This is not the case at Caring For Women Wellness Center, where the philosophy is more like Mae West’s advice: “Too much of a good thing can be wonderful.” Dr. Goodman has both a special interest in sexuality and sexual issues and the training to translate that interest into helpful ideas and instruction for his patients, of any age or gender.

Towards that end, Dr. Goodman is pleased to direct you to some useful websites (see below), and to announce the establishment of a free lending library of sexuality resources for his patients. A list and brief description of these books follows.

Even if you are not fortunate enough to consult with Dr. Goodman (who also does telephone consultations), please feel free to look up these excellent resources.

Online Resources

This is by no means a complete list but a great place to get started!

1. www.siecus.org (Sexuality Information and Education Council of the U.S.)
2. www.sexualityresources.com (Tasteful shopping, sex education & health information)
3. www.secretgardenpublishing.com (Instructional books and videos to enhance sexual intimacy and sexual tantra)
4. www.healthysex.com (Promoting healthy sex and intimacy)
5. www.bettydodson.com (“Better orgasms; better world”)
6. www.sexualhealth.com (Men’s and women’s sexual health questions answered)
7. www.royalle.com (“How to tell a naked man what to do…” featuring Candida Royalle)
8. www.grandopening.com (Toys, toys, toys)
9. www.goodvibes.com (more toys…)
10. www.toysinbabeland.com (…what the name says!)

Dr. Goodman’s Lending Library

Additional titles added occasionally; all books may not be available at all times.

1. The G – Spot and Other Discoveries about Human Sexuality, by Beverly Whipple, PhD, Alice Ladas, EdD, and John Perry, PhD. “…The groundbreaking New York Times bestseller that combines the science of sexual function with the study of sexual satisfaction. “…Timeless…Read it and learn how to access and experience this most natural and uniquely feminine pleasure.”
2. The Elusive Orgasm. A Woman’s Guide to Why She Can’t and How She Can Orgasm, by Vivienne Cass, PhD. “…The best book, hands down, for women whose orgasms play hard-to-get.” Identifies women’s orgasm difficulties and offers advice on how to overcome them.
3. The Heart and Soul of Sex: Making the ISIS Connection, by Gina Ogden, PhD. “…To read this book is to remember and reawaken to the melody of the life force that both created and sustains our bodies and our life…” “…Redefines female sexuality, letting us discover our own brand of sexual pleasure… a holistic, nonperformance- based model for women…re-awakening our sexual spirits…”
4. Journeys by Heart: A Christology of Erotic Power, by Rita N.Brock. “…An emotionally provocative book; a revisioning of Christianity, it stretches traditional concepts and sheds new light on the fact that through our acts of love and lovelessness we create each other.” “…What I find most powerful in this book’s approach to the gospel is its emphasis on the need to break out of death-dealing, hierarchical patterns of life in our families and communities…”
5. Transcendent Sex: When Lovemaking Opens the Veil, by Jenny Wade, PhD. “…But what could be better than sex? How about lovemaking that sweeps people into new realities, producing altered states of consciousness a thousand times more powerful than the most earth-shattering orgasm? Lovemaking so spectacular that it truly is a religious experience…”
6. Private Thoughts. Exploring the Power of Women’s Sexual Fantasies, by Wendy Maltz, M.S.W. and Suzie Boss. “…At last, a wonderful and important book that reveals the full power of women’s sexual imagination- to play, to excite, to heal…” “…Private Thoughts teaches women to listen to our deepest longings… encourages us to know ourselves, deeply and passionately…”
7. Because It Feels Good: A Woman’s Guide to Sexual Pleasure and Satisfaction, by Debby Herbenick, PhD. “…Loving your body isn’t just about looking good- it’s about feeling good. This book humorously and directly demystifies the path to personal pleasure in a way that every woman can understand…” “…[it] offers a wealth of basics for anyone returning to or embarking on what America has demonized far too long: sex for the sake of pleasure…”
8. Women Who Love Sex: Ordinary Women Describe Their Paths to Pleasure, Intimacy, and Ecstasy, by Gina Ogden, PhD. “…This book explores a whole new landscape: the sexuality and sensuality of healthy women on their own terms. You will find inspiration and affirmation in this book… Opinionated, articulate, and uninhibited…”
9. The Sexual Healing Journey: A Guide for Survivors of Sexual Abuse, by Wendy Maltz, M.S.W. “…Men and Women who have despaired that their sex lives would never change will find hope and answers in this friendly, encouraging, and essential guide…”
10. Sex Matters for Women: A Complete Guide to Taking Care of Your Sexual Self, by Sallie Foley, M.S.W, Sally Kope, M.S.W., and Dennis Sprague, PhD. “…This is a book you can trust. The authors obviously know and care a great deal about helping women have fulfilling sex lives… The most comprehensive book on women’s sexual health I have ever read…”
11. The Art of Sexual Ecstasy: The Path of Sacred Sexuality for Western Lovers, by Margo Anand. “…The most comprehensive and clearly written work on contemporary Tantric Sex. An exceptional detailed program for both the beginner and the advanced practitioner…”
12. Becoming Orgasmic: A Sexual and Personal Growth Program for Women, by Julia Heiman, PhD, and Joseph Lopiccolo PhD. “…If you have any inhibitions about sex or want to enhance the pleasure you get from sex, this revised and expanded edition is for you… Whether you’re married, separated, divorced or widowed; under 30 or over 60 or somewhere in between; the program presented within these pages will help you feel comfortable with yourself and your ideas about sex…”
13. The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse, by Ellen Bass and Laura Davis. “…Through moving first-person narratives, this book illustrates how to come to terms with the past and work constructively towards the future… Compassionate and supportive… New help for today’s survivors..!”
14. Dr. Sprinkle’s Spectacular Sex: Make Over Your Love Life with One of the World’s Great Sex Experts, by Annie Sprinkle, PhD. “ Annie Sprinkle has been there, done that, and her advice is enlightening and to the point. I know of no better guide to having good sex… This book is a high-spirited “Joy of Sex” for the third millennium; keep it by your bed as a ready reference- your partner’s sure to love it too!”
15. Women’s Sexualities: Generations of Women Share Intimate Secrets of Sexual Self-Acceptance, by Carol Ellison, PhD. “…Drawing on the experiences of over 2600 women, this book is designed to enhance your lovemaking skills and deepen your knowledge and acceptance of your sexual self… a gentle, hopeful, and safe guide to the varieties of sexual pleasure that increases women’s health and selfesteem at any age…”
16. The Art of Sex Coaching. Expanding Your Practice, by Patti Britton. “…Groundbreaking and courageous! This book will help make ‘sex coaching’ a household term. A valuable resource for life coaches, clinicians, and advanced practitioners alike…”
17. For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life, by Jennifer Berman, MD and Laura Berman, PhD. “…Full of crucial new information about female sexual response… how female anatomy and sexual response really works… how to talk with your partner…your doctor…resources and helpful techniques from true experts in the field…”
18. Satin Sheet Lover In a Plastic Bag World, by Gitane, PhD “….Written by a sex therapist, this short book of quite insightful homilies gives many intuitive ideas towards a better sexual connection…”
19. The Joy of Sex: A Gourmet Guide to Love Making, edited by Alex Comfort, PhD (review copy only- not lent out; this wonderful “cookbook” of sensuality is strongly suggested reading to be purchased at your local bookstore…)

Erotica

1. Joy of Sex/ More Joy, Edited by Alex Comfort.
2. Sex Spoken Here: Good Vibrations Erotic Reading Circle Selection. Queen and Davis, Editors
3. Herotica 5 & 6: A Collection of Women’s Erotic Fiction. Marcy Heiner, Editor
4. **Most all books edited by Lonnie Barbach or Joni Blank are good..!!

For more information on a wide range of topics from sexual health/enjoyment and menopausal medicine to general health and wellness to the specific topic of labiaplasty in California, visit http://www.drmichaelgoodman.com/.

Since much of my practice time is spent working with and hopefully helping women saddled with pelvic and vulvo-vaginal pain and chronic fatigue issues, I thought I’d take the time to speak to the issue of vulvar and vaginal pain syndromes (“vulvodynia”) and other “Functional Pain Syndromes,” such as interstitial cystitis (“IC”), chronic fatigue syndromes (CFS), fibromyalgia, and chronic pelvic pain (CPP). This will only be a brief review; only so much can be said in several hundred words.

What is a “Functional Pain Syndrome?” Functional pain is real, perceived pain (no one is faking anything!) that has no demonstrable anatomic lesion. The operative factor in functional pain is the feedback between the central nervous system (the brain) and the autonomic nervous system—that part of the nervous system that operates “automatically” on its own with no “conscious” control.

Could chronic pelvic pain, vulvodynia, IC, Fibromyalgia, irritable bowel syndrome (IBS), and even migraines be “Functional Pain Syndromes?” Most likely, they are.

Many clinical similarities have been noted among these syndromes: pain as a prominent symptom, chronicity, overrepresentation in women, generally normal laboratory values, exacerbation by stress and menstruation, history of physical or sexual abuse, and association with depression and anxiety. Specific anatomical or pathological abnormalities are absent, and if an individual has one of these syndromes, (s)he is likely to have others.

Interestingly, these syndromes share some common findings:

• abnormalities in the hypothalamus-pituitary-adrenal axis connecting brain with adrenal gland,
• abnormalities in autonomic functioning (the functioning of the “automatic” nerves of the body over which the individual has no conscious control),
• and sensory processing (how we perceive what is going on in our bodies and react to it).

For some reason, the central nervous system in these individuals has difficulty processing the sensory input it receives.

Their many similarities and the fact that they often appear together points to these syndromes being related in some way, and they are often discussed as a group with the name: Functional Somatic Syndromes.

To better understand the impact of multiple factors on Functional Pain Syndromes, one might consider the “Biopsychosocial Model of Pain,” developed by Engel in 1977. This model takes into account the impact of the mind and body, and also takes into account the biological (physical), psychological and social influences for understanding one’s pain experience; in other words, it considers the whole person.

Understanding the Level of Pain in Functional Pain Syndrome

There are many important variables for understanding the intensity of pain a person is experiencing and how it interferes with their functioning. These include one’s beliefs about what difficulties the pain causes (e.g. “I can’t do anything because of my pain condition.”), pain behaviors and impact on activities (not enough exercise), impact on mood (e.g. depression, anger, anxiety), as well as the degree of support from one’s social network.

Not surprisingly, considering the nature of the condition, one of the most effective approaches to pain management is cognitive (thought processing) and behavioral interventions (Cognitive-Behavior Therapy or CBT).

According to CBT theory, physical reactions (e.g. pain intensity) are influenced by:

• Cognitions (thoughts, beliefs)
• Mood (depression, anxiety, anger)
• Behaviors (avoidance, withdrawal, overdoing it).

Beliefs exacerbate depressive symptoms via withdrawal from activities one used to enjoy, and anxiety escalates secondary to fear and avoidance. Additionally, the nervous tension associated with negative mood states impacts our bodies, worsening the physical intensity of the pain condition.

How CBT Treats Functional Pain Syndrome

The goal of CBT intervention is to educate individuals on the nature of their pain condition by understanding the model and cause of the pain. From there, individuals are taught how to correct their distorted pain beliefs/cognitions, adjust their pain behaviors, and treat problematic mood states. By doing this, in theory, the intensity and experience of their pain will moderate; pain will be better addressed by treating the whole person rather than focusing exclusively on “pain control.”

Mindfulness-based meditation instruction has also been proven to work wonders for Functional Pain Syndromes. Local availability for both CBT and mindfulness-based meditation programs may be obtained by accessing AACBT.org, and Googling “cognitive behavioral therapy” along with your city name, and by Googling “mindfulness-based meditation” along with your city name. Additionally, Googling “Jon Kabat Zinn” will put you in touch with mindfulness-based material from a master teacher.

(** In compiling this piece, I have relied heavily on the writings of Dr.s John W Warren, Vadim Morozov, Fred M Howard, and especially Dr. Sheryl Green.)

For more information on a wide range of topics from menopausal medicine to general health and wellness to the specific topic of labiaplasty in California, visit http://www.drmichaelgoodman.com/.

Dr. Goodman asked me to write a story about my experience as someone who has a great deal of contact with our genital plastic surgery patients. Although we perform several different procedures, I’ve chosen to write about our patients who have labiaplasty done. I feel I have a stronger connection to them since I have also had a labiaplasty and clitoral hood reduction and can personally relate on so many levels.

My job consists of many duties, but a large part of my day is spent answering phone calls and emails. I would say at least once a day I receive a call or email from a woman who is desperately seeking information about a very intimate and personal subject. They don’t always know the proper terminology; on many occasions don’t even know how to start the conversation or what questions to ask. That’s where I come in, reassuring them that I know what they are going through and that they need not be embarrassed. I let them know nothing they can say will shock me.

Although these women are of different age groups, ethnicities, backgrounds and of course have their own stories, we share many similarities. Almost all women complain of being uncomfortable in form-fitting clothing and swim suits and with doing exercises like bike riding or running, or even with what most would consider a minor activity such as walking up a few flights of stairs.

Of course, sexual intercourse also causes discomfort and pain. Some women say that because they’re unhappy with the appearance of their labia, they have abstained from being sexually active, have not allowed their partner to see them without clothes on, and only make love with the lights off. In some cases, the women refrained from being in a romantic relationship completely.

All of them are being held back in their everyday lives in one way or another. Something I also find important is that most women speak of a loving, caring, supportive partner who has never said anything negative about their physical appearance and had no influence on their decision to have labiaplasty performed. Most of these women have a partner who just wants them to be happy with themselves.

The most fulfilling part of my job is when a patient comes in to have their surgery done. I have been able to be there along the entire process assisting them in this very special decision. On many occasions, I am also by their side assisting Dr. Goodman during their procedure. I have become close to many of these ladies by this time and love seeing everyone’s hard work come full circle. Being there to see a patient’s reaction to seeing themselves for the first time after surgery is extremely touching. They are always so grateful to all of us involved.

I am honored to be a part of this type of practice and hope that those of you reading this find it helpful and enlightening in some way. Mostly, however, I really hope that you women out there, who have feelings similar to our patients and me, now know that you are NOT alone and find some comfort in that.

Erin’s Story: Successful Labiaplasty Offers Renewed Hope and Happiness

Erin was a 20-year-old vibrant and intelligent college student living here in Davis. She came to see us, along with her mother Sherry, for a consultation for labiaplasty. Erin was very shy, and her mother was uninformed and curious about what exactly her young daughter was interested in having done and why.

After Erin’s visit, they called the office a few times, both with general questions about the process and procedure as well as to inquire about my own personal thoughts, opinions and experiences. I was happy to disclose any and all information possible to ensure that they were both comfortable and confident with the decision to proceed.

Approximately three weeks after her initial visit, Erin decided to go ahead with her surgery. She again was accompanied by her mother; both were visibly and understandably nervous. That’s when they were both greeted by our experienced, warm, caring and friendly registered nurse. She introduces herself to Erin, shaking her hand, “Hi, I’m Lisa, your nurse, and I’ll be taking care of you today.”

Lisa has two young adult children of her own and could empathize with the mixed bag of emotions Sherry was experiencing. Lisa comforted Erin’s mom saying, “Don’t worry, she’s in good hands. I’ll be by her side the whole time.” Both patient and parent took a deep breath and shared a hug before Erin was brought back to the surgical suite.

The procedure went well. After completion of her procedure, Erin was ready to view her results and requested that her mom be present as well. Together, they took a look at her newly reconstructed labia. Even immediately after surgery, with stitches all over the place, Erin was overjoyed with the difference; she couldn’t help but shed a few tears. This in turn caused her mother to become emotional as well, and they embraced as they shared this unique and memorable moment.

When Erin returned for her one month post-operative visit, she came in a different young lady, smiling and bubbly. She also had with her a gift, a big hug and “THANK YOU!” for Dr. Goodman. She was so excited and looking forward to the new experiences she felt were now going to be possible for her—the things she was hesitant to do before having surgery.

It’s these kinds of stories that make what we do here at Dr. Goodman’s office so rewarding. Erin’s story of transformation is one of many, and I look forward to even more in the future.

For more information about genital cosmetic surgery, vulva-vaginal aesthetics, including labiaplasty in California and other areas, visit www.drmichaelgoodman.com.

Dr. Goodman delivers the Keynote Address at the 6th Annual Congress on Aesthetic Vaginal Surgery, Tucson, AZ, November 2011

Dr. Goodman was recently honored by the American Academy of Cosmetic Gynecologists by being asked to deliver the Keynote Address at their Annual Meeting in Tucson, AZ.  Dr. Goodman gave his address, titled, “A Review of Female Genital Plastic and Cosmetic Surgery: Patient Selection, Sexual Issues, and How to Stay out of Trouble.”, as wells as a second lecture which reviewed the different techniques for female genital plastic/cosmetic surgery, how to choose, and “Do’s and Don’ts” of each technique.

More Photos From the Meeting:

“Mindfulness” involves attending to relevant aspects of experience in a non-judgmental manner. It is an ancient eastern practice with roots in Buddhist meditation and is manifested and taught in America and abroad by a variety of teachers, including S.N. Goenka, Thich Nhat Hanh, Jack Kornfeld, Jon Kabat-Zinn, and many others.

Mindfulness-based stress reduction (MBSR) involves achieving harmony by seeing things as they really are, thus helping diminish agitation, irritation, disharmony and unhappiness, enabling us to live at peace with ourselves and others. Simply stated, mindfulness is the practice of relaxed wakefulness; it is the study of the “Art of Living.”

I have previously written about the deleterious effect of stress on the immune system—our only barrier between health and illness. It is both intuitive and evidence-proven in peerreviewed medical literature that stress is a genitive factor in many different forms of disease. As important as BHRT (bioidentical hormone replacement therapy), the activities of stress reduction and mindfulness are imperative.

Gynecologically, Y.M. “Irv” Binik and Sophie Bergeron’s group in Montreal and Rosemary Basson and Lori Brotto and their colleagues in Vancouver have previously published regarding the positive relationship of both MBSR and cognitive-based behavioral therapy (CBT) in the therapy of both sexual dysfunctions and female vulvo-vaginal pain syndromes (vulvodynia, vulvar vestibulitis, vestibulodynia).

In an article newly published in the respected journal Menopause, the # 1 medical journal covering menopausal issues, J.F. Carmody and his team from the University of Massachusetts studied the effect of a MBSR program on the degree of ”bother” from hot flashes and night sweats. The study was a randomized trial of 110 late perimenopausal and early postmenopausal women experiencing an average of five or more moderate or severe hot flashes (including night sweats) per day.

The study’s main outcome identified the degree of bother from hot flashes and night sweats in the previous 24 hours. The study group was paired with a control group suffering the same symptoms, but not participating in MBSR.

The “intervention” used in this trial was a widely-used eight-week meditation course based on an approach introduced by Jon Kabat-Zinn: eight 2.5 hour weeknight classes and an allday weekend day during the sixth week, as well as mindfulness practices to be done at home for 45 minutes for six days each week. The meditation work was not directed specifically at hot flashes but instead conformed to standard MBSR interventions used across a wide range of medical conditions. Secondary measures were hot flash intensity, quality of life, insomnia, anxiety, and perceived stress.

The results are interesting and revealing. Although no significant reduction in hot flash frequency was noted, there was a statistically significant reduction in the degree of “bother,” with a reduction from an average of “moderately to severely bothered” down to “mildly-moderately bothered.” These effects were comparable with the findings from a recent randomized, placebo-controlled trial of escitalopram (Celexa™), an anti-depressant medication in the SSRI group, sometimes used for suppression of hot flashes and night sweats, without the potential side-effects of the medication.

Writes Pauline Maki from the department of Psychiatry at the University of Chicago, in her recent Menopause editorial on Dr. Carmody et al’s study:

The failure of MBSR to have a profound impact on hot flash frequency or severity, however, does not detract from the potential benefits of MBSR for midlife women with moderate to severe [hot flashes.] With respect to the benefits of MBSR in women with moderate to severe hot flashes, the effects on hot flashes were quite modest when compared with the more impressive results on measures of psychological well-being and quality of life. The overall quality of life, sleeprelated quality, anxiety, and perceived stress were greatly improved in the MBSR group.

Although mindfulness did not reduce the frequency of hot flashes (estrogen therapy is the “gold standard” for that), it reduced both the “hassle factor” and at the same time conferred other stress-reduction health benefits on the immune system and, most importantly, greatly improved “quality of life,” without the use of hormonal or medicinal therapy. What’s not to like?

To find MBSR opportunities near you, Google “mindfulness-based stress reduction” along with your city or a relatively large metropolitan area near you. Other keywords you can use in your search include “Vipassana” and “Jon Kabat-Zinn.”

Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at http://www.drmichaelgoodman.com/.

I have a question regarding a patient one of my supervisees is seeing. The patient is a 24-year old female with severe body dysmorphia. This is a result of over hearing her brother and some of his friends discussing female genitals as disgusting when she was a teenager. She wants surgery on her labia majora because she thinks they are ‘not right’. My Supervisee is a gynecologist who runs a psychosexual clinic and has looked and said the vulva is absolutely normal, indeed many would choose her vulva if they needed surgery. My supervisee is not happy to refer her for surgery for what is a perfectly normal and indeed ‘tidy’ vulva.

We have thought about working with her body image and are attempting that, but she is convinced that she is disfigured and will not hear opinions to the contrary.  She has been shown photos and DVD of other vulvas by my supervisee, which has had little effect. We have used CBT on the obsessive thoughts.

Dr. Goodman’s Response:

It is an issue more complex than one may think at first blush. We all admit that when it comes to body parts there is a very wide variation in “normality.” And I think we can agree that just because it is “normal” does not mean the “wearer” is satisfied or comfortable with the appearance, or that she would not wish to alter the appearance.

Few of us would be very disturbed if our patient wished to enlarge very normal, perhaps “A” or “B” cup-sized breasts to a size she feels she will be more confident in. Same thing applies to someone wanting to alter a quite normal but perhaps slightly hooked nose or have liposuction of a very normal midlife paunch, or to have a smallish, but normal 4-inch erect-sized penis enlarged. It may not be what you or I or the doctor down the hall would do, but we would not deny the person his or her decision to alter the body part and, for the most part, we would not pin the label of “Body Dysmorphia” (BDD) on him/her solely because he/she wished to alter a body part we thought was fine.

Where do we draw the line between a personal and acceptable request for a body alteration, and a DSM diagnosis of Dysmorphia? Who is to say? Who is the arbitrator?

Why do the same persons who might not themselves have “body work” not get terribly upset when their patient invites our opinion of a good plastic surgeon for their augmentation of very normal but small breasts, but have serious issues if their patient with a largish but “normal” sized vulva inquires about labial or vaginal alteration?

Aahhh….here’s where parental and puritanical overtones often come into play.  This is a female’s intensely personal, forbidden and sexual area, and modification for reasons of cosmetics, or to gain additional comfort, or to tighten for improved sexual satisfaction is anathema to so many of us.

In a very interesting and revealing study entitled “Ratings of Female Genital Attractiveness Pre- and Post-Genital Cosmetic Surgery Differ by Age and Gender” (submitted for publication), data from Cindy Meston’s group from Austin shows that women with positive genital self-image experience higher levels of sexual functioning and lower levels of sexual distress. It also reveals that female genitalia modified by genital cosmetic surgery are considered more attractive by a large sample (>900), including young women, mid/older age women, and men.

Gynecologists in particular, perhaps because we see so many more vulvae than any other group of individuals, are inured to the variability in vulvar size, know that “it’s all normal,” and wonder why on earth anyone would like to alter (ouch!) such a sensitive and sexual area. In fact, we are not afraid to lecture our patients against affecting any change. But this is not our body, our genitalia, or our sexual sensibility.

Let’s for the moment “objectivise” (sic.) and think of the vulva solely as a “body part”—no different from one’s nose, breasts, belly, phallus, hair (color, style, etc.). I know, it’s hard to do.

In my opinion, the vast majority of women requesting genital alteration do not have Body Dysmorphia. In a small pilot study to be published this fall in the Journal of the American Academy of Cosmetic Surgery, Lori Brotto, Samantha Fashler and I found, based on a widely validated instrument for diagnosing BDD (the YBOCS-BDD), that 48% of women requesting vulvar alteration qualified for “moderate body dysmorphia.” However, six months after their single genital procedure, this percentage had fallen to 7%, indeed slightly lower than the control group.

Did these women truly have Body Dysmorphia based on their desire to alter one specific body part and the resulting high score on the BDD instrument? Or did they only have a significant cosmetic or (even more frequently) functional, concern about a specific body area, carrying with it all the cache that society has given the female genitalia? Perhaps they wanted what so many normal individuals want: instant gratification and a solution to their specific discomfort— not lectures about their normality, or to be told to “live with it,” or to spend time with their therapist discussing how to fit comfortably into the body that they have.

What does all this blather have to do with your supervisee’s patient? In genital plastic/cosmetic surgery, the mantra should be “the right procedure on the right patient for the right reasons.” (Really, this should be the mantra of all plastic and cosmetic surgeons!)

Certainly, Body Dysmorphia or requesting a surgical fix for a psychosexual insult is NOT the right reason. I would suggest the following for this specific individual:

• Ask the supervisee: How have you arrived at your diagnosis of “severe body dysmorphia?”

• Ask your supervisee to re-evaluate the size and configuration of her/his patient’s genitalia (you stated her labia majora). Is there indeed some wrinkling/pouching/protrusion that, while entirely normal, might cause the patient distress about appearance?

• Additionally, you might administer to her a couple of validated instruments for Body Dysmorphia and ask her to fill out each instrument twice—once for her feelings “in general” about herself presently, and the second set of data for herself if her self-perceived vulvar enlargement were totally resolved. Does she still qualify for dysmorphia?

• Additionally, in view of her history of psychosexual trauma from remarks made by a family member, I would require of her several uncovering sessions with a therapist skilled in evaluating and treating Body Dysmorphia.

At first glance, this patient is the proverbial individual that a surgeon should not touch with a ten-foot pole, who has “danger” stamped all over her. Whatever you and your supervisee determine to do, of course, work with her body image! Tell her that you are not rejecting her request out of hand and fully respect her feelings about her body, but that first you would like her to gain more understanding about the possible deep effects of these insensitive comments.

However, if she indeed appears to have an isolated anatomical “splinter,” is not truly dysmorphic, has understood the trauma inflicted by her sibling’s insensitive remark, and still requests removal of that “splinter” that is psychosexually so traumatic to her, we should not reject her request out of hand.

By the way, I congratulate you on the use of CBT, a therapeutic modality that shows increasing promise in enabling individuals to live well in their current skin.  But isn’t the use of CBT acknowledging that indeed this is a true and chronic problem for her (the self-perceived “abnormal” labia) that perhaps can be ameliorated by good, intuitive therapy and/or (in the right patient) genital plastics?

For more information on a wide range of topics from menopausal medicine to general health and wellness to the specific topic of labiaplasty in California, visit http://www.drmichaelgoodman.com/.

Unequivocal evidence from both the Women’s Health Initiative (WHI) and several large clinical trials now provide indisputable evidence that there is a “window of opportunity” to begin peri/post-menopausal hormone therapy. This “window” stretches between menopause (around the time of the final menstrual period) and the next two years— probably up to five years in some cases. If hormone therapy is started within this “window,” all evidence points to a reduction of coronary artery disease/cardiovascular disease of 30%, as well as a 30% reduction of late-life cognitive impairment, and a reduction of osteoporotic fractures of well over 50%!

The WHI’s premature termination of recommended hormone therapy was due to a small increase in breast cancer in the group of patients (averaging age 63 at inclusion—an average of 13 years post-menopause) taking a relatively high dose oral estrogen (Premarin™) plus the relatively strong synthetic progesterone, Provera™. This WHI recommendation was hyped to the extreme by the press. Unfortunately, both most physicians and media pundits got their “news” from the non- menopausal medicine media.  In the resulting panic, more than 60% of women then taking hormone therapy quit, frequently with the advice of their not-very-knowledgeable-physicians.

Interestingly, the only physician group not to recommend mass discontinuance was menopause practitioners, which was the only group to carefully read the study and realize that its conclusions were faulty as they applied to the long-term safety and risk: benefit ratio of estrogen therapy. This group waited to see complete data, which has since been forthcoming.

Further analysis of the vast amount of data generated by the WHI has shown:

1. The real culprit in the increased incidence of breast cancer in the “Prem-Pro™” group was the “Pro” (Provera™) part. A second group of women took estrogens (Premarin™) only (no Provera™). After 11 years of follow- up, there is no increase in breast cancer in this group. In fact, the latest data to emerge from the WHI study group is showing a statistically significant decrease in cancer rate (LaCroix et. al. for the WHI Investigators: “Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy.” JAMA April, 2011). Remember, women who took the PremPro™ had a not-statistically significant increase in breast cancer rate, which was reported in 2002, with a follow- up showing the same findings in 2008.
2. Premarin™ is a potent oral estrogen. The dose studied (0.625 mg) gave a blood serum level of 87pg/ml. Average blood levels of all low-dose FDA-approved bioidentical transdermal estrogens is 15 to 35 pg/ml. It is known that the incidence of breast cancer increases with increased blood estrogen concentration.
3. There is a real “window of opportunity” in which to start menopausal hormone therapy. Although hormone therapy initiated in older, high-risk (obese, diabetic, poor lipids, smokers, etc.) individuals has cardiovascular (CV) benefit long-term, short term there is a definite increase in CV problems. The WHI study group had many women in this category. However, re-analyzing the group of women who were near to menopause (within two years and probably within five years of their final menses) showed significant cardio-protection, with rates of cardiovascular disease and cognitive problems falling 30% long-term in the group of women starting early and staying on therapy for 10 years or more.

Your health and well-being are worth digging a little deeper to get the real story on hormone replacement therapy. Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at http://www.drmichaelgoodman.com/.

“Sex is good, but not as good as fresh sweet corn”
–Garrison Keillor

Sexual and general health are entwined in both men and women. It is well known in medical literature that sexual activity can affect testosterone (“T”) levels in both of the sexes. Also known is the fact that lowered T levels reduce sexuality. For this reason, it can be hypothesized that sexual activity is able to “feed” itself through activation of the feedback loop existing between the pituitary gland in the brain and T-sensitive receptors, which regulate sexual activity, energy production and mood, among others.

More sex means more physiologically produced T, and more T correlates with both psychological and general health. Ample evidence exists in medical literature to suggest that full, satisfactory sexual intercourse is not only associated with better hormonal function, but with improvement of corresponding physical and psychological parameters.

Sexual health correlates so much with general health that general health may be considered a surrogate marker for sexual health. A famous study published in 1997 in the British Medical Journal found that men who had fewer orgasms were twice as likely to die of any cause than those having two or more orgasms a week.

In a “chicken and egg” scenario, arterial vascular disease (the kind that leads to heart attacks, stroke, and peripheral vascular disease) first affects small arterial vessels, such as the penile artery, responsible for bringing the penis the blood necessary for erection. Poor arteries = poor erections. Poor erections = poor T, and poor T = poor erections. ‘Round it goes…

What about Sexual Activity and Depression?

Take a look at the potential benefits to sexual activity and how it impacts depression:

• Well respected investigators in the field of sexual health have reported effects as diverse as an increased pain threshold in women undergoing vaginal stimulation.
• Deposition of sperm into the female genital track may have mood-enhancing and anti-depressant effects.
• Sexual auto activity (self-pleasuring) has been shown to represent a reliable primary reinforcer for depressed women in a situation where other pleasures, such as food, may have lost their reinforcing value. Masturbation may represent a selfadministered mood enhancer.

Reduced sexual interest is one of the signs of depression in both men and women; conversely, clinically depressed individuals have less interest in sex. Another vicious cycle.  Paradoxically, the same medications that may lift the cloud of depression rain on the parade by diminishing sexual desire and frequently blunting arousal and orgasmic response.

Studies Reveal Reasons and Solutions for Low Sexual Desire

A recent study in the journal Climacteric, a journal devoted to aging (“Testosterone Treatment of Hypoactive Sexual Desire Disorder in Naturally Menopausal Women: The ADORE Study”), proved again, as have other studies, that transdermal testosterone, in this case administered via a skin patch, significantly improved sexual desire in women whose low desire was problematic.

Another study in the Journal of Women’s Health (“Sexual Desire during the Menopausal Transition: Observations from the Seattle Midlife Women’s Health Study”) supported a vulnerability to reduced sexual desire with aging. Lower estrogen and testosterone levels were correlated with poorer perceived health, elevated sense of stress, and menopausal symptoms of depressed mood, fatigue, and sleep disturbance.

The same dietary factors that improve overall health, such as a “Mediterranean diet,” also improve sexual health. Fit individuals have greater sexual desire and experience more sexual activity than the unfit and/or obese. Conversely, “roadrunners”—individuals with very little body fat, especially those who train excessively—have significantly lower testosterone levels and diminished desire (and lower bone density), secondary to increases in endorphins and serotonin, which bind testosterone and render it less active.

Moderate alcohol intake is associated in many studies with greater sexual activity and improved sexual health (another “chicken ‘n egg??”). Another recent study in the Journal of Sexual Medicine (“Regular Moderate Intake of Red Wine is Linked to Better Women’s Sexual Health”) out of Italy (where else?!) finds that regular moderate intake of red wine is associated with higher scores on tests for sexual desire, lubrication, and overall sexual function, pointing to a potential relationship between red wine consumption and better sexuality.

Watching Out for Snake Oil Salesmen

On the more smarmy side of the issue is what I call the “snake oil salesmen,” who lead a multi-billion dollar a year “sexual hope” industry, promising everything from better erections to long-lasting desire and improved orgasms. These salesmen misuse the legitimate terms “alternatives” and “complementary” and “integrative therapy” for their own gain, capitalizing on the natural healing powers of the body and a strong placebo effect produced by satisfying sexual encounters (again, “chicken and egg”) by taking credit for improvement. Of course, if the treatment doesn’t work, they often shift the blame to damage caused by prior conventional medical treatment.

Finding Real Answers through Science and Proven Methods

We know the brain mediates sexuality like no other organ, responding positively to stimulation from oxytocin (a product I have compounded and utilized with success) which improves trust and communication, and dopamine—a key player in the brain’s pleasure center. Simply put, the largest sexual organ we have is between our ears. Health, trust and intimacy, acting on a brain bathed in appropriate hormonal levels lead to enhanced sexual health.

Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at http://www.drmichaelgoodman.com/.

Through his practice, Dr. Goodman receives many questions from patients regarding menopause and bioidentical hormone replacement therapy. Below is a recent question from a patient and what follows is Dr. Goodman’s response:

I started menopause at about 49 years of age and am now 56. Two years ago I had a blood clot in my lung, which was attributed to my HRT (hormone replacement therapy) medication and was told to quit it cold turkey. My doctor at that time advised “natural” medicine—none of which have really worked. Amberen required a double dose. iCool works to a point but cannot be doubled up. My gyno, with whom I had an appointment in January, told me no matter what I took to diminish my hot flashes, the result would have the same problematic impact on my hormones, creating a tendency for blood clots. Is this true or not? If this is the case, what can be done to lessen or stop my hot flashes OR am I doomed to have them the rest of my life? My mother is 82 and has been off HRT for years and as soon as she stopped using it the hot flashes came back. I’d love to know your opinion on this.

Dr. Goodman’s Response:

The blood clot you got may or may not have been related to your hormone therapy. A large volume of evidence-based literature in major respected medical journals over the past several years has clarified the possible role of hormone replacement therapy in the genesis of “blood clots.” It turns out that it is not the estrogen itself that may generate an increase in clotting potential. It is, rather, the oral form of the estrogen, especially if combined with the potent progestin (synthetic progesterone- like medication), medroxyprogesterone(Provera ™) and other progestins found in oral contraceptives.

Evidence collected over the past 5-10 years is showing with increasing certainty that transdermal delivery of estrogen (via patch, spray, gel, etc) is safer than oral. Orals, however, are cheaper, so your insurance company, in an effort to improve their profits by providing the cheapest medications, may seek to charge you a higher co-pay when you seek the safer delivery system.

What to do? First, have your PCP or gynecologist (if they’re savvy enough) test you for any genetic predisposition to form blood clots. If they do not know what tests to conduct, ask for a referral to a “Hematologist.” In the absence of increased genetic risk, there is no reason why you cannot re-start hormone therapy, with the following provisos:
1) Use low dose and transdermal.
2) If you still have your uterus and need a progesterone-like substance to “balance” the estrogen, it should only be micronized progesterone (one brand name is Prometrium™) given either daily or (better) given at a dose of 200mg for 14 days every 3-4 months.
3) Avoid situations that may be conducive to blood clots, like long periods of sitting in a cramped space; make sure you are able to get up every hour or two and walk around.
4) Also, remember that obese people get more blood clots than their thinner sisters.  Exercise a lot and focus on good nutrition.

That said, if you or your doc decide against hormones for whatever reason, there is still hope. Consider these options for managing symptoms without hormones:
· The medication Gabepentin taken once/twice per day and at bedtime, especially if combined with the antidepressant meds fluoxitine (Prozac™), sertraline (Zoloft™),
citralopram (Celexa™), venlafaxine (Effexor™), and others, can help with hot flashes and mood.
· For vaginal dryness, whether or not you decide to use the low dose transdermal estrogen, you are totally safe using a microdose vaginal estrogen product like estradiol cream (Vagifem™) with absolutely no increased risk of thromboembolism.
· Most importantly, do your best to avoid hot flash triggers, which include stress, heat (e.g. hair dryer, hot places, etc), and spicy foods. Everyone has their own unique triggers, so identify yours and work to reduce or avoid them.

There’s always hope when it comes to your menopausal symptoms. Don’t be afraid to ask questions to get the information you need to make your life as comfortable, enjoyable and vibrant as it can be.

Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at http://www.drmichaelgoodman.com/.

Through his practice, Dr. Goodman receives many questions from patients regarding menopause and bioidentical hormone replacement therapy. Below is a recent question from a patient and what follows is Dr. Goodman’s response:

I am wondering since I have not had a period in 5yrs why now am I experiencing hot flashes dryness and feeling irritable?

Pertinent question, Linda, and a situation that is not all that rare.

“Menopause” is the final menstrual period. More importantly, it is the cessation of ovulation, where you mature and ovulate an egg. An ovulating woman’s ovaries secrete estrogen in the form of estradiol (from the egg follicle), estrone (from the ovarian tissue) and progesterone (only if the follicle ovulates) and, if you don’t get pregnant, you have your period two weeks after you ovulate. Of course, you never know if any given menses is your last, so the “official” definition of menopause is no menses in a year.

By this definition, it certainly sounds like you’re in menopause.  Women’s reactions to the internal ups and downs of estrogen levels accompanying the peri menopause and menopause vary according to many factors, including the degree of ups and downs in a given woman, her “sensitivity” to these changes, her mental state (anxiety and stress always make these symptoms significantly worse), her weight, and other factors. Women who are significantly overweight, as a group, seem to suffer fewer symptoms, as fat cells secrete estrogen-like substances, making symptoms milder (and risk of breast cancer slightly greater).

Some women’s estrogen levels experience wild variations and/or plummet, producing bothersome symptoms. Some women’s levels very gently diminish over time, meaning it may be years after their final period that their individual estrogen levels reach a critical level for them—a “tipping point,” if you will, where they become symptomatic. Also, the post-menopausal ovary (no more ovulation) secretes a variable amount of the estrogen hormone “estrone.” The more estrone you have, the less your symptoms. With more estrone comes a slightly increased risk of breast cancer, since estrone is stronger than estradiol and stronger than most low-dose hormone replacement products.

Simply put, you have been “let down gently” and now you’ve reached your own personal “tipping point.” Alternatives at this time include no therapy, herbs and botanicals, or low-dose transdermal (through the skin via patches, gels or creams) estradiol therapy. Low-dose transdermal is the safest way to take post-menopausal hormone replacement. If started within five years of menopause, the hormone replacement therapy can reduce your risk of cardiovascular death and cognitive decline by 30%, and definitively protect your bones from osteoporosis.

Ask your gynecological menopause specialist which path is best for you. Specialists can be found on the North American Menopause Society website: www.menopause.org. Good luck, and good health!

Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at http://www.drmichaelgoodman.com/.