Sexuality, Intimacy & Menopause in Cancer Survivors | June 15, 2021

June 16, 2021

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Presentations by Drs. Elena Ratner, Mary Jane Minkin, Johanna D'Addario, MHS, and Denise Tortora, PT

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00:00I am Elena Ratner.
00:02I'm one of the Joanna colleges
00:05at scale and we're so excited
00:08to have you with us today to
00:11discuss issues of survivorship,
00:14sexuality and intimacy.
00:15All the issues that we find to
00:19be of paramount importance.
00:21I would like to introduce my colleagues,
00:24Mary Jane Minkin, who is the guru
00:28of menopause and sexuality and.
00:30Joanna Daddario, who is also now
00:33the guru of sexuality in menopause,
00:36and who runs the sexuality and intimacy.
00:39Clinica TL doctor Minkin reminded me today.
00:42That's the whole reason why this
00:45program started in the 1st place
00:48was because many years back I was
00:51shadowing that convention to try to
00:54learn from her some of the wisdom
00:57of how she takes care of women
00:59with menopause and sexuality and.
01:02Intimacy problems and at some
01:04point I was amazed by the miracles
01:07that Doctor Minkin was doing with
01:10her patients in the office,
01:11and I commented to doctor Menkin that
01:14I felt that in the world of oncology
01:17we did not pay enough attention and
01:20we did not spend enough time dealing
01:23with those issues and helping women
01:25with these issues or truthfully even
01:28asking women about their concerns.
01:30You know,
01:31and I felt it at the time.
01:33As a as a surgeon,
01:35by practice,
01:36we spent so much time doing
01:38surgery and doing chemotherapy and
01:40radiation and we were so happy that
01:43women were living and surviving.
01:45But we will,
01:46forgetting how much our treatment
01:48and how much cancer itself was
01:50affecting women and it was
01:52affecting their quality of life
01:54and these issues of survivorship.
01:56So really,
01:57in that one day with Doctor Minkin,
01:59when I realized the impact that this
02:02kind of interventions can make.
02:04We brought that back to Smilow and
02:07that is how our practice of sexuality,
02:10intimacy and menopause Clinic
02:11was established.
02:12It was really established to
02:14help women to not just survive,
02:16but but excel and exceed then lived well.
02:20Everything that we tried to do is
02:22to try to get women back to their
02:25normal lives and to give them their
02:28lives back of the lives that were
02:31changed somewhat by cancer and by treatment.
02:34And that is everything that
02:36we try to do in this practice.
02:39So we're so happy today to have
02:41you all with us on this call,
02:44because this issue is so important
02:46and these issues are frequently
02:48so under discussed an under asked
02:50about and we want you to know
02:52that that is just not OK.
02:54And then there's so much
02:56that can be done for this,
02:58and there's so much intervention
03:00that can be done,
03:01and there's so many different options
03:03between physical therapy and pelvic floor.
03:06Therapy and psychotherapy and hormonal
03:07management and naturopathic management.
03:09Is acupuncture and that is
03:11the conversation that we would
03:13like to have with you today.
03:15So that could mean Ken and joining
03:17the diarrhea will start having
03:19this conversation and then we
03:21will certainly save a lot of time
03:24for questions so that we can
03:26make sure that all of your
03:28questions are addressed.
03:29So that's the main Canon Joanna.
03:31If you would like to share your slides.
03:36Thank you Doctor Ratner.
03:37I'm going to take some time to
03:40share my screen here and hopefully
03:41everybody will be able to see it.
03:43And as I do that, I'll let doctor Minken
03:46go through some of our slides here,
03:48so hopefully you can see what I'm sharing.
03:51Look, I can see it just fine.
03:53Everybody OK with it. We're good.
03:58Excellent, OK, so as you
03:59all can see here the slide
04:01this is actually put together by Joanna and
04:03it's a slide deck that she put together.
04:06Actually is an educational one for providers,
04:08but I think it's an educational one for
04:11patients as well and I think that we selected
04:13the perfect ones for folks to learn about.
04:16So anyway, so this is for us and
04:18our friends to be discussing here.
04:20This is just a little summary about our
04:22program at the cinema stands for sexuality,
04:25intimacy and menopause,
04:26and this is the program that smile
04:28when you see the little cards here.
04:30That we have some propaganda they earn.
04:33If you can pick these up at the hospital,
04:35it's on line as well.
04:37As far as what we offer in this,
04:39we're going to be talking about.
04:41We truly have a multidisciplinary
04:42program from day one.
04:44When Elena started talking about,
04:45we should have a program like this.
04:47She realized not only do we
04:49want you in oncology input,
04:51but we also want to general gynecology
04:52to be talking about some of the
04:55menopausal and sexuality issues.
04:56But we also realized how crucial
04:58psychological issues an from day one we
05:00asked our psychology colleagues to join us.
05:02And so unfortunately this last year with
05:04the pandemic it's been a little tricky.
05:06Incorporating our site colleagues with
05:08our visits, particularly ones in person,
05:09because they were off site,
05:11but we certainly have them on
05:12going as far as relationships.
05:14The program is available to any
05:16female cancer survivor at any stage.
05:17Unfortunately, was we see it,
05:19we have two sessions a month.
05:21We don't have any men in our practice.
05:23We've been trying to incorporate urology.
05:25It hasn't quite worked out,
05:26but we can help find some
05:28excellent urologist as a resource.
05:29If we have problems for the men as well, so.
05:32Next line that we can talk about that this
05:35is just some terminology that folks use,
05:37and of course the survivor.
05:38As many of you know,
05:40unfortunately it's a it's a person
05:41who's been diagnosed with cancer,
05:43but Ekko survivor is somebody who's
05:44dealing who's basically caring for a
05:46loved one with cancer that you are.
05:48It's a partnership and we also deal
05:49with a very special group of people
05:51called Previvor's an it's a term that
05:53actually folks use around the country.
05:55And I think we were one of
05:57the first places to use it.
05:59And this is basically talking about
06:00people who were who had surgery to reduce
06:03his or her risk of developing cancer.
06:05For example a classic situation.
06:06Is there somebody has been
06:07diagnosed as being a BRCA carrier?
06:09Has unfortunately not had cancer
06:11at this point and they take out
06:12their ovaries to reduce the risk
06:14of getting ovarian cancer.
06:15That's sort of a typical term and we refer
06:18to those young folks and their young folks,
06:20and that's important to emphasize in general,
06:22as previvor's and there are phases me.
06:24OK,
06:24there's a cute survivorship extended
06:26in permanent survivorship and
06:27will hopefully be talking about
06:29all of those issues here.
06:30I'll be at briefly.
06:32Our next slide you OK?
06:35Got the next slide there Joanna
06:37yeah great just one quick thing to
06:39talk about on the previous slide if
06:41you want to go back to the previous
06:43slide here justice sorry, no problem.
06:45This is a brief slide talking about the
06:47numbers of patients who are dealing
06:49with cancer and there are unfortunately
06:51a lot of folks out there and we have
06:53the numbers up there for 2019 up top.
06:55But as you can see in the next 10 years,
06:58we're going to be having you know
07:00we're having burgeoning numbers of
07:02folks being diagnosed with cancer.
07:03But the most important thing is we
07:05have burgeoning numbers of survivors.
07:07We're doing great and we want
07:09them leading normal lives,
07:10and that's the important thing.
07:12OK, so can we go to our next slide here.
07:16Add doctor Minkin that as you can see,
07:19the most common cancers that men and
07:22women survive really can have a big
07:25impact on intimate relationships.
07:27You look at the the top few prostate
07:30cancer colon, cancer rectal cancer,
07:32breast and uterine cancers,
07:33and those really are directly
07:35impacting people's sexuality.
07:37Absolutely and and even other
07:39things can impact sexuality,
07:40even things you might not think of
07:44impacting sexuality and will try to
07:46talk about a few of those as well.
07:49And this is from the American Cancer
07:51Society and this is linked to their
07:53Recon treatment and survivorship facts.
07:55But one thing we sort of circled
07:57here is the quality of life is
08:00extremely important for people,
08:01obviously, and social well being
08:03refers to the health of relationships
08:04with family members and friends,
08:06including intimacy and sexuality.
08:08So these are really important things for
08:10people to talk about and to understand.
08:12An involves both the you know the
08:14medical issues going on and some
08:16psychological issues going on.
08:18And why are.
08:19You know, psychology teammates are really,
08:21really important in this in
08:23this paradigm here.
08:25On the next slide, this is just an.
08:28This doesn't list.
08:29This is not totally comprehensive,
08:31it's good list,
08:32but that what can contribute
08:33to sexual dysfunction problem.
08:35Having sexual issues.
08:36And there are a lot of emotional
08:38factors is relationship stresses.
08:40Unfortunately,
08:40many of you know having dealt
08:42with a cancer diagnosis,
08:43there are issues on fertility for many
08:46young people who were affected with
08:48the diagnosis of cancer early in life.
08:50How do we deal with this?
08:52And there are issues involving body image,
08:54self-esteem, femininity,
08:55masculinity.
08:56Of course, unfortunately many of our
08:58folks are dealing with depression.
08:59Many are people dealing with fatigue,
09:01which is both emotional and physical,
09:03and there's tremendous anxiety
09:04about sexual activity.
09:05Am I going to be OK?
09:06Will I be able to have sex?
09:08Is it going to be like it was before?
09:13Very important,
09:13and again the unfortunate thing that
09:15can happen is that areas that typically
09:17were pleasurable erogenous zones.
09:18The previously gave people a good
09:20time that people can get gold,
09:22some negative feelings about it,
09:23and so unfortunately pleasure can
09:24turn to pain and we don't want that.
09:27We want people to have pleasure
09:28and keep on having pleasure.
09:30And then of course there are some
09:32changing roles in relationships you know.
09:34Can I have a sexual activity with
09:36somebody who's been my caregiver?
09:37You know,
09:38dealing with some of my bodily
09:40functions which may not be
09:41pleasant for me to think about her.
09:43Talk about these are all issues,
09:45and again,
09:45they're all important to talk about.
09:47We're vulnerable and people are
09:49vulnerable even without dealing
09:50with a cancer diagnosis,
09:51but many people with cancer
09:52diagnosis or feeling much more
09:53vulnerable and they're embarrassed
09:55about what's going on sometimes,
09:56which they shouldn't be.
09:57But they are,
09:58and there may be a fear of rejection.
10:00Is my partner going to feel about
10:02me like she or he did before?
10:04And these are real issues
10:06that that folks are feeling,
10:07so there are those going on,
10:09so these are some of the
10:10multifactorial things.
10:11Then, of course,
10:12there are some physical activities,
10:13physical issues going on as well.
10:15We'll see the next slide there.
10:18That there are hormonal changes for me.
10:21OK,
10:22there can be issues related
10:23with hormonally can decrease
10:25in manifest themselves in
10:26to decrease labille libido.
10:28There can be issues as far as
10:31achieving arousal or orgasmic
10:32responses then with the guys.
10:34There can be issues involving erectile
10:37dysfunction which can be a direct
10:39effect of surgery or radiation therapy
10:41or other emotional things going on.
10:44Then of course there are issues involving
10:46vaginal dryness, balvar, dryness.
10:48And pain with intercourse secondary.
10:50The dryness, or potentially
10:51scarring from surgical procedures.
10:52Then, of course,
10:53there are the fabulous things
10:55like hot flashes that if ovarian
10:57function is taken away,
10:58women are going to be put into menopause,
11:00which can occur from surgery or
11:02can occur from chemotherapy or can
11:04incur from some of the hormonal
11:06therapies we used to deal with
11:08their cancer from coming back.
11:09So all these real issues and of course
11:12unfortunately on some of the people
11:14would probably sit there saying,
11:15yeah, I know about this is sleep
11:17disruption which can occur.
11:19From either second,
11:19even just spontaneously, you know.
11:21Some people just can't sleep well,
11:22or there can be things like hot
11:24flashes which are bothering folks.
11:26All these things contribute to the
11:27sexual dysfunction, libido issues,
11:28so it's a it's a very broad outline,
11:30broad, you know,
11:31a number of problems that can be going on,
11:33and we're here to try to deal
11:35with all of them.
11:36If we can help you at the next one.
11:40I'm
11:41sorry, did I miss the physical,
11:43the physical one?
11:45The physical slide?
11:46I think I must have missed it in the
11:50PowerPoint, but there are physical changes.
11:53Things like scars, ostomies ports,
11:55people who've had a mastectomy,
11:57people who've had prostate surgery,
11:59just physically have changes that can
12:02either be affecting their you know,
12:05ability to have certain positions during
12:07intercourse, ability to you know,
12:10maybe there's loss of sensation after
12:12a mastectomy that affects the breast.
12:15As an erogenous zone,
12:16or maybe pain with certain sexual positions.
12:19So I'm sorry that I left that
12:21slide out Doctor Minkin,
12:22but also the physical changes.
12:25From cancer treatment,
12:26then can certainly
12:27affect sexual function as well. No question,
12:30no, but would also add
12:32reconstruction in there, right?
12:34So with reconstruction changes
12:36in anatomical changes. Yeah. Now.
12:41And some of these things there are problems
12:43and we understand that what goes on in
12:45a typical visit that you know there are
12:48people are dealing with a lot of problems.
12:50And in a visit to the oncology follow up
12:53folks, and so there's oftentimes a lack
12:55of time to address the sexual health
12:57issues and the complexities of cancer care.
12:59And sometimes providers were the
13:00guilty ones because we say, well,
13:02the patients are going to bring up
13:04topics that they're dealing with issues
13:06of sexual dysfunction or menopause.
13:07No, if we've learned that if we don't ask,
13:10they don't tell.
13:11Oftentimes, I mean, some folks well,
13:12and God bless him, and that's terrific.
13:15And we love it.
13:16Yes, they do, but oftentimes people won't.
13:18They were embarrassed and they're
13:19waiting for the provider to ask,
13:21and lots of times they're not asked.
13:23And the other thing is you know patients,
13:25men and women may not feel comfortable
13:27discussing their symptoms,
13:28and there are multiple surveys
13:30that can be used.
13:31And again,
13:32one of the most unfortunate things
13:33is in Elena alluded to this a
13:35little bit as far as you know,
13:37in the topic of you know where
13:39surgeons and taking care of people
13:41that many unfortunately surgeon
13:42sometimes have the feeling, well,
13:44you know, we operated on you your.
13:46Sure, that's great.
13:47You know that's enough and you know
13:48many patients say feel guilty about.
13:50Well,
13:50I really want to do a lot more
13:52with my life than you know.
13:54Just having matured in my cancer.
13:56And you know,
13:56they feel embarrassed and they feel
13:58like they're they're asking for too
13:59much and they're not asking too much.
14:01It's perfectly with the right thing to do
14:03to be asking for a normal life afterwards.
14:05So that's an important thing.
14:07So I think our next slide we
14:08have a list of some of this one,
14:11or some of the some of the
14:12ways to assess things,
14:13and there are guidelines to do this.
14:15This is there's documentation
14:16for people who have to have,
14:18you know, a guideline to say,
14:19yeah, there NCC send national.
14:21Survivor Networks and we're supposed to.
14:23This is part of the guidelines that
14:25we were supposed to ask about sexual
14:27function at regular intervals.
14:28Ann,
14:28we should discuss issues about fertility,
14:30particularly with young patients
14:31who are diagnosed early.
14:33There are plenty of screening
14:34tools out there,
14:35will talk about a couple of them,
14:37and you can adapt some of these
14:39yourself and bring it up stuff with
14:42your providers and their patients
14:43who will do well if they need to
14:45see a sexual health specialist.
14:47If the survivor is interested in it and
14:49then make the appropriate referrals for this.
14:52Or from the provider for
14:53therapy couples counseling,
14:54sexual counseling,
14:55regular GYN care,
14:56neurology or sexual health specialist
14:58will talk about some of them later
15:00and then follow these things up.
15:02Re-evaluate irregular intervals and
15:03this indeed is survivorship guidelines
15:05published just basically a year ago.
15:07So these are up to date and their
15:09guidelines, rivers and these are
15:11the things that we're supposed to
15:13be doing and supposed to be asking.
15:16And I would add here that we can
15:18certainly also consider a referral
15:20to our friends from physical therapy,
15:22and we have the Nice here
15:24on the call as well.
15:26And Denise is one of the wonderful
15:28pelvic floor physical therapists at
15:30Smilow who helps us with patients who
15:32have any challenges with the muscles
15:34and the complex anatomy of the pelvis.
15:36And she can help with a lot of the
15:39sexuality challenges that people
15:40have so we can also refer to our
15:43physical therapist colleagues as well.
15:46Absolutely, and we do regularly.
15:47Now we don't and I was just thinking
15:49for those who heard me thanking Denise
15:51for helping one of my ladies there.
15:53She's been very active and now this is
15:54what I was alluding to before and this is
15:57just some brief sexual symptom checklist.
15:59As you can see with their mess
16:00for guys and for ladies.
16:02And so I'm going to focus in 'cause
16:04we're focusing in tonight on the women,
16:06but there are issues that men look
16:07so certainly could well bring up
16:09with their providers. An for women.
16:10Just a simple question.
16:12Are you satisfied with your sexual function?
16:13I'm going to ask people listening.
16:15I want to ask for a show of hands right now.
16:18But you know,
16:19are you satisfied with sexual thing?
16:21Yes no, if you are OK,
16:23that's cool, that's terrific.
16:24But if not, how long is this been going on?
16:27For how long have you been dissatisfied
16:29with your function and then what are
16:31the problems that you're dealing with?
16:33'cause female sexual dysfunction is
16:34a whole bunch of areas and this is
16:36not to deal with cancer survivors.
16:38This is just overall in female
16:40sexual function.
16:40There are folks who have issues
16:42with little or no interest in sex.
16:44There are people who have problems with
16:46decreased genital sensation feelings.
16:47There are people who have decreased
16:49lubrication issues.
16:50Women wearing dryness.
16:51There are women who have problems
16:52reaching orgasm.
16:53There are problems with women having
16:54pain with sex both with penetration
16:56but also deeper on the pelvis and
16:58which problem is the worst for you?
17:00Which one?
17:00If we could say,
17:01let's focus first on that one,
17:03which is the most bothersome for you?
17:05So we can focus in on working
17:06on that first and then the next
17:08most important things.
17:09Would you like to talk about it
17:11with your health care provider,
17:12you know, and we hope you will,
17:14and we hope that we can be here to help.
17:17So those are just some simple things to
17:19maybe generate some thoughts, you know.
17:20Of people listening and watching the same?
17:23Maybe I could,
17:24you know,
17:24deal with some of these issues
17:26and that's what we're here.
17:28These are the issues we deal
17:30with every single clinic.
17:31I can't think of a clinic we don't.
17:34We've done Joanna,
17:35that we haven't dealt with these issues.
17:37This is called.
17:38This is called days days stay today.
17:40It's Milo here.
17:41Absolutely OK now this just emphasizes
17:43a little bit some of the overlap
17:45that we're dealing with here on the
17:47management of sexual dysfunction.
17:49And there's input from everybody.
17:51'cause their issues from the fertility
17:52for are particularly for younger folks.
17:54Issues of sexuality for anybody who's
17:56sexuality is is a human problem,
17:58not a problem of younger or older
18:00folks or anything like that.
18:02And these are some of the folks that we
18:05may bring in as well to help deal with it.
18:08We may bring in reproductive
18:10endocrinologist if we're dealing with,
18:11you know, trying to do ovarian preservation.
18:13Genetics folks are mental health
18:15workers we've talked about.
18:16We have tremendous input
18:18from our psychologists.
18:19We also occasionally referred to
18:20a psychiatrist or social worker.
18:22We have our GMA oncologix friends with
18:24us and then as far as as Joanna Lootere
18:26pelvic floor PT is really important.
18:28We may refer to with a full time
18:31sex therapist and you know we have
18:33ways to contact those people so we
18:35can draw in all these people and at
18:37the center of this is the patient,
18:39either herself or or with a
18:41partner without or with apartment.
18:42These these are how we try
18:44to approach the issues,
18:45'cause they're all at play here.
18:47There always are, and
18:48one of the most important things is that
18:50we know cancer survivors at any stage.
18:53Can be can have a partner they can be dating.
18:56They cannot have a partner and
18:58sexuality looks different to
18:59everybody and we want to be inclusive
19:01of patients who have a partner.
19:03Are looking for a partner and
19:05concerned about that.
19:06Or even if you don't have a partner
19:08doesn't mean you're not a sexual person.
19:11So we certainly are happy to help you
19:13in whatever stage of your life you are.
19:16Absolutely. OK, and these are some
19:19of the psychological interventions
19:20that our team will work about that.
19:22Of course, there's grief and loss,
19:24which happens to everybody in this process.
19:26But we want to establish a new normal.
19:29This is where you are and you're going
19:31to be OK trying to deal with anxiety
19:33and getting rid of negative patterns of
19:35thinking to think about the positive way
19:37we're going to address all these issues.
19:39As Joanna talked about ways to
19:41cope with dating and communicating
19:42with current or potential partners.
19:44OK, this is a problem. I've had.
19:46This OK? Are you OK with this?
19:48On how can we make it OK if it's
19:50not relational issues that are
19:52there that can affect sexuality,
19:54intimacy, we want to facilitate
19:56communication between among everybody.
19:57To clean between partners,
19:58we want to help folks develop
20:00relaxation skills to help make
20:01things more comfortable and get
20:03our partners engaged and again,
20:05getting back to this new normal.
20:06Embracing the new normal to say OK,
20:09things are a little bit different,
20:10but let's,
20:11let's say this is OK and make it better.
20:16And this is actually a book that from
20:18a book that Joanna hands out regularly
20:21to our patients and it's just a
20:23little bit of a guide as far as some
20:26of the behavioral interventions we
20:27talk about their different lifestyle
20:29and interventions that can happen.
20:30Just simple positioning within a course
20:32that things can be better and we can
20:34help guide people different positions
20:36they may not have thought about.
20:38You know, given what's been done
20:40surgically or radiation therapy wise,
20:41kegle exercises, it's very important.
20:43I love kegle exercises.
20:44Everybody should do them.
20:45The guy should do him too.
20:48I want everybody doing him and of
20:50course getting Denise and her team
20:52involved with pelvic floor, PT.
20:54And the important thing experiment
20:55and explore.
20:56Just keep trying different things
20:58and you know that a person that
21:00I quote regularly,
21:01who I've had the privilege of working with,
21:04and Joanna knows who I've got
21:06a quote is the esteemed Doctor
21:08Ruth West Timer and Doctor W.
21:10Heimer taught me many many things in my life.
21:13But one thing if it should between
21:15consult this consenting adults, it's fine.
21:17Whatever you wanna do,
21:18consenting adults at school kids,
21:20no, but it's consenting adults, yes.
21:22And so there's a lot of exploring to do.
21:24A lot of experimentation as long
21:26as you guys are both comfortable,
21:28that's terrific.
21:29And this is really one of one of my
21:32favorite pictures to use in my job,
21:34and I've actually reached out to the
21:37American Cancer Society and gotten
21:39permission to use this picture and share
21:41this picture because I think you know a
21:43lot of patients feel really uncomfortable
21:45talking about intimacy even with us,
21:47but also with their partner
21:49and this kind of helps,
21:51and you can find this on the
21:53American Cancer Society website
21:55and we have some books about female
21:57and male sexual health and cancer.
21:59And I like this picture because
22:01it makes people feel probably
22:03a little bit uncomfortable,
22:04but it makes you realize that
22:06you can try different things.
22:08And if it doesn't work for you,
22:10that's fine.
22:11It may give you some new ideas,
22:13but hopefully it means that you can start
22:16talking about it freely and realizing
22:18that this is part of your health,
22:20even though it's a very sensitive topic.
22:24Exactly.
22:26Absolutely, now I refer to this a little bit.
22:29Before that there is or
22:31actually organizations.
22:31A sect is one of the most important
22:34ones and they have both certified
22:36sexuality counselors to work on.
22:38Is she at the bottom American Association?
22:41Sexuality educators,
22:42counselors and therapists and you can
22:44even look that up right now if you want.
22:47While we're talking to help
22:49resolve sexuality concerns,
22:50specific exercises techniques,
22:51and there can be medical providers
22:54are a couple of people in town
22:56who are sex therapists in our.
22:58You know, be juliennes and medical folks,
23:00and then there were certified sex
23:02therapists who are mental health
23:03professionals who focus on sexuality
23:05again to assess diagnosing.
23:06Provide in depth psychotherapy.
23:07So there are different folks around,
23:09and this is one way to get ahold of folks,
23:12and we can give you some advice
23:14when we see you in the clinic.
23:16As far as different people to contact,
23:18this is one of my favorite slides.
23:20I love this slide.
23:21Joanna knows that,
23:22and these are some of the stuff
23:25that we talked about in the
23:27clinic from a point of view here.
23:29Medical interventions for women.
23:30We got lots of stuff available.
23:32Many women for example,
23:33don't know the difference
23:34between a lubricant,
23:36which is something that people will use at
23:38the time of intercourse or a moisturizer,
23:40which is something that we
23:42use an ongoing basis.
23:432 three times a week can be hormonal,
23:46can be not normal.
23:47There are various medications
23:48which we can use.
23:49Those beautiful things that look like
23:51those little cylinders there and the
23:53pretty colors are vaginal dilators
23:55among my favorite gadgets in the world,
23:57and we love to also prescribe sexual devices.
23:59You'll see a vibrator up top.
24:01In vibrators are great and people think,
24:04oh these are not.
24:05You know they're not naughty and they
24:07have medical benefit because they
24:08anything that will increase pelvic
24:10blood flow and vibrators do increases
24:12moisture and moisture is good.
24:14So these are important things.
24:16The other things you see by the
24:18way up top on the left is a gadget
24:20that I was totally unfamiliar with
24:22until Joanna taught me about this
24:24and this is called the owner.
24:26And so if a woman has a vagina
24:29that's been somewhat shortened
24:30by surgery or radiation.
24:32Therapy and she's concerned
24:33about penetration,
24:33but her partner going too deep.
24:35This little gadget can be very,
24:37very helpful as far as limiting
24:38the amount of penetration.
24:39But basically so people can
24:41have good sex even if they have
24:42a somewhat short and vagina.
24:44So we got lots of stuff to talk about
24:46and to suggest your folks Anna.
24:48Simple thing that you'll see on the bottom.
24:50There is a little bit of Novocaine
24:52lidocaine Jelly and I try to sort
24:54of tease people with this because
24:55I'll say you ever been to the
24:57dentist and gotten novocaine and
24:59people have these ideas of needles
25:00and stuff and I like jump no no.
25:02This is a cream and you can be very,
25:05very helpful for people who are having some
25:06pain with penetration with intercourse.
25:08Just using a little novocaine Jelly
25:10takes about 3 minutes to set up,
25:11and people can be a lot more
25:13comfortable with sex and then
25:15we will show them in the clinic.
25:16How much more comfortable before
25:18we do a pelvic exam.
25:19Even so, lots of tricks that we have.
25:22And what you might find,
25:24if you haven't taken a look in
25:26the boutique recently is that the
25:28Smilow boutique on the 1st floor
25:29near the atrium in New Haven
25:31has some of these things that
25:33you can ask about and our smile.
25:35A boutique staff is very
25:37knowledgeable and helping you.
25:38If you have questions about
25:39any of these or they can give
25:41you some resources to help you
25:43find them. Absolutely OK.
25:45And now I'm not gonna go
25:46through all of this stuff,
25:48but this is from a scientific paper.
25:50This is from the scientific literature from.
25:52One of the menopause and International
25:54menopause journal and it's written
25:56actually by three friends of ours,
25:58a Sharon Bober, who is a psychologist up,
26:00and even if they're from Boston, it's OK.
26:05I, Sheryl Kingsberg who's from
26:06Cleveland and Stephanie, if Albion,
26:08who's the executive director of the North
26:10American Menopause Society from Male Clinic.
26:12So these are some some
26:14good substantial people.
26:15And how do you treat folks?
26:17Well, these are all things that we do.
26:19We offer education,
26:20counseling and sex therapy,
26:22lubricants and moisturizers, vibrators,
26:23dilators to help stretch the cervix,
26:25pelvic floor, physical therapy.
26:26Just showing these are acceptable
26:28therapies in the scientific literature.
26:30Had the next slides are joining to
26:32go on the rest of the stuff here.
26:36Denise, do you want to talk real quickly
26:38before we move on about what you?
26:39What types of specific therapies you
26:41do or do under that at the end? Either
26:44is fine. We could probably till the end,
26:47because it could be a little more expensive.
26:49Yeah, so well, we'll have Denise
26:51give us some more specific
26:52pelvic floor techniques and then
26:54just some of the particular
26:56products that we use.
26:57These are different vaginal estrogens,
26:59which are really quite safe for
27:01almost everybody who's had a tumor.
27:02Most men that a few people who can't
27:05but most people can if we need to.
27:08So these are different forms of
27:09vaginal creams for suppository's rings.
27:11And then we talked a little bit
27:13about the Lidocaine and Novocaine.
27:15And there actually is 1 oral medication
27:17which is listed here is asrm,
27:19which is called a spammer.
27:21Feanor osphena.
27:21And this is actually a sister
27:24drug of the drug tamoxifen.
27:26Which is which is the maximum
27:28doesn't really help.
27:29Particularly moisten the vagina,
27:30but this drug happens to so very,
27:32very clever molecule here,
27:33so we got a lot of options that we
27:36can use for folks so they don't say,
27:38oh I had this. I had that.
27:40Now we can use it and this is just a
27:43slide I throw in here because the even
27:45systemic therapy can be OK for many,
27:47many women with cancer.
27:49No,
27:49we're not going to put a breast cancer
27:51survivor in general on systemic estrogens,
27:53but people who have
27:54haematological malignancies,
27:55people had different leukemias or lymphomas.
27:57Colorectal certain cancers cervical
27:58cancers vulvar vaginal cancers these
28:00folks can can take pills or patches of
28:02estrogen so they can do very well with that,
28:05and there's low dose vaginal estrogen for
28:07localized symptoms for just about everybody.
28:09And then for people who have the
28:11hot flashes and stuff like that,
28:12we tend to go with the systemic type stuff.
28:15If they are a candidate for it.
28:17So we got a lot of options out there.
28:20Folks.
28:20Don't don't cut yourself off from thinking
28:23about different things that may sound.
28:24Oh my goodness, yes,
28:26we can do it, OK?
28:27So,
28:27and this is just a list and we'll
28:30go over these with you.
28:31We said we give handouts like this
28:33regularly as far as different
28:34organizations which you can look up on
28:36line and these are reliable things.
28:38Now I'm not saying Doctor Google
28:40isn't reliable,
28:40but there are certain things that we
28:42sometimes people will come in saying.
28:44Well, maybe that's not quite true.
28:45These are pretty much reliable
28:47sources there as far as options.
28:48Yeah, OK,
28:49so I think with that I think that's
28:51our last slide for folks there.
28:53Joanne, I think yeah, so Elena,
28:54did you want to say something now?
28:58No magic, I think you did such an amazing
29:00job as always discussing this issues,
29:02and I think the most important thing is
29:04just we all put this communication and we
29:06have this conversation was really nothing
29:08is more important than than acknowledging
29:10this and an appreciating that there is
29:12room for conversation in this room.
29:14Folk knowledge minton. And then there's
29:15so many things that can be done.
29:17There's so many options you know.
29:19I think the thing that breaks my heart
29:21the most is when our patients say,
29:23well, I didn't bring this up because
29:25I didn't think one.
29:26I didn't think this was a problem. Two,
29:28I don't think anything could ever be done,
29:31and I think that's the important thing
29:33that we acknowledge that this is something
29:35that our treatment does to women and
29:37that this should not be accepted.
29:39It is not OK to live like this.
29:41There's there's many things that
29:42can be done and this has to be
29:45addressed from every single direction.
29:46And we're here for you and many
29:48other providers are here for you,
29:50so we very much would love to open this
29:53conversation and we're open to any questions.
29:56So
29:57our first question and I'll I'll
29:58ask Doctor Minkin to weigh in
30:00on this or or Denise as well.
30:01And then we we do want to still
30:03have Denise explain some of
30:04her therapies as well, but.
30:06Let's do one question first.
30:08When you use a dilator doctor,
30:10minken if it if it hurts or you
30:12have some blood on the dial later.
30:15You know what should we do and and
30:17does that mean that it's dangerous
30:19or we should be a little more
30:21forceful in pushing it harder?
30:23If it feels like it's stuck?
30:26Excellent questions whoever asked
30:27that mean OK and a couple of things.
30:29Number one what we will do is
30:32oftentimes have people come to the
30:34clinic and and it's hard to do this on.
30:36Tele Health will say we've had some.
30:38We've had some tricky times
30:39thinking about doing it LL,
30:41but that's why we like having
30:43folks in person for these kind of
30:45issues that bring your dilators
30:46with you so we can work with you.
30:48And let's do some show and
30:50tell and see what's going on.
30:52You OK much of the time if there's
30:54if it's like stenosis, that the.
30:56Radio radiation and stuff like that
30:58has been a problem that we can help.
31:01Moisturize the tissue to make
31:02it stretch here OK.
31:04And if you're somebody which is
31:06really most everybody who can use,
31:08for example some topical estrogen cream, OK,
31:10we oftentimes we use little estrogen cream.
31:12Have people rub the estrogen
31:14cream with their fingers,
31:15or at my terminology, smear it around.
31:17I never write down her prescription folks,
31:20but I just tell you what to do
31:22to take some estrogen cream.
31:24Smear it on that area.
31:25Do it. Daily every other day,
31:27whatever.
31:28Until we get that tissue softer
31:29and we'll have more.
31:31Give you OK and then we'll work on
31:33using more often times is using a
31:35little bit of Novocaine when you're
31:36actually working with the dilators,
31:38'cause that will make it more
31:40comfortable for you so it doesn't hurt.
31:42And then starting with little tiny
31:44dilator and working its way up
31:46to help stretch that tissue and
31:48it will go most of the time.
31:50I mean,
31:50we really can have great success
31:52most of the time.
31:53In the example I tell everybody
31:55with dilators is that.
31:56There's a condition.
31:57Fortunately it's very rare,
31:58but it's a condition that young girls can
32:01be born with that they have no vaginas.
32:03That they're born without a
32:05vagina an using dilators.
32:06They can actually manufacture vagina.
32:08They can stretch that tissue to make a
32:10vagina so that area has good amount of give.
32:13If we can just get to it so
32:15that using estrogen creams,
32:17a little bit of Novocaine gentle dilatation,
32:19these things can work so you know,
32:21can I say it works for everybody?
32:23Nope, we have pretty good success rates.
32:25Joanna can I turn that over to you?
32:29Yeah, and absolutely if you're if there
32:31is bleeding that you're concerned about,
32:32please call us you. Can you know,
32:34pop into the clinic on a day that
32:37I'm there even if Doctor Minkins
32:38not there that day, you can come
32:41in and you know if I'm available.
32:43I'm happy to take a look and see if
32:45sometimes breaking up the scar tissue,
32:47especially people who've had radiation
32:48just breaking up the scar tissue can
32:50cause some spotting or bleeding.
32:52And it can be pretty scary.
32:54So if you feel like something
32:55might be going on,
32:57you would like us to take a look.
32:59We're certainly happy to do that.
33:01Yeah, come in and do it with us there
33:03so I will give you the hopefully the
33:04confidence to say let's take care
33:06of this and that there is anything
33:08we can take care of there as far as
33:09you got bleeding will fix it over.
33:12And Denise works with the dilators too,
33:15and she's excellent in helping women.
33:17So Denise, I was gonna jump in.
33:19So two things that that I think
33:21were missed was lubricant.
33:23So certainly making sure that
33:25things are gliding well.
33:26Because I agree that issue is pliable
33:29and will will start to conform.
33:31Kind of like you know,
33:33clay or something that you can kind of
33:35work to slowly and gradually mold it.
33:38But also position I think makes a difference.
33:41You know, thinking about the.
33:43Anatomical position of the hips
33:45the diaphragm and and you know,
33:47from a PT perspective, abdominals,
33:49so you know are we gripping or
33:52tightening the abdominals because
33:54things aren't feeling comfortable
33:55and so you know just by working
33:58on expansion of the diaphragm,
34:00can we also be mobilizing the pelvic
34:03floor so you know if we're holding
34:05our breath because we've experienced
34:08pain and know subconsciously or
34:10consciously we know from experience that.
34:13This penetration can be uncomfortable,
34:15you know are are we kind of
34:17biasing the situation,
34:18so certainly not from the blood
34:21perspective but but you know,
34:22situationally,
34:23if we've had pain with penetration
34:25in the past or even most recently,
34:28put our our mindset kind
34:29of be contributing to that.
34:31So working on calming the central
34:33nervous system, working on,
34:35making sure that the tissues
34:37that surround the pelvis,
34:38whether it's the abdominals,
34:40the glued, the adductores,
34:41all of these muscles, are moving, and.
34:44And helping to kind of mobilize this area
34:47and then positionally you know how are.
34:49How are my hips position?
34:51So could that be influencing or kind of
34:54shutting down or closing the vaginal canal?
34:56So can I move those to kind of help to
35:00influence the mobility of the tissue?
35:04Yeah,
35:04I think it's it's looking at it.
35:06You know from my PT brain of like
35:08how and what is going on and how
35:10can I influence this or modify
35:12these situations to kind of make
35:14things feel a little bit.
35:16You know more easy and work smarter,
35:18not harder essentially.
35:21Yeah, and and some women.
35:22That's a great point. Denise.
35:24Is is what are the angles that
35:26we're looking at here and someone
35:29would be really surprised that
35:31if you try if you're lying flat
35:33and try to insert the dilator
35:35straight towards your head,
35:36you'll probably hit your pubic
35:38bone or your urethra,
35:39which is which is you know
35:41where you urinate from
35:43exactly knowledge is power, right?
35:45So so the vaginal canal
35:46kind of comes post here.
35:48So right you you certainly want to avoid.
35:5112:00 o'clock right the urethra.
35:53And then you know,
35:54kind of pointing the dial later or
35:57whatever penetration device you're
35:58using towards kind of the spine,
36:01will certainly help to
36:03kind of guide things along.
36:06Greed. Yep, so I usually tell
36:09women if you're lying in
36:11your bed and you're using the dilators
36:13point the dilator tored your bottom
36:15or tored the bed as opposed to
36:18tored your head right right.
36:21Are we ready for another question?
36:23Sure, sure so.
36:27Another question from one
36:28from one of our visitors here,
36:30Doctor Minken, thank you.
36:31You saved me during chemo and
36:33I had a lot of dryness.
36:35But do you have anything for
36:37libido that's any?
36:38Is there anything new
36:39out there for sex drive?
36:40Because it's hard to
36:42get that sex drive back.
36:44It is hard, you know there's no
36:46question about that and that's
36:48the trickiest thing of all.
36:49And again, this is something that's tricky.
36:51You don't have to have had cancer to
36:53be dealing with this decreased libido.
36:55Unfortunately, it's very,
36:56very common problem that we face.
36:58The key thing.
36:58The first thing I say is you
37:00gotta be comfortable.
37:01So even again and somebody who's
37:03not having cancer diagnosis patient
37:04mind just comes routine checkup.
37:06But she said she's got no no libido.
37:08I'll say well,
37:09what about you know she's post menopausal?
37:11What about your vagina?
37:12How comfortable is it?
37:13Are you having pains say Oh
37:15yeah I have pain but that's.
37:16That's not what's giving me the problem.
37:18It's like, yeah,
37:19it is because the other thing
37:21is I don't want people to want
37:22to have sex if it's gonna hurt.
37:24That's not a good thing either.
37:26So what we usually like to do is to
37:28try to get the vagina comfortable.
37:30Let's moisturize and stuff like that.
37:31Now, sometimes I will just do the trick.
37:33Sometimes people will come back.
37:35Well, that's totally pain free,
37:36but I still could care less.
37:38That's a different story.
37:39OK,
37:39and the issue that we're dealing
37:41with libido is premenopausal women
37:42and women who are post menopausal.
37:43I know it sounds crazy to divide it,
37:46but actually.
37:46There's one medication I should
37:48say medication,
37:49herbal preparation that we we've started
37:51using in the last couple of years.
37:53Pretty widely is and this is new.
37:56This is a new one.
37:57How is something called wrist LARISTELA?
37:59And that's an interesting compound
38:01is available over the counter.
38:03It is non hormonal an what it basically
38:05does is it increases the production
38:07of nitric oxide from from the
38:09medication itself with herbal product itself,
38:11which increases pelvic blood flow
38:13which will increase moisture,
38:14which is a good thing too.
38:17But also your blood more.
38:18You know, more juices flowing in the
38:20pelvis will think more about sex,
38:21and we've had reasonable results with it.
38:23And that can be used in premenopausal
38:25and postmenopausal women.
38:26It is not normal,
38:27just about everybody can use it.
38:29So that's we use that fairly commonly
38:30and that is a fairly new product.
38:32It's been in Europe for a number of years,
38:35just came over here a couple of years ago.
38:37As far as other medications,
38:38one of the things that people have
38:40now gotten to the point of accepting
38:42is the fact for post menopausal
38:43women that testosterone can be
38:45helpful in particularly for women
38:46who've had their ovarian function.
38:48Either the ovaries are out or their overly.
38:50Is there a function has been
38:52stopped by chemotherapy?
38:53Whatever that they have are dealing
38:55with lower testosterone and it indeed
38:56is long as your trimmer was not a
38:58hormonally influenced tumor that
39:00testosterone could be contributing to,
39:01then we should be able to use it,
39:04and so it isn't.
39:05It's sort of a strange thing.
39:07It is legal in the United States
39:08to use it
39:09when it's not commercially available,
39:11but we have our ways and sources of
39:14getting it so that's not a problem,
39:16and so testosterone is come on the scene as
39:18being an acceptable therapy and advisable
39:20therapy for people with post menopausal.
39:22Decreases and beat up for
39:24premenopausal women. Actually.
39:25If somebody's got intact ovarian function,
39:27we wouldn't push testosterone or somebody
39:29who's had her ovarian function taken away.
39:32Then testosterone is totally reasonable
39:34and there are a couple of other new meds
39:37out for premenopausal women out there
39:39which are one medication that basically
39:41both designed to increase libido.
39:43One is a pill that you take every day
39:46and the other one believe it or not,
39:49is an injection like an EpiPen.
39:51They'll get nervous.
39:52That you can actually inject
39:54without feel like an EpiPen.
39:5645 minutes to an hour before
39:58you want to have sex.
39:59You say I wanna have sex Saturday night.
40:02OK, pipe yourself.
40:03This little injectors called by
40:04Alessi and the success is reasonable.
40:06So we allow little tricks that
40:08we can use there.
40:09I don't think we have and not
40:11many of these are new so we have
40:13some some newer tricks out there.
40:18There are also a lot of
40:20things you can find on line.
40:22We do have some certain websites that
40:24we tend to like that are a little bit
40:27little bit more medical based websites but
40:29have different stimulating oils and gels.
40:31Some some toys and games,
40:33some different things for partners as well.
40:35Vibrators can be helpful for
40:37foreplay and stuff like that,
40:39so if you need a little bit of a head
40:42start or if you have a birthday coming up,
40:45you want a gift we can give
40:47you some of those websites.
40:49To look at.
40:51Denise, another question from the group
40:53is what do you recommend for lubricants?
40:56Do you usually recommend water
40:58based or silicone?
41:01Great question and I think
41:03it depends on the patient so
41:06and what you're using it for with or
41:09four so oftentimes I I. I'm kind of
41:12currently an oil based lubricants.
41:14Actually the there's one in particular emu
41:17oil that tends to be very helpful for people,
41:21but if you're using it with a dial,
41:24so technically you're not supposed
41:26to use it with a dial later because
41:29it can penetrate the silicone.
41:31Surface so cleaning wise it's not.
41:34You know recommended so so if it's
41:37if it's intercourse based of the
41:40connotation without a tool or toy,
41:43I would recommend usually a water based Lube.
41:46Otherwise a water based lubricant
41:49or a silicone based lubricant,
41:51just depending on personal preference
41:53and how it feels for the patient.
42:00Yeah, and there's another question too
42:02about lubricants for people who have
42:04an estrogen sensitive breast cancer.
42:06And so you know.
42:07Again, it's really important to feel
42:09comfortable with what's being recommended,
42:11so we do know that you know in in many
42:14cases even with estrogen sensitive
42:16or estrogen positive breast cancers,
42:18we can try a low dose of a vaginal estrogen
42:21because again it's a local medication.
42:24But for women who say, you know,
42:26I just don't feel comfortable.
42:28I don't want to start with that,
42:30and oftentimes we don't start with estrogen.
42:33We start with something called a vaginal
42:35moisturizer and so you think about
42:37you know lubricants are really good
42:38at the time of intercourse or when
42:40you're using your dilator and you just
42:43need a little bit of extra moisture.
42:45But but sometimes we recommend
42:47vaginal moisturizers for regular use,
42:49and there are a couple different
42:51ones on the market.
42:52Some are little suppository's that kind
42:54of melt inside and some common gel forms.
42:58You can get these over the counter
42:59and none of them have estrogen
43:01because they're non prescription,
43:03but a moisturizer is good just like your
43:05moisturize your skin after you take a
43:07shower or when you wash your face at night,
43:10you can actually moisturize the vagina,
43:11so there are a couple of different ones.
43:14Summer,
43:14high aloe uronic acid,
43:15which you may see in the face creams
43:17that are out there these days and
43:19there are some other that are aloe
43:21based so there are different types
43:23of moisturizers and those are
43:25for regular use and we usually
43:27recommend two or three nights a week.
43:29To use the moisturizers and
43:30probably best to do it before bed,
43:32because they can sometimes leak out.
43:34And so if you put it in in the morning,
43:37you're walking around all day.
43:38You may feel little leaky or
43:40like you have some discharge,
43:41so you use it at night with your body
43:43heat at night while you're sleeping.
43:46It tends to kind of melt into the vagina.
43:48Get into those vaginal tissues and really
43:51moisturize. So I hope that helped.
43:55Sweetly.
43:59Effect.
44:02Doctor Minken, can we ask
44:04another question of course.
44:07Can you talk a little bit about
44:09urinary symptoms that may
44:10happen for cancer patients and
44:12survivors and how you know?
44:14How do you, you know,
44:16figure out if it's a urinary problem?
44:18Should I see a urologist?
44:20Is this a medical issue or is
44:22this a menopause issue?
44:24How do you know the difference?
44:27Well, I always think it's a
44:29gynecological issue for everything so.
44:31You know my answer, of course.
44:34That couple of couples
44:36and couple of things that.
44:37So basic biology is that the
44:39tissue that lines the vagina is
44:41very similar to the tissue that
44:43lines the bladder and the urethra.
44:45There drive from the same,
44:47the same when our mommies tummies
44:49being formed they are derived
44:50from the same kind of tissue.
44:52So it's not surprising that the bladder
44:54tissue in the urethral tissue responds
44:56to estrogen or the lack thereof.
44:58OK, so anything that basically
45:00will will lead to a decrease in
45:02estrogen levels will oftentimes
45:03lead to bladder problems,
45:05which can be a real issue.
45:08So in general,
45:09if somebody's got complaining of
45:11bladder issues and discomfort
45:12and they may be waiting to
45:14pain frequency incontinence,
45:15recurrent urinary tract infections,
45:17all the above can be related to
45:19loss of estrogen in that tissue and
45:21the key thing to remember is again
45:24fortunately coming back to biology
45:26that indeed the bladder in the
45:28vagina are attached to each other.
45:30Yeah, OK,
45:31when Doctor Ratner does those
45:33surgeries I need to take out your
45:35uterus or something like that.
45:37But she actually has to peel
45:39the bladder down.
45:40To take it off of the of the uterus to
45:43do the surgery so that that's, you know,
45:46that's really close anatomy there.
45:47So in general,
45:48when I will often do is if
45:50somebody's got any of those in
45:52one of those urological symptoms.
45:54If they are a candidate for vaginal estrogen,
45:57I almost always think it's worth the trial.
46:00To get some vaginal issue,
46:01we can't put estrogen right into the bladder.
46:03It's too tricky,
46:04but we certainly can put it into the vagina.
46:07And again, if as long as somebody is OK,
46:09but using it and that will permeate
46:11its way up to the bladder and the
46:13urethra and make that issue healthier.
46:15The other thing that happens is again
46:17when the vagina gets dried you end up,
46:19believe it or not,
46:20with nasty or bacteria hanging around there.
46:22And when you have a bladder that is sort
46:24of weaker because of lack of estrogen,
46:27and there are nastier bugs hanging
46:28around there and ask your bacteria
46:30which can invade the bladder.
46:31You can end up with some pretty
46:33nasty urinary tract infections,
46:35so basically that I I'm a great believer.
46:37If somebody is able to take
46:39estrogen vaginally to use it,
46:40because I think it will help the
46:42bladder symptomatology in many,
46:44many conditions.
46:44Now sometimes it's not now OK,
46:46sometimes that you'll have the
46:48patient still dealing with symptoms,
46:49and then we may never see urologist
46:51or urogynecologist.
46:52We have, you know,
46:53several folks at Yale who are quite good.
46:55You know,
46:56as far as dealing with these issues,
46:58but I almost always think about
47:00using some vaginal estrogens first.
47:05I mean, I think it's another important.
47:09Important thing to know that.
47:12You know if there's something
47:13that you can't figure out,
47:15or your community provider,
47:17your primary care doctor,
47:18your primary gynecologist.
47:19There's just something that
47:21doesn't seem right, you know.
47:22You may want to go back
47:24to your oncologist, Ann.
47:26Just ask is this anything
47:28related to my cancer?
47:29Could this be an issue from my hormones
47:31or my treatment and then see if they can?
47:34Or you're of course you can
47:36come to the same clinic,
47:38but it's hard to know sometimes
47:39whether you know a symptom is from
47:41a cancer treatment or if it's a
47:43symptom that anybody in the community
47:45can experience and so asking,
47:47you know,
47:48going back to your treating
47:49oncologist and saying,
47:50what are your thoughts on this, if if.
47:53You know your your general PCP just
47:55can't seem to figure something out.
47:59And one thing I will put in in my sort
48:01of shameless self promotion mode.
48:04I've been good.
48:05I haven't said it yet Joanna.
48:07I'm doing fine that I will encourage
48:09everybody to go to my fabulous website,
48:12which is Madame ovary French spelling.
48:14MAD AM YOVARY.
48:15Well, that's not friendship anyway.
48:16Madam ovary.com an on my exciting website.
48:19We have some nice videos for menopause
48:21for cancer survivors and I now
48:24have come into the 21st century.
48:25I have podcasts so if you would
48:28like to listen to a dry vagina.
48:30Podcast or sexuality.
48:31Intimacy and menopause.
48:32For cancer survivors,
48:33podcasts come on over.
48:34Listen to him and hopefully will
48:36answer some of your questions
48:37for you and then maybe generate
48:39some more questions that we
48:41could answer for you it seems.
48:49Thank you, Heather, thank you. Thank you.
48:51My shameless self promotion here.
48:53Yeah click on it look at all the
48:55exciting things you can watch.
48:58So I want to doctor Doctor Ratner.
49:00I don't know if you have thoughts
49:03or things you want to add.
49:07I just think that we are so blessed
49:09to have the three of you ladies
49:12doing this in our community.
49:14I think we take this for
49:16granted and we don't this much.
49:18Appreciate what a difference you
49:20make by the care that you provide
49:23and this is very much something
49:25that I'm so proud of to be part of
49:28smilow because we don't just treat
49:30cancer with truly treat women and
49:33we think of women and we just want.
49:36You ladies not just to be cancer free.
49:38But also to be happy and have your life back.
49:41And this is all that all of
49:43us are trying to do.
49:44So thank you to the three of
49:46you for everything that you do.
49:48And again,
49:48we're so grateful to be part
49:50of this community.
49:52Thank
49:52you for you for making the trouble to get
49:55this started their doctor Ratner. Yeah
49:57Doctor Renner for starting the program
49:59and I you know I think that this is
50:02so important for our our patients and
50:04also for the partners and we you know
50:07in the same clinic we certainly welcome
50:09partners to be part of the visit.
50:11Be part of the conversation and I
50:13think you know for the men men out
50:16there for the male survivors ask
50:18your oncologist if you're struggling
50:20with issues you know the biggest.
50:22You know male cancers that that cause
50:25sexual challenges or prostate cancer,
50:27testicular cancer,
50:28colorectal cancer for men and women
50:30can be really challenging and
50:32a lot of it can be emotional,
50:35but also physical changes.
50:37And for men with prostate cancer,
50:39there can be hormonal changes as well,
50:42and physical changes from surgery,
50:44radiation, chemotherapy.
50:46Anybody getting chemotherapy
50:48can have nausea fatigue.
50:52You know hair loss,
50:53even hair loss can really cause
50:55you know changes in your self
50:57confidence and how you feel.
50:59Whether you're with a partner for many,
51:01many years or not,
51:02it's normal to feel like you look different.
51:05You may be a little shy.
51:08We deal with all of that.
51:10You know we have great psychology folks
51:12who will help you be able to have
51:14the conversation with your partner.
51:16A lot of partners are also worried
51:18you know your partner loves you and
51:20is worried about hurting you or
51:22causing any pain or not wanting to,
51:24you know,
51:25have intercourse with you if you're
51:26in pain or if you're tired or
51:29if you just don't feel well,
51:30so you know we want you to be able
51:32to feel comfortable with your partner
51:34and talking about it and having
51:36these difficult conversations.
51:38And even if it comes to.
51:40Finding different ways to be intimate.
51:42If it's, you know,
51:43going on dates again or or
51:45holding hands and cuddling,
51:47watching a movie,
51:47you know we're here to help you get
51:50back to whatever your intimacy level
51:52that feels right for you and your
51:55partner so you know we're always
51:56happy to meet you where you're at.
51:59Try to, you know,
52:00help you find new things that
52:02work for you and support you.
52:05You know, in medical ways,
52:06but also in in emotional ways
52:08and psychologically as well.
52:09So we're here for you.
52:11We're here for your partners, men,
52:12we can help you will just find
52:14you the right people to go to.
52:17Because for males there are
52:18different procedures that can help.
52:20There are medications for men.
52:21Some men get hormones as well as women,
52:23so you know,
52:24I know there are some men on the call
52:27here and I don't want you to feel that we're,
52:30you know, neglecting you.
52:31But we can certainly point
52:33you in the right direction.
52:35Absolutely.
52:38And I just want to add quality of
52:40life is just equally important,
52:43so it's fantastic to
52:44survive and to continue on.
52:46But the quality of life is,
52:48you know what we've been talking about.
52:50And I think that's just really
52:52equally as important.
52:53At a certain point is you know,
52:56feeling like you are.
52:57There and able to do the things that
53:01you want to enjoy and you know, as a PT,
53:04my perspective is all about function, right?
53:07So being able to function in the
53:09way that you want and and you know
53:12you guys have said that already,
53:14but I just think it's important
53:16to echo because you know you.
53:18You've done a tremendous job already
53:21and now you know it's time to kind
53:23of get back to the things that you
53:26want to do and and a relationship is.
53:29Huge piece of that.
53:30So you know,
53:31thinking about how how all of
53:34these different symptoms are
53:35affecting and kind of putting
53:37all these puzzle pieces together.
53:39And I always say that a multidisciplinary
53:42team approach is kind of the best
53:45way to find all these different
53:47pieces and make sure that they are
53:50whole again as much as possible.
53:56Excellent please. We
53:57have a we have a great question
53:59from an audience member about
54:01somebody who's had lymphoma.
54:03Doctor Minkkinen has a stem cell transplant.
54:06Should there you know what
54:07might be the consequences of
54:09that in his hormone therapy?
54:11Safe if needed. That's
54:13an outstanding question and the answer
54:15is that's actually one of my arch
54:17typical ones that I say these folks
54:19are great candidates for hormone
54:22replacement therapy because particularly
54:24if we have somebody who's young.
54:27Who's had in much of the time
54:29she had chemotherapy before she
54:30said her stem cell transplants,
54:32or ovarian function, you know has been,
54:35is is not there at the moment and we
54:37we are concerned because we want these
54:39folks to lead normal lives afterwards.
54:42Totally normal lives and we do know that
54:44if we don't give these folks estrogen,
54:47they may end up with some increasing
54:49problems of bone loss or heart
54:51disease or cognitive issues.
54:52These things are very important,
54:54so we actually do recommend hormonal
54:56replacement therapy for most of these folks.
54:58And the answer is it's quite safe,
55:00will not encourage a secondary
55:02malignancy shelat,
55:02which is the question and you know,
55:04just encourage you handling this season
55:06though if somebody's got her uterus
55:08in place we give progesterone when we
55:10give the estrogen to balance it out as
55:12far as stimulating the lining of the uterus.
55:15But it's certainly quite safe to give now.
55:17One thing we do tend to use a
55:19little bit more in our program that
55:21may be in the general population.
55:23An some people are concerned
55:25about blood clots with certain.
55:26You know having had certain cancers
55:28so we can minimize that risk very
55:30nicely by using a patch by using
55:32a transdermal estrogen.
55:33And we use a lot of trans dermal.
55:35We only use exclusively transdermals,
55:37but so we can basically minimize the
55:38risk of getting blood clots by using
55:40the patch of estrogen an we have lots
55:42of those folks on estrogen therapy.
55:44So not a problem.
55:50Great, thank you.
55:55Do we have any more questions for Mark
55:57this is this has been a wonderful audience.
56:00That's great, we got lots of excellent
56:02questions and great questions from you.
56:06How about Doctor Minkin if if I?
56:09If there's a great question in the audience,
56:12I haven't had any hormone replacement
56:14and it's been 10 years now and now it's
56:17becoming more uncomfortable and have
56:19more dryness and what we call atrophy.
56:21Is it too late to start
56:23any treatment for that?
56:26The answer is absolutely not.
56:27Vaginal estrogens.
56:28We can start at any point you know OK,
56:31and that dryness tends to be just a
56:33function of time away from estrogen
56:35till she gets drier and drier.
56:37But the vagina is an amazingly
56:39forgiving organ. It's wonderful.
56:41It's a fabulous organ.
56:42What can I tell you and that you
56:44start using vaginal estrogens?
56:46We can make anybody have
56:47a really great vagina.
56:49So, well, she'll have make the great
56:51vagina will give her the medications so,
56:53but the the changes are
56:55pretty much reversible.
56:56And the woman can regain really
56:58normal vaginal function,
56:59and sometimes there may be a
57:01little dilator therapy to help
57:02with things that will narrow.
57:04But you know how to use dilators and
57:06we can get these folks using dilators,
57:08so the answer is no,
57:10we can fix the vagina.
57:11The controversy actually would
57:13be as far as putting somebody on
57:15systemic estrogen if she hasn't
57:17been on systemic estrogen patches
57:18or pills for 10 years or more.
57:20And there may be some questions and
57:22not some more esoteric questions about
57:24heart issues and stuff like that.
57:26But as far as vaginal therapy.
57:28No problem come visit us will
57:30start you tomorrow no problem.
57:32Well, I guess next week later Marian clinic.
57:35Well,
57:35you know vaginal vaginal tissue
57:37is is very very
57:39fixable there. And one thing I think that
57:41that is worth learning is that you know
57:44what exactly is considered menopause.
57:46And so in in the cancer population
57:49it's actually a little bit unique
57:51in that certain therapies you know,
57:53like chemotherapy can put somebody
57:55into a temporary menopause.
57:57So what does that mean?
57:58Well, young women on chemotherapy.
58:00Their ovaries kind of shut down and during
58:03chemo there they stopped having periods.
58:05They have the hot flashes and night sweats.
58:08And then once their chemo
58:10is done at some point,
58:12sometimes the ovaries kind of wake up again,
58:15and so you know that can be a temporary
58:18thing in in natural menopause.
58:20Or if somebody has menopause
58:22from surgery or radiation,
58:24which tends to give more permanent menopause,
58:26the hot flashes and night
58:29sweats can be temporary.
58:31You know, for women we think about that
58:33naturally happening around age 50.
58:34Some women have hot flashes for a year,
58:37or some people have them for five years.
58:39Some people don't get hot flashes at all.
58:42The vaginal symptoms, though,
58:44tend to be more long lasting and
58:46in those can also be added on to.
58:49If somebody had radiation.
58:50For example,
58:51even if the radiation was ten years
58:53ago or the menopause was ten years ago,
58:56the vaginal symptoms can tend to be
58:58more long term and actually worsening
59:00overtime because it's been that long
59:03without getting estrogen to those tissues.
59:05Same with the urinary symptoms,
59:07so you know, even though certain
59:09symptoms of menopause can be,
59:11you know, temporary and stop.
59:13The vaginal symptoms,
59:15dryness,
59:15pain with sex tightening of the
59:18vagina that we call stenosis.
59:20Scarring from radiation tissue.
59:22Those can unfortunately get worse
59:24overtime if we don't manage them and try
59:27to work with you a little proactively.
59:39Maximum. So we've had some great questions.
59:42We encourage you to reach out if you
59:45if there's anything we can do to help.
59:48If you'd like to connect,
59:50we can connect you with Denise.
59:52I will actually.
59:53Well, while we're closing up here,
59:55I'll I'll provide our clinic
59:58website so that you can find us.
01:00:02And I'll let you close
01:00:03Doctor Minkin if you'd like.
01:00:05Well, I would say Echo Joann sentiments,
01:00:08which I usually do.
01:00:10And she said it better than me.
01:00:13But you know, we were delighted to
01:00:15have the interest to have people
01:00:16you know visiting with us tonight,
01:00:18asking great questions.
01:00:19And we're here for you.
01:00:21So you have any questions or problems.
01:00:23And the other thing is, you know,
01:00:25we know there's great community in in
01:00:27cancer survivors, which is wonderful.
01:00:28I mean people supporting each other,
01:00:30which is terrific.
01:00:31So if you have a friend who's
01:00:33having some issues and saying, Gee,
01:00:35you know these are problems that
01:00:37I've been dealing with sender over,
01:00:38you know we were happy to see folks.
01:00:41And you know, we want we.
01:00:42We have a lot of people who come and
01:00:44re Ferd by patients. You know them.
01:00:46You know you know my friends.
01:00:48You know Susie.
01:00:48Oh yeah, we know Susie Ann,
01:00:50you know that you know,
01:00:51come on over and you know we
01:00:52want everybody to be good.
01:00:54And as you can see,
01:00:55Joanne is just sending a message here.
01:00:57As far as how to get ahold of us
01:00:58and to learn more about the program
01:01:00and come and visit and we're
01:01:02happy to help take care of you.
01:01:05And we are doing Tele medicine too,
01:01:07even though we can't.
01:01:08Unfortunately, we can't do good exams if
01:01:10it's something that we can try to help,
01:01:13even without doing an exam.
01:01:14And oftentimes we don't
01:01:15do exams in our visits.
01:01:17Because if you have dryness,
01:01:18we know you have dryness.
01:01:20And we don't always need to take
01:01:22a look so we can try to figure
01:01:24things out over the video.
01:01:25If you live far away right now we
01:01:27are doing Tele Medicine video visits
01:01:29with zoom phone visits as well,
01:01:31so we're happy to see you in
01:01:33whatever way works for you.
01:01:36And sometimes you know because of
01:01:37work schedules and stuff like that,
01:01:39sometimes it's easier for folks because
01:01:41of work schedules to do a zoom visit,
01:01:43and it may be easier for them to
01:01:45incorporate their partner as well.
01:01:46You know if if you want and sometimes
01:01:48you don't want your partner, that's fine.
01:01:50We understand that she's too, but you know,
01:01:52you want to be there with your partner.
01:01:54A video visit may be helpful for you know,
01:01:57maybe at a times time saver for
01:01:58coordinating schedules and stuff.
01:02:00So whatever works, we want to do it.
01:02:02And Denise, you're at a
01:02:04couple different locations,
01:02:05I think, right yeah, so we
01:02:07have a team of pelvic PT's actually
01:02:10across the health system so from
01:02:12Greenwich all the way up to westerly.
01:02:15And I myself am in New Haven.
01:02:18So yeah, physicians building.
01:02:19I see patients at guilt and our
01:02:22Guilford site next to bishops.
01:02:24And then all the way up to Old Saybrook.
01:02:27And then we have Wendy Price actually
01:02:30just returned to is at our Smile Clinic.
01:02:33And then she's going to split her time
01:02:36down in our Milford clinic as well.
01:02:38So that's kind of Yale.
01:02:40New Haven centric. But then we
01:02:43have people across the across the.
01:02:45The Gold Coast as well.
01:02:48And we're also doing Tele
01:02:49visits or virtual visits.
01:02:51And in person.
01:02:52And and again, you know,
01:02:54I do do a lot of hands on work,
01:02:57but it it really depends on the person,
01:03:00their comfort level,
01:03:01and kind of what's going on.
01:03:03So it's not something that is,
01:03:05you know, forced on someone.
01:03:07It's it's really dependent on
01:03:09symptoms and and need at the time.
01:03:14Well, thank you for what
01:03:15you do for our patients.
01:03:17It's just wonderful and helpful and
01:03:18and it's helpful when they don't have
01:03:20to always come down to smilow as well.
01:03:23Right?
01:03:25Thanks for having me.
01:03:27Thank you for being here.
01:03:32Alright, well thank you so much.
01:03:34All of the panelists.
01:03:35We are so appreciative of your time
01:03:37and and ladies were so appreciative
01:03:39and an man was so appreciate
01:03:41everybody being on this call
01:03:42and be part of this conversation
01:03:44and we're all available to you.
01:03:46Anything we can do to help so thank
01:03:48you so much everybody goodnight. Thank
01:03:51you all. Thank you very
01:03:53much. Night. Goodnight