered obese but whose recurring attempts at diet and exercise have failed.
The Fix: Dr. Floch has found a new class of weight loss medications including Qysmia, Contrave and Belviq, that are beneficial for those trying to lose a stubborn twenty pounds or so. “If you’ve worked on your nutrition and are exercising, and it’s not going anywhere, these can be effective,” says Dr. Floch, who also prescribes these for his post-bariatric surgery patients whose weight loss has plateaued after months of big losses. The caveat with these medications is that some seem to work better for some people than others. They also have side effects ranging from constipation to dry mouth. “You may have to experiment before you find the right one but most people do,” says Dr. Floch.
Medical Advice: If you are trying to lose a few pounds—or more—focus on eating more gut-filling fiber. “My mantra is more fiber and less of everything else,” says Dr. Floch.
5. OPENING UP
ON MENTAL HEALTH
Even though booking an appointment with a therapist implies a willingness to divulge intimate thoughts, professionals in the listening business say that’s not always how things work. Secrets from substance abuse and domestic violence are topics that practitioners say often take a lot of coaxing before potentially life-saving or course-altering disclosures are made. What do patients have trouble sharing that their health care practitioners really should know about? Here’s what they said.
DOMESTIC VIOLENCE The cycles of domestic violence and abuse can be so insidious, it can be extremely challenging for someone to admit to the emotional or physical trauma being inflicted by an intimate partner.
Dr. Joseph Flynn says that domestic violence victims may seek therapy but don’t come forward about abuse, “because the very nature of domestic violence makes them incredibly fearful of the person harming them if they do disclose.” Often, he says, it takes careful probing to get patients, “who tend to circle around their fears,” to share honestly. “You’ll hear about a lot of fights, and when you ask more probing questions, the truth gradually begins to come out.” Family therapist Maud Purcell says getting patients to recognize the cycle of abuse they’re experiencing is critical, “because domestic violence tends to escalate and get worse over time.”
While extreme thinness associated with anorexia nervosa may be obvious to a medical practitioner, it can be harder to detect bulimia or an exercise addiction, says Purcell. “They have a dramatic impact on our health and can be devastating to our emotional state,” she says. Even though she says patients with eating disorders often seek therapy, it remains challenging for many of them to divulge disordered patterns relating to food and exercise. “People don’t like to share because it involves a fear of giving up these behaviors, which are about controlling their world in the first place.”
Besides the risk of STDs and the damage they can do marriages and families, “affairs are important to be honest about because, for some people, they can cause stress and anxiety,” says Purcell, who notes many individuals having affairs also need medication for anxiety and depression.
Dr. Flynn says an affair also tends to speak to much deeper problems in someone’s life. “There is some kind of dysfunction—in their personal history, in a relationship—which has driven a person to go outside the relationship. That’s often at the heart of what people need to be talking about, but by not disclosing the affair there’s a whole area that’s cut off therapeutically. Sometimes getting a patient to divulge this can take a long time and that’s too bad, because it’s standing in the way of so much work they need to do.”
“People are very likely not to admit the actual amount they drink,” says Purcell. “I will hear about a daily glass of wine ‘to relax’ that’s actually more like a bottle.” Dr. Flynn says honestly owning up to one’s drinking habits is critical for those who are struggling with mood disorders, including depression. “Alcohol is a known depressant and it can make people’s struggles that much worse.” (The same is true with addictions to prescription drugs like opioids.)
“One of the biggest things that is not disclosed by mental health patients is that they’ve stopped taking their medication,” says Dr. Flynn. “For some people, this is really serious and not something they should gloss over, but you would be surprised how many people will come in for an appointment and not divulge this. If they were having trouble with side effects or didn’t like taking the medicine, it’s critical that the people treating them know because there can be a whole host of problems that develop.”
Engaging in a steady diet of porn “can interfere with your life in the same way an affair can,” says Purcell. “It can also impact the way we think about sexuality and what’s normal and what is not, harming our relationships,” says Dr. Scott Chudnoff.
“There is so much fear and shame and confusion if you’ve experienced sexual abuse, especially if this happened when you were young; the trauma can impact you for a lifetime,” says Purcell. “The biggest reason why they don’t come forward is they tend to blame themselves. Nothing could be further from the truth, but it keeps them from going forward in so many ways.”
SEXUAL ORIENTATION AND GENDER IDENTITY
“There are people, including some in heterosexual marriages, who are leading closeted lives,” says Purcell, who notes she’s seen more and more of this in her therapy practice lately. “It’s a big thing that doesn’t come up because of the fear and shame of disclosure. But not living an authentic life can contribute to all kinds of emotional disturbances.”